Self-harming adolescents: how do they perceive and explain this behavior?

Adolescentes que se autolesionam: como percebem e explicam tal comportamento?

Adolescentes que se autolesionan: ¿cómo perciben y explican este comportamiento?

Abstract

Self-harm is a prevalent adolescence behavior, indicated as a public health problem. The objective was to understand how adolescents perceive and explain this behavior, considering family and school characteristics. It’s a multiple case study, in which five self-harming adolescents participated, enrolled in a public school in Novo Hamburgo-RS, participated in the study. They answered the following instruments: Sociodemographic Data Sheet, Semi-Structured Interview, Family Support Perception Inventory, Youth Self-Reporting and Delaware School Climate Survey-Student. Each case was individually analyzed and cross-case synthesis was performed. Self-harm was indicated as a strategy to relief suffering and regulate emotions. Low familial support, lack of skills, and presence of internalizing and externalizing problems were evidenced, as well as negative evaluation of peer relations and student engagement. When faced with a complex phenomenon, it is important to contemplate individual and relational issues in interventions.

Keywords:
self-harm; adolescence; family support; emotional and behavioral problems

Resumo

A autolesão é prevalente na adolescência e indicada como um problema de saúde pública. Objetivou-se compreender como adolescentes percebem e explicam esse comportamento, considerando características de seu contexto familiar e escolar. Trata-se de um estudo de casos múltiplos, do qual participaram cinco adolescentes que se autolesionavam, matriculados em uma escola pública de Novo Hamburgo-RS, que responderam aos instrumentos: Ficha de Dados Sociodemográficos, Entrevista Semiestruturada, Inventário de Percepção de Suporte Familiar, Inventário de Comportamentos Autorreferidos para Jovens de 11 a 18 Anos e Delaware School Climate Survey-Student. Analisou-se individualmente cada caso e realizou-se a síntese de casos cruzados. A autolesão foi indicada como uma estratégia para aliviar sofrimento. Evidenciou-se baixo suporte familiar, carência de competências e presença de indicadores de problemas internalizantes e externalizantes, assim como avaliação negativa das relações entre pares e do engajamento estudantil. Frente a um fenômeno complexo, faz-se importante contemplar questões individuais e relacionais nas intervenções.

Palavras-chave:
autolesão; adolescência; suporte familiar; problemas emocionais e de comportamento

Resumen

La autolesión es frecuente en adolescencia y se indica como un problema de salud pública. El objetivo era comprender cómo adolescentes perciben y explican este comportamiento, considerando características de su contexto familiar y escolar. Es un estudio de caso múltiple, en el participaron cinco adolescentes con autolesión, matriculados en escuela pública en Novo Hamburgo-RS, que respondieron a los instrumentos: Hoja de Datos Sociodemográficos, Entrevista Semiestructurada, Inventario de Percepción de Apoyo Familiar, Auto informe para Jóvenes de 11 a 18 años y Delaware School Climate Survey-Student. Cada caso se analizó individualmente y se realizó una síntesis cruzada de casos. La autolesión se indicó como estrategia para aliviar el sufrimiento. Se evidenció poco apoyo familiar, falta de habilidades y presencia de indicadores de problemas de internalización y externalización, así como una evaluación negativa de las relaciones con los compañeros y la participación de los estudiantes. Ante un fenómeno complejo, es importante contemplar problemas individuales y relacionales en las intervenciones.

Palabras clave:
autolesiones; adolescencia; apoyo familiar; problemas emocionales y de comportamiento

Introduction

It was in the 1960s that American physicians observed an increasing number of individuals cutting themselves without intent to cause death (Graff & Mallin, 1967), which aroused interest in self-harm. Since then, this behavior has become more frequent, especially in adolescence (Cedaro & Nascimento, 2013; Jorge, Queirós & Saraiva, 2015), although it is also observed in other age groups. The prevalence rates of self-injury in young people have ranged from 7.5 to 46.5% (Cipriano, Cella, & Cotrufo, 2017). In Brazil, a study involving 517 participants aged between 10 and 14 years revealed that 9.48% of respondents reported the behavior (Fonseca, Silva, Araújo, & Botti, 2018).

The act of hurting oneself can be called self-harm, self-mutilation, self-harming conducts and behaviors, there is no consensus in the literature on the most appropriate nomenclature to describe it (Guerreiro & Sampaio, 2013). In this study, the terms self-harm and self-harming behaviors will be used, because they are considered synonyms and refer to any and all acts that include the following behaviors: “cutting oneself; burning oneself, beating oneself, biting oneself, pinching oneself, rubbing objects against the skin, preventing wounds from healing, excessively scratching the skin, among others” (Arcoverde & Soares, 2012, p.294). It is emphasized that even if it does not imply suicidal intent, self-harm has been indicated as a predictor for such behavior. In addition, the World Health Organization (WHO, 2016) has released a manual of good practices to establish and maintain surveillance systems for self-harm and suicide attempts, considering that the monitoring of self-harm behaviors helps in the prevention of suicide.

In addition to the association with suicide, the practice of self-harm has been related to mental disorders of an internalizing and externalizing order. A systematic review found that all externalizing disorders examined in the contemplated studies had strong associations with self-injury (Meszaro, Horvath, & Balazs, 2017). Also Nock, Joiner, Gordon, Lloyd-Richardson and Prinstein (2006), in a survey of 89 Euro-American, Latin-American and African-American adolescents, who presented non-suicidal self-harm behavior and were hospitalized in a psychiatric unit, found that 87.6% of them met criteria for disorders that were externalizing (62.9%), internalizing (51.7%) and of substance abuse (59.6%). For this, self-injury has been configured as a public health issue (Guerreiro & Sampaio, 2013; Santos & Faro, 2018).

Self-harming behavior can be understood as a way to indicate conflicts or difficulties (Jorge et al., 2015), being related to “impulse control and decision-making, as well as the elaboration of strategies to deal with stress situations and solve problems” (Arcoverde & Soares, 2012, p.295). Cutting has been indicated as the most common method present in self-injury (Kapur et al., 2013). According to Oliveira (2016), although the cut is seen in a repulsive way by society in general, it can be identified as an inscription, that is, a way of belonging. In this sense, self-harming behavior can be considered contagious, since it can occur from one group to another, because individuals often instigate others to adopt such a practice. For Gonçalves (2016), the body areas in which individuals most often self-harm are arms, legs and chest, as they are the easiest parts to access and hide.

Regarding the causes, in the research by Young, Sproeber, Groschwitz, Preiss and Plener (2014), conducted with 206 German adolescents who self-harmed, it was indicated that the prevailing reasons were to receive more attention from friends, be understood by parents and cease bad feelings, as pointed by 41%, 37.8% and 35% of adolescents, respectively. Therefore, self-injury presents different motivations and these tend to change according to the situations experienced in contexts such as family and school (Guerreiro & Sampaio, 2013; Klemera, Brooks, Chester, Magnusson, & Spencer, 2017).

The family context, when characterized as conflicted, with little communication and low level of cohesion and/or support among members, is associated with self-harming behavior in adolescence (Klemera et al., 2017; Silva & Siqueira, 2017), which may even trigger suicidal ideations (O’connor, Rasmussen, & Hawton, 2014). The portuguese study conducted with 831 adolescents, whose objective was to investigate emotional experiences with the family and its relationship with the practice of self-harm, indicated that participants who reported memories of family interactions guided by devaluation and high levels of negative affection, tended to engage more frequently in self-harm behaviors (Xavier, 2017).

Regarding the school context, the result of a research showed the occurrence of self-harm in 85.7% of the school institutions evaluated, highlighting that the behavior can occur individually or in groups (Silva & Siqueira, 2017). Such behavior has been the focus of debates among adolescents, as well as on social networks, places where they share their experiences (Almeida, Crispim, Silva, & Peixoto, 2018). Thus, the need for attention to the school climate is highlighted, as well as to the difficulties in interpersonal relationships, which may be associated with emotional problems, which trigger and are associated with self-harming behaviors (Santos & Faro, 2018).

Considering the evidence about the increase in self-harming behaviors and the lack of national research on the subject, the objective of this study was to understand how adolescents who self-harmed perceive and explain this behavior, considering characteristics of their family and school context. The results are expected to support professional practice, considering its impact on health services and education, which deal with the lack of resources to meet such a situation, in addition to the usual overload of demands.

Method

Outlining and participants

This is a qualitative, exploratory and cross-sectional research, with the design of multiple case studies (Yin, 2015), in which five adolescents who presented or had already presented self-harming behavior participated. They were intentionally selected from the referral for psychotherapeutic care in a child-youth psychosocial care center (CAPSi) in the municipality of Novo Hamburgo, in the state of Rio Grande do Sul, which was done by the school in that they were enrolled. However, two adolescents did not adhere to the treatment. The prevalence of self-harm cases in this school was higher when compared to the others in the municipality, having registered 15 adolescents who self-harmed.

The adolescents had a mean age of 14.8 years (SD = 0.45) and attended the 8th and 9th years of the same public school in the municipality, where they lived. The main characteristics of the participants are shown in Table 1.

Table 1
Description of participants

Participants	Age	Grade	Failure	Religion	Psychotherapy	Psychotropic
Ana	15	9th	No	Catholic	Yes	No
Helen	15	8th	Yes	-	No	No
Julia	14	9th	No	Catholic	No	No
Eduarda	15	9th	No	Catholic	Yes	No
Lucas	15	9th	No	-	Yes	No

• Note. The names used are fictitious, to preserve the identity of the participants.

Instruments

Sociodemographic data sheet: prepared by the authors and composed of 10 closed questions that sought to characterize the demographic and social profile of the participants.

Semi-Structured Interview: developed by the authors and composed of 16 topics, related to the past and the present, aiming to understand the history of self-harm behavior, in addition to the perception of the adolescents about such behavior and how they understood it. The interview made it possible to realize when the adolescent began to self-harm and if there were influences; in addition to what it was for him to self-harm and which parts of the body they used to harm; the reason, frequency, methods used, thoughts/feelings, intentions and the level of intensity of the injuries. It was also verified whether the adolescent had friends and people to talk about their thoughts/feelings, evaluated how they perceived the relationship between adolescence and self-harm and questioned about the desire to cease such behavior.

Inventory of perception of family support-IPSF (Baptista, 2009): composed of 42 items answered on a three-point scale (almost never or never = 0 to almost always or always = 2) that evaluate the perception of family support. Recommended for people aged between 11 and 57 years-old, the IPSF results in three dimensions: (1) affective-consistent, (21 items): highlights the expressions of warmth, positive interest, affection, closeness, empathy, and clarity of the intrafamily and intracommunity rules, and skills in problem-solving (α = 0.91); (2) family adaptation (13 items scored in reverse): an examination of negative feelings, such as anger, isolation, and exclusion, aggressive relations (quarrelling and shouting), shame, lack of understanding, the perception of competitiveness, and guilt among the members in situations of conflict (α = 0.90) and (3) self-sufficiency in the family (8 items): assesses perceptions of the individual on the autonomy of the family, which demonstrates the relationship of trust, privacy and freedom among the members. (α = 0.78). Also, a total score is derived that can vary from 0 to 84 points (α = 0.93), in which the higher it is, the better the perception of family support.

Youth Self Report - YSR (Achenbach & Rescorla, 2001): comprised of 119 items assessing the mental health of adolescents, taking into account the competences (competence in activities, social, academic and total), and the indicators of behavioral and emotional problems from eight scales that make up three indexes: internalizing problems (anxiety/depression, isolation/depression, and somatic complaints), externalizing problems (deviant and aggressive behavior) and total (including all items, in addition to the social, thought, and attention problems). The items are answered on a three-point scale (0 = false to 2 = quite true). The data obtained can be classified into clinical (percentiles between 20 and 30 for competencies and from 70 for problems), borderline (percentiles between 30 to 35 for competencies and between 65 to 69 for problems) and normal (percentiles below 35 for competencies and from 64 for problems). The YSR is in the process of validation for the Brazilian population, but shows validity of its factorial structure (RMSEA = 0.03), indicating good adjustment (Rocha, 2012). In addition, Bordin et al. (2013) revealed that the average test-retest reliability was 0.82 and the internal consistency of the problem scales ranged from 0.67 to 0.95, considered satisfactory.

Delaware School Climate Survey - Student-DSCS-S [Bear, Blank, Chen, & Gaskins (2011), adapted and validated for Brazil by Bear et al. (2015)]: composed of 78 items arranged in four scales: school climate, school techniques, bullying and student engagement. However, only the first scale was used, which refers to the quality and character of school life, its norms, values and expectations that support the people who interact there socially, emotionally and physically (Bear, Gaskins, Pell, & Yang, 2014). It contains 29 items and six subscales that evaluate: 1) teacher-student relations (teachers are attentive to the emotional needs of students and listen to them when they have problems; α = 0.77); 2) student-student relations (quality of interactions regarding respect, affection, sympathy and cooperation between them; α = 0.81); 3) fairness of rules (degree of fairness of the rules, clarity of the consequences when broken and expectation of the students’ behavior; α = 0,84); 4) school safety (degree that the school is seen as safe by students; α = 0.89); 5) student engagement schoolwide (degree to which students perform their tasks, respect school rules and dedicate themselves to have a good school performance; α = 0.66); and 6) bullying schoolwide (degree of threats and fear of violence between students; α = 0.70). The questions are answered on a four-point scale (1 = “strongly disagree” to 4 = “strongly agree”). The interpretation is made by the mean, and the higher ones represent greater perception of the factor. The validation in Brazil indicated satisfactory qualities of the instrument, which ranged from 0.74 to 0.83 for the six subscales, and 0.86 for the total scale (Bear et al., 2015).

Ethical procedures and data collection

A first face-to-face contact was made with the management of a primary school, which belonged to the municipal network of Novo Hamburgo-RS, to enable the development of the research. This institution was selected because the first author had a professional internship experience in CAPSi, which facilitated the contact, and there was a known prevalence of cases of self-harm in students in the contemplated school, with both institutions holding systematic meetings for referral and follow-up of cases. After that, the Research Ethics Committee of the Universidade do Vale do Rio dos Sinos approved the research, for compliance with the ethical procedures in its implementation, according to resolution 510/2016 of the National Health Council (CAAE: 92844418.8.0000.5344).

The school management appointed six adolescents who self-harmed to integrate the research, which were invited to participate in individual conversations to explain the theme, objectives and instruments of the research. Of these, five adolescents showed interest in participating. They were given the free and informed consent form for their legal guardians to take knowledge of the study and authorize it. Subsequently, a time was agreed for data collection, which would take place in the premises of the school. At this first meeting the ICF signed by the guardian and the consent form, signed by the adolescent himself, were requested. The participants responded to the instruments already signaled in an individual and self-applied way. The semi-structured interview was conducted by the first author, supervised by the second. They were recorded and transcribed for analysis. The collection time was approximately 1 hour and 30 minutes.

Procedures for Data Analysis

Each case was analyzed individually and, after that, a cross-case synthesis was produced, as proposed by Yin (2015), which is applied in studies that analyze multiple cases. We considered the data of IPSF, YSR and DSCS-S, which were computed in IBM SPSS 22 software (Statistical Package for the Social Sciences), for descriptive statistical analysis. To obtain the YSR scores, their data were added to ADM (Assessment Data Manager, version 9.1), a software that includes modules to enter and analyze the data obtained by the said instruments, assigning a profile to each adolescent regarding the scores of competencies, internalizing problems, externalizing problems and total problems.

The interview, in turn, was analyzed through qualitative content analysis. The coding of the material was performed by the authors, and there was 87% agreement, obtained considering the total agreement, divided by the total agreement added to the total disagreement, multiplied by 100 (Robson, 2002).

Results

The cases described below will be presented from the categories defined based primarily on the objective of the study, namely: 1) characterization of self-harm behavior (when it began, frequency, methods used and injured body parts); 2) feelings, thoughts and behaviors associated with self-harm; 3) indicators of emotional problems and behavior; and 4) family support and school climate. The first two categories comprise the data from the semi-structured interview. Categories 3 and 4 stem from the results of YSR, IPSF and DSCS-S.

Case 1 - Ana

Ana was fifteen years old, studying in the 9th grade and lived with her mother, father, older brother and baptism godmother. Both parents worked and Ana was a young apprentice of woodworking at SENAI after school.

• 1) Characterization of self-harming behavior

Ana described that she began to self-harm when she was in the 8th grade and that it had not been for long: “from what I remember it lasted about three months!”. She emphasized: “I had no influence to initiate the behavior and I don’t remember exactly why I started it, but my ex best friend did it.” The injury was performed on the arm, with a razor blade and, it used to happen “from time to time. I think it was a couple of times a week”.

• 2) Feelings, thoughts and behaviors associated with self-harm

The adolescent reflected on when she performed self-harm and indicated: “I think it cured something, like a medicine, but I was a retard. Currently, I also think that when I did this in the past, it was like a drama, a relief.” She related the self-harming behavior to her rapidly changing mood. Ana recalled: “if I was yelled at, I would be sad, because it seemed that people did not like me, I felt excluded, especially from the group of friends.” She believed that self-harm “would relieve something, but over time I realized that it was only making things worse, because I thought that if I was sad, I would cut myself and I would be jumping with joy.” She added: “I think if I cut myself, everything will get better. Then I realized I was doing something stupid.” In addition, she considered that self-harm was related to adolescence, because she had never seen an adult self-harm, only had knowledge of cases with adolescents.

Ana said she made superficial cuts to not get too much attention. However, her mother found out that she was cutting herself and from there they started talking about it, which helped her stop the behavior. At the end of the interview, the adolescent reported a lived experience: “my friend went to sleep at my home and she began to cut herself, only she bled a lot and soiled the entire carpet in my room and I had her clean it”. Ana said she was shocked by the amount of blood and the depth of the cuts and, from that, began to reflect on self-harm, realizing the damage that the practice could cause.

• 3) Indicators of emotional and behavioral problems

The scores related to activity and total competence resulted in a normal classification, while social competence was classified as clinical, as well as the indicators of internalizing and externalizing behaviors. The total problems were also characterized as clinical. The most relevant issues that Ana described were that she cried a lot, noticed concentration difficulties, did not have a good relationship with her peers and felt inferior. In addition, Anna was nervous, anxious, and her mood quickly changed. At the end of the instrument, Ana reported: “well, my feelings are very confused, my mood changes very quickly”.

• 4) Family support and school climate

Regarding the perception of family support, Ana obtained a medium-high rating in the affective-consistent dimension, high in adaptation and low in autonomy, reaching, in the general score, a medium-high rating. These results indicate that the adolescent perceived her family as affective, close, interested and affectionate, with established rules, seeking the well-being of its members. She felt belonging to the family and did not characterize relations as aggressive, nor competitive. However, she had little autonomy to perform activities and express herself, as well as no privacy and freedom, because she did not have authorization to go out and perform the activities she liked.

Regarding the school climate, Ana pondered that the teachers and staff of the school treated the students with respect. She understood that the school rules were fair and that teachers cared and listened to their students, and students liked their teachers. For the adolescent, the students knew about the school rules, however they did not behave in the expected way, not paying attention in classes, not striving to achieve good grades and not handing over homework. She did not consider the school safe and noticed the presence of bullying, since the students did not care about each other and did not treat each other with respect.

Case 2 - Helen

Helen was fifteen years old, she studied in the 8th grade, having had a failure in the 3rd grade. She resided with her mother, who had a job as a cleaning lady, and two younger brothers. The adolescent had no current contact with her father.

• 1) Characterization of self-harming behavior

The adolescent reported that she had started self-harming when she was in 5th grade. When asked if there was any influence, she confirmed: ”I was influenced by my best friend at the time, but today I am no longer friends with her.” To hurt herself, she used sharpener and razor blades. She reported the first time she hurt herself: “I broke (the sharpener) and started cutting my arm”, but she stressed: “I don’t hurt myself anymore, it’s been a while”. She pointed out that she hurt herself mainly “on Mondays, Tuesdays, sometimes Saturdays and Sundays, but also when someone annoyed me, my father beat me, or I did it just for doing it”.

• 2) Feelings, thoughts and behaviors associated with self-harm

Helen said that with the self-harm she “ felt good because the cut relieved the pain. I also felt angry and when I did it, it calmed me down, because I was stressed and had nothing take it out on” The thoughts on the behavior were: “I just thought about cutting myself. I felt very good about it, it seemed to create relief.” She also pondered that the fact of being in adolescence had no relation to self-harm, since those who self-harm “do it just for doing it or for going through a difficult time, not because they are adolescents”.

The adolescent talked about her feelings and thoughts with her boyfriend and her mother and stated that, at the moment, she had no friends who were self-harming. She said that she stopped cutting herself due to the support of her boyfriend: “he was angry, because I was going to be all scarred and I like him so much, right? So I didn’t want to lose him because of the cuts. Mom also said it would get ugly when I wore summer clothes.” Helen narrated a relevant fact in her life: “when I stayed at home, my father was drunk and beat me. So I would go to my room and cut myself. The same thing happened when my boyfriend argued with me and did not forgive me or when my mother bought something for my brothers and not for me.”

• 3) Indicators of emotional and behavioral problems

For competence indicators, Helen scored clinical classification in activities, social and total competences. Similarly, internalizing and externalizing behaviors resulted in clinical classifications, as well as total problems. According to the answers on the instrument, Helen had no friends, besides not having a good relationship with her brothers. Other important characteristics were that few things gave her pleasure, she cried a lot and felt lonely. She felt inferior, anxious, unhappy, sad, depressed, acted without thinking and thought that peers did not like her. In addition, her mood and feelings suddenly changed.

• 4) Family support and school climate

Regarding family support, the results presented low classification in affective-consistent dimensions, adaptation and autonomy. The overall score, likewise, obtained a low rating. Thus, the results indicated that Helen perceived her family to be without rules, duties and responsibilities and with little interaction. She saw that they did not hug and had little physical contact, but provided emotional comfort. She perceived aggressive relationships and negative feelings in her family, making her feel strange and excluded. She indicated that she had privacy, could dress without restrictions, but did not feel she had autonomy to make decisions and go out freely.

Helen assessed that the teachers and staff at the school did not care about the students and did not listen to their problems, just as the students did not like their teachers. There was respect for diversity, but the school rules were not clear and fair. She indicated that the students did not behave as the school would like, did not strive for good grades, did not obey the rules and did not deliver homework. According to the adolescent, classmates were not friendly to each other, did not care about each other and did not treat each other with respect, not being safe at school. However, she did not identify bullying.

Case 3 - Julia

Julia was 14 years old and studied in the 9th grade. She lived with her mother, father and two older brothers. The parents were self-employed seamstresses and had separated, however they had resumed their relationship.

• 1) Characterization of self-harming behavior

Julia reported that she began to self-harm when she was in the 8th grade. He pointed out that: “The first time I hurt my arm and for me it was normal. Until a month ago I still did it!”. The frequency of self-injury was “almost every week, like once a week” and she used a sharpener or knife to injure herself. She had no influence to initiate the behavior but had acquaintances who self-harmed.

• 2) Feelings, thoughts and behaviors associated with self-harm

For the adolescent, self-harm was: “something that passes. The pain you feel in your arm is the same as you feel internally.” She related that the behavior was triggered by “fighting a lot with parents and siblings. We always fought!”. Her thoughts were “anger and sadness. I wanted to end that. I was saddened by the fact that I had quarreled with the family and it got to that point. With the cut it seemed that the pain inside me went away”. According to her, her intention was exclusively to hurt herself and she considered that the cuts she made were superficial. Julia associated adolescence with self-harm due to “lack of maturity because I consider that I am a person who did not present maturity. I’d cut myself, right? That’s pretty immature.”

The teen said she talked about her feelings/thoughts with her sister and that she had colleagues who self-harmed. She told that she stopped self-harming and related this to a break from quarreling with parents and siblings. Julia recalled that “parents keep clearly touching everything. They forbid things. Since mom didn’t have love from her family, she doesn’t show her feelings for us, you know? So she ends up talking without thinking and these things hurt me a lot”

• 3) Indicators of emotional and behavioral problems

Regarding the indicators of competence, Julia obtained a clinical classification in competence in activities, social and total. Similarly, internalizing and externalizing behaviors indicated clinical results, as well as total problems. Julia’s answers were relevant in the sense that few things gave her pleasure, she had difficulty concentrating, cried a lot, felt inferior and had difficulties in school.

• 4) Family support and school climate

Regarding family support, Julia obtained a low rating in affective-consistent dimensions, adaptation and autonomy, as well as in the overall score. With this, the results showed that she realized that there were no clear rules and closeness in her family. She also understood that they did not provide emotional comfort, did not like to spend time together, and did not fulfill duties and responsibilities. The adolescent identified fights permeated by negative feelings, which made her feel strange and excluded. She realized that the family allowed privacy, because she could dress the way she liked, but she did not have the freedom she would like, since she could not go out and make decisions herself.

As for the school climate, Julia understood that teachers and staff worried and listened when students had problems. She assessed that there was respect and that the school rules were clear and fair. Despite this, she indicated that the students did not know how to behave according to the expectations of the institution. She understood that most of them paid attention in class and obeyed the rules, but did not deliver homework, nor did they strive for good grades. Among the students, she identified that there was a good relationship, although they did not care about each other and did not treat each other with respect. In addition, Julia perceived threats, fear and bullying, but she perceived the school as safe.

Case 4 - Eduarda

Eduarda was 15 years old and studied in the 9th grade. She resided with her parents, who had already separated three times, when she was six, nine and ten years old. Mother and father worked as a merchant and sales promoter, respectively.

• 1) Characterization of self-harming behavior

Eduarda said that she began to self-harm in the 8th grade and that she had friends who already self-harmed. According to her “I’d hurt my arm and it was good. It seemed like a relief. Then I started cutting my leg.” I hurt myself pretty much every day, with sharpener or shaving blades, and with my nails.” She considered that “the cuts were superficial, with little scarring, although I wanted to die””

• 2) Feelings, thoughts and behaviors associated with self-harm

The adolescent reported: “I hurt myself to relieve myself, since the pain inside hurt more than the cut and also to feel free.” To her, self-harm served as a “relief, when my parents quarreled with each other and with me, and also to ease my sadness. Her thoughts were linked to death “I thought of killing myself. I was insufficient for my family. They needed someone better than me.” She also stressed that she intended to “show my mother what was happening to me”. She pondered that being in adolescence was related to self-harm, because “we are growing up. School graduation is close, it’s normal to get anxious and end up getting hurt.”

As reported by Eduarda, the mother noticed her cuts a few days before this research and they were able to talk about it. She reported that her mother was very worried and found it important that the girl underwent psychological care. After the conversation, they began to dialogue more often, including about the cuts. The teen also said she talked about her feelings/thoughts with her best friend and indicated that at the moment none of her friends were self-harming. Eduarda wanted to stop self-harm “ throwing away the objects I used and by cutting my nails. When I’m anxious, I try to look at what makes me calm.”

• 3) Indicators of emotional and behavioral problems

Regarding competence indicators, activity competence was clasified as clinical, while social and total competencies presented had classifications. Internalizing behaviors and total problems exhibited clinical classification, while externalizers presented normal classification. Eduarda mentioned that she had several friends and liked to help others, but she perceived herself with a childish behavior and had the perception that no one liked her. In addition, she had nightmares, felt anxious, guilty, unhappy, sad, depressed and shy, and realized that her mood and feelings changed quickly. Few moments gave her pleasure.

• 4) Family support and school climate

Regarding the perception of family support, Eduarda presented a medium-low rating in the affective-consistent dimensions, adaptation and autonomy, and also a medium-low rating in the general score. The adolescent perceived her family as affective, interested, affectionate and close, in which members provided emotional comfort and praised each other. She understood that there were no clear rules, but family members had specific duties and responsibilities. She believed that in her family there were no negative feelings and competitiveness towards each other, but sometimes they manifested aggressiveness, which made her feel strange, thinking that the family did not understand her. Despite this, Eduarda perceived herself with autonomy, privacy and freedom, since they let her out and she could dress according to her taste.

Regarding the school climate, Eduarda realized that teachers worried and listened to students when they went through problems, which promoted a good relationship. In addition, there was respect for diversity. She understood that the school rules and the consequences for breaking them were fair and clear. Students paid attention in classes, strove to achieve good grades,and delivered homework. For her, although the peers were friendly and cared for each other, they did not treat each other with respect, there were threats, fear and bullying. For the adolescent the school was safe, but the students did not feel safe in it.

Case 5 - Lucas

Lucas was 15 years old and was studying in the 9th grade. He lived with his father and an older brother.

• 1) Characterization of self-harming behavior

Lucas reported that he began to self-harm “when I was 12 years old. I think it lasted around two years”. The triggering factor of self-harming behavior was: “my mother had cancer and had a very hard time and I thought I was ridiculous. I saw all this happen and had nothing else to do. One month went on like this and then my mother passed away.” He injured himself “in the arms, most of the time, but also in the calves.” He stated that he was self-harming because “I didn’t have people to talk to. I myself blamed myself for this.” The frequency of self-harm was “three or four times a week. It depended on my emotional state. For example, if I was sad, angry, had nothing to do, I would cut myself. I used any sharp object, like scissors and knife, except for glass, because I was afraid to catch tetanus.”

• 2) Feelings, thoughts and behaviors associated with self-harm

Lucas’ intentions with self-harm were: “To really hurt myself, because I thought the problem was me.” The adolescent stated: “I felt good cutting myself. It was an explosion of feelings every time I cut myself. Then the ecstasy came”. He described the cuts as “shallow in the lower arm, because the pain was average, and deep in the upper arm, because it hurt much more.” He had friends who self-harmed, however he stated that self-harm was not related to adolescence, because “it is not only a adolescent who does that. I know some adults who also cut themselves.”

The adolescent claimed to have no close people to talk to about his feelings/thoughts: “I don’t trust anyone, so I keep everything to myself.” However, he said that he stopped self-harming because “I began to keep myself busy doing activities. I ride a bike, go to the gym and do boxing too. I think it helps to know how to deal with my feelings.”

• 3) Indicators of emotional and behavioral problems

The competencies in activities, social and total presented results classified as clinical. Internalizing and externalizing behaviors also obtained clinical classifications, as well as total problems. According to Lucas, he had several friends, but liked to brag, as well as lying and deceiving others. He also expressed a preference for being alone. He also indicated the occurrence of nightmares and mood and feelings swings that occurred quickly.

• 4) Family support and school climate

Regarding the perception of family support, Lucas presented a medium - low rating in the affective-consistent dimension, low in adaptation and medium-high in autonomy, resulting in a low rating in the overall score. He perceived his family as affective, close, interested, which sometimes provided him with emotional comfort. According to the adolescent, the family had problems with communication and establishing rules, but he thought that everyone’s opinion was taken into account. He saw the relations as being competitive, but not aggressive. He felt anger (without hatred and shame), perceiving himself as strange and excluded. Lucas identified freedom by being able to dress as he wanted, and privacy to be himself and do the activities he liked.

Regarding the school climate, Lucas understood that teachers and school staff care about students but did not listen to them when they had problems. In any case, he believed that the students liked their teachers and that they treated them with respect. On the other hand, the same did not occur in the relationship between employees. The adolescent perceived balance of the rules and considered them fair and clear. However, for him, the students did not know how to behave: they did not pay attention in classes, did not strive for good grades, did not obey the rules and did not deliver homework. He indicated that there was friendship and respect between them, but they did not care about each other. In any case, he did not perceive threats and bullying, but was afraid that it would occur. For Lucas, school was safe.

Integrative case analysis and discussion

As seen, it is possible to observe similarities and differences between the cases. Most of the participants were female and began to self-harm between the ages of 12 and 14, which corroborates the literature (Cedaro & Nascimento, 2013; Rodham & Hawton, 2009). It was also found that adolescents related self-harm to negative feelings, especially sadness, anger, irritation and stress (Santos & Faro, 2018). They described that the behavior was triggered when a negative mood prevailed, which decreased after cuts, a type of self-harm produced by all (Kamphuis, Ruyling, & Reijntjes, 2007), leading to feelings of relief. However, this is a maladaptive form of coping, since even if it shifts the focus of the stressful event, the sensation produced is brief and tends to reinforce the occurrence of new events (Santos & Faro, 2018).

The indicators of emotional and behavioral problems were evident and the percentiles obtained were quite high, which must be negatively impacting the lives of the adolescents, interfering in their psychosocial development (Leusin, Petrucci, & Borsa, 2018). All participants presented clinical results in relation to internalizing behaviors, which include excessive worry, withdrawal, sadness, insecurity and are usually manifested through indicators of depression, anxiety, psychosomatic complaints and social isolation (Achenbach & Rescorla, 2001). Equally, they also presented clinical indicators of externalizing behaviors, with the exception of Eduarda. Externalizing behaviors include impulsivity, aggressiveness, hostility, hyperactivity, opposition, disobedience to imposed limits, and delinquent behaviors (Achenbach & Rescorla, 2001). Particularly, the difficulty of impulse control has been associated with self-harming behaviors (Arcoverde & Soares, 2012) and requires attention.

Another aspect assessed concerns the competence indicators. These are associated with extracurricular activities, friendship relationships and physical exercise, linked to the establishment of healthy relationships, which are considered protective factors and preventive of emotional and behavioral problems. Most participants presented clinical indicators for competencies, except for Ana and Eduarda. Therefore, it is plausible to assume how much the activities in which Ana engages may be a resource for coping with the emotional and behavioral problems experienced. In the same way, Eduarda, through her social competence, may be managing to not develop externalizing problems. Lucas also explains that the physical activities he was doing helped him deal with his feelings, however, this perception is not corroborated by the data of competence in activities, social and total, which presented clinical results. It should be considered that the research was carried out after the occurrence of self-harm among adolescents and it is not known whether in the past they had similar indicators of competencies. The ratings obtained for skills and emotional and behavioural problems are shown in Table 2.

Table 2
Ratings and percentiles of the indicators of competence and emotional and behavioral problems

Cases	Activities Competence	Social Competence	Total Competence	Internalizing Problems	Externalizing Problems	Total Problems
Ana	Normal (58)	Clinical (31)	Normal (46)	Clinical (95)	Clinical (76)	Clinical (93)
Helen	Clinical (4)	Clinical (< 3)	Clinical (< 2)	Clinical (98)	Clinical (98)	Clinical (98)
Julia	Clinical (10)	Clinical (5)	Clinical (< 2)	Clinical (97)	Clinical (89)	Clinical (96)
Eduarda	Clinical (21)	Normal (73)	Normal (50)	Clinical (98)	Normal (42)	Clinical (97)
Lucas	Clinical (12)	Clinical (21)	Clinical (12)	Clinical (90)	Clinical (76)	Clinical (90)

Regarding family support, in general, adolescents presented low perception of autonomy, affectivity and adaptation, as can be seen in Table 3. However, the question of autonomy may be related to age, because adolescents who are finishing elementary school may be feeling capable, but they are not yet seen and treated as such. However, the score on the instrument showed important variations from one participant to the other. Differences were observed in relation to the perception of the family support of Ana and Lucas, which indicated some of the dimensions as more present. Both perceived the family with characteristics of affectivity, closeness and interest, in addition to no occurrence of aggressive relationships. Meanwhile, the other participants presented low and medium-low ratings in all dimensions evaluated.

Table 3
Classification of Family Support

Cases	Affective-consistent	Adaptation	Autonomy
Ana	Medium-high	High	Low
Helen	Low	Low	Low
Julia	Low	Low	Low
Eduarda	Medium-low	Medium-low	Medium-low
Lucas	Medium-low	Low	Medium-high

The relationship of adolescents with their parents is seen as protective by Tomé, Camacho, Matos and Simões (2015), which signals their quality when associated with the adolescents’ life satisfaction and health. Still, according to the authors, the worse the communication with parents, the lower the adolescents’ satisfaction with life. According to the research by Silva and Siqueira (2017), which investigated the profile of adolescents with self-harming behaviors, most participants presented the occurrence of important family conflicts. Despite the plausible association between family relationships and self-harming behaviors, only one national study on the topic was found. The research conducted by Raupp (2015) evaluated the perception of adolescent girls with self-harming behaviors and found that they evaluated their family relationships as being of low quality due to poor cohesion between members, as well as intense psychological and behavioral control by the parents.

As for the school climate, the perceptions were quite diverse. Respect for diversity was the only subscale identified as present by all participants. It considers issues related to culture, gender, sexual orientation or religiosity (Bear et al., 2011). In addition, when there is peer respect, bullying rates tend to be lower (Bear et al., 2014). However, according to the results of the research, adolescents perceived the presence of bullying in school, with the exception of Helen, and recognized the relationship with peers as negative, except Julia and Lucas, aspects that can be associated with self-harming behaviors (Cypriano & Oliveira, 2017, Santos & Faro, 2018). The teacher-student relationship, in turn, was perceived as positive among the participants, as was the clarity, expectation and balance of school rules, except for Helen. Finally, regarding school safety, there were different perceptions. Julia, Eduarda and Lucas perceived the school as safe, but Ana and Helen did not, relating this fact to the behavior of their peers. In addition, Julia and Eduarda noticed the occurrence of student engagement, while Ana, Helen and Lucas did not. Helen was the only participant who said that bullying is not a problem at her school.

In general, a positive school climate is often associated with low levels of risk behaviors. On the other hand, the perception of a negative school climate contributes to less pleasure in carrying out curricular activities, little inventiveness, alienation, self-indulgence and frustration (Klein, Cornell, & Konold, 2012). In any case, few studies in Brazil have been found relating self-injury to the experience in school, which indicates that it is an area that needs to be explored further (Silva & Siqueira, 2017).

Finally, it should be noted that Eduarda stood out among the cases analyzed because she was the only one who remained self-harming, even expressing the will to die. Even if she understood that self-harm hurts her, she said she was not able to cease the behavior. As seen above, despite having family support, social competence and positive school climate, such things were not sufficient to interrupt the self-harming behavior, possibly due to the intensity of her internalizing difficulties. As a result, the adolescent, who was already being monitored at CAPSi, was referred to perform psychotherapy in the teaching-clinic at the higher education institution located in the municipality.

Together, the data allows us to see how much, for the adolescents that participated in this study, self-harming behavior is associated with emotional difficulties, both internalizing and externalizing, and the lack of skills that would make it possible to deal with them. They also indicate difficulties in relation to family support, especially regarding affectivity and autonomy, which is a fundamental exercise in adolescence. These issues seem to be reflected in the school, particularly in the quality of peer relations and student engagement.

Final considerations

Self-harm is a problem with clinical and social repercussions, which prevails in adolescents, mainly because it is considered a period of important changes. The data showed that self-harming behaviors present a common sense among those who had them, as a way to relieve and enable mood regulation, indicating that they were experiencing difficulties. Thus, a better understanding of self-harm is necessary, in addition to paying attention to the contexts in which adolescents are inserted.

The results made it possible to verify that self-harming behaviors occur and are experienced in a similar way to what international researches have pointed out (Hawton, Saunders, & O’connor, 2012; Kamphuis et al., 2007). In addition, it presented a qualitative analysis, considering that most of the studies on self-harm are quantitative and seek to determine the prevalence of these behaviors, as well as their association with other variables (Borges, 2012).

The data suggest the need for a more careful look at self-harm among adolescents. In general, this behavior was related to low perception of family support and lower development of competences, as well as with a higher incidence of clinical indicators of emotional and behavioral problems and greater fragility in peer relations, such as having a friend who self-harmed, in addition to school engagement. Therefore, it is expected that the present study collaborates with professionals, mainly from the health and education areas, searching for greater and contextualized understanding, since they interact with these adolescents and, most of the time, experience such situations as challenging. We suggest that new researches be carried out in the Brazilian territory, especially in clinical contexts, with goals of preventing and treatment of this complex phenomenon which is currently quite present, and which involves the understanding of variables of various orders, individual, relational and contextual.

Acknowledgments:

Paper derived from the undergraduate thesis by Luiza Selbach, carried out under the supervision of Angela Helena Marin, presented to the Psychology Course at the Universidade do Vale do Rio dos Sinos, São Leopoldo-RS.

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Publication Dates

• Publication in this collection
  11 Mar 2022
• Date of issue
  Oct-Dec 2021

History

• Received
  24 Sept 2019
• Reviewed
  19 Oct 2020
• Accepted
  26 Oct 2020