Motivation and emotion/Book/2016/Self-harm motivation in adolescence

What is self-harm?
Self-harm, also referred to as self-injury, is deliberate and voluntary behaviour which causes significant non-fatal harm to the individual (Moran et al., 2012), such as cutting or burning the skin, or ingesting toxic substances. While a considerable body of research has examined self-harm behaviours in adolescents, the results are difficult to reconcile as a whole, as sample populations are chosen to represent one of two subdivisions of the behaviour, that is, self-harm occurring in adolescents with suicidal intent, and those without suicidal intent (Madge et al., 2008).

Self-harm: A modern issue?
Self-harm has become an increasingly significant issue in modern times, with the prevalence of such behaviours reported amongst adolescents increasing dramatically in recent years (Muehlenkamp et al., 2012). This is a significant cause for concern as the majority of self-harm incidents are hidden and studies have shown that only approximately 12% of adolescents committing the behaviours present for medical treatment of their injuries (Hawton et al., 2002.) Increasing prevalence of self-harm in adolescents is also significant because the behaviours, both with and without conscious suicidal intent has been consistently found to have a strong association with increased suicidality, with studies reporting the risk of suicide to be up to 100 times higher among self-harm patients (Owens et al., 2002).

Previous Research
While a significant body of literature addresses the issue of self-harm in adolescents, the generalisability of previous research is widely regarded as insufficient as not only do studies differ in their definition of self-harm, but the majority of studies have been conducted using clinical samples (Hawton et al, 2002), and therefore results cannot be generalised beyond the psychiatric populations in which they were conducted.

Difficulties in assessment
The characteristics of adolescent self-harm behaviours have proven difficult to assess due to the often secretive nature of the behaviours and the tendency for the majority of self-harm patients not to seek medical treatment for their injuries (Hawton et al., 2002). In recognition of this limitation of previous research, more recent studies have moved away from the emphasis on samples undergoing clinical psychiatric care. A number of significant recent studies have utilised self-report questionnaires, administered to large samples of adolescents in schools, in an attempt to assess self-harm in the general population (Madge et al., 2008).

Sex differences
Numerous studies have found consistent differences between the sexes in regard to both the frequency of adolescent self-harm and the types of injury caused. Self-harm has been found to be up to twice as common in adolescent girls (Madge et al., 2008). One explanation for this sex difference is that young girls are more likely than boys to internalise negative experiences, which are then expressed through harmful behaviours (Laye-Gindhu & Schonert-Riechl, 2005). Other theories of self-harm suggest that sex differences are due to differences in motivate between boys and girls; with literature suggesting that girls utilise such behaviours as a coping strategy (Laye-Gindhu & Schonert-Riechl, 2005), whereas boys are more likely to commit such behaviours as an expression of suicidal intent.

Demographic self-harm variations
Other variables which have been found to be significant predictors of self-harm in adolescents include sexual orientation and cultural differences. Concerns regarding sexual orientation have been found to be a strong predictor of self-harm, as LGBTI adolescent are at greater risk of engaging in self-harm behaviours (Madge, et al., 2011). One possible explanation for this is associated bullying and feelings of alienation associated with exploring sexual orientation during adolescence. Differences in self-harm behaviour can also be attributed to cultural differences, with studies conducted in England finding that adolescents from Asian backgrounds where less likely to engage in self harm that Caucasians (Hawton et al., 2002).

Self-harm progression
The majority of patients who self-harm do so for the first time during adolescence (Muehlenkamp et al., 2012). Acts of self-harm usually occur impulsively, with the majority of incidents occurring within an hour of the decision to do so (Madge et al., 2008). As most adolescents engaging in self-harm do not present for medical treatment, the behaviours can be difficult to treat. If left unaddressed, self-harming behaviours can become habitual. However, the literature is not conclusive in regard to the duration of self-harm behaviours. Some studies have shown that approximately one in six patients who do not receive treatment will repeat self-harming within the next year, and are likely to develop a high risk of suicide (Owens et al., 2002). However, in contrast to this, other researchers has described adolescent self-harm as ‘transient’, suggesting that where the behaviour is not indicative of any underlying psychological problems, it tends to quickly resolve (Hawton et al., 2002).

Differences in Method
Adolescents engaging in self-harming behaviours most often utilise one of three main methods to produce injuries. These are the cutting or burning of the skin, or the ingestion of toxic substances. Deliberate self-harm by poising, while less common than the other methods of injury provided, tends to be indicative of more serious underlying problems and high suicide risk, as research has found self-poisoners to be less impulsive in their decision to self-harm (Scoliers et al., 2008). One reason suggested for this difference is that overdoses require greater planning. Self-poisoners also make up the majority of hospital admissions related to self-harm, whereas very few patients present with deliberate cutting and burning of the skin (Hawton et al., 2002).

Triggering events
Previous research has found strong support for the concept of self-harm as a response to a number of adverse life events and experiences. A significant body of research has found stressful life events to be a strongly associated with adolescent self-harm, including physical and sexual abuse, trouble with law enforcement and experiencing the suicide or self-harm of another person (Madge et al., 2011). Research has also found strong positive correlations between deliberate self-harm and deviant behaviour in adolescents, such as the consumption of cigarettes, alcohol and drugs (Hawton et al., 2002). Research has also demonstrated associations between adolescent self-harm and poor interpersonal experiences, including bullying, aversive familial relationships, declining romantic relationships and friendships, and fear of repercussion from poor academic performance (Hawton et al., 2005).

Association with other disorders
Adolescent self-harm is often regarded as an expression of low self-esteem and anxiety, with studies finding that, for many patients, self-harm results from psychiatric difficulties (Muehlenkamp et al., 2012). Further investigations into this association have found that psychological characteristics and psychological and psychiatric disorders are often the root cause of deliberate self-harm (Madge et al., 2011). Individuals who suffer from depression and anxiety disorders are considered a particularly high risk for self-harm (Laye-Gindhu & Schonert-Riechl, 2005). Research has also supported an association between self-harm and psychopathology, resulting from patients report of increased levels of anger and hostility (Laye-Gindhu & Schonert-Riechl, 2005).

Plea Motivation
The majority of literature addressing adolescent self-harm consistently supports a two dimensional motivational model of self-harm, similar to that used in studies of suicide motivation (Scoliers et al., 2008). Such research suggests that self-harm occurs as a response to a situation, which is motivated either as a cry of pain or a cry for help (Scoliers et al., 2008). Adolescents most commonly report engaging in self-harm as a cry of pain, and are motivated by a desire to achieve feelings of relief or to express a wish to die (Madge et al., 2008). According to suicide research, people will engage in a cry of pain only when they feel that their situation has defeated them, and they cannot escape nor be rescue from their circumstances. Less frequently, adolescents are motivated to engage in self-injury as a cry for help. Also considered to be an attention seeking motivation in some studies, adolescents who engage in self-harm as a cry for help report motivations concerning their relationships, such as "to see if they really loved me" and "to frighten someone for treating me badly" (Scoliers et al., 2008).

Coping Mechanism
Other theories of self-harm suggest that the injury is utilised a coping mechanism and is therefore motivated by a desire to reduce feelings of anxiety and negative affect (Laye-Gindhu & Schonert-Riechl, 2005). While models of self-harm as a coping mechanism have been examined mainly in clinical samples in relation to psychiatric disorders (Laye-Gindhu & Schonert-Riechl, 2005), the affect regulation model has been more widely examined in the general population. A strong body of research has demonstrated that the majority of adolescents report negative affect preceding most episodes of self-injury, and positive affect and relief as experienced after incidents of self-harm (Moran et al., 2012). The use of self-harm for affect regulation is particularly concerning as the feelings of relief achieved may act as a positive reinforcer, increasing the likelihood of repeated incidents.

Modelling
A modelling effect of self-harm in adolescents has been considered, similar to the contagion effects of adolescent suicide (Hawton et al., 2002). The concept of modelling soft-harm is a relatively new concept, suggesting that increasing influence of the internet and social media may have some influence on the increasing rates of adolescent self-harm (Hawton et al., 2012). This theory suggests that the increasing role of online platforms in adolescent social life has increased their access to the experiences of self-harm and suicide of others, which have been shown to have a strong association with both the frequency and severity of self-harm (Madge et al., 2011).

Types of therapy
Treating not just the injuries themselves, but the motivation responsible for self-harm in adolescents is important for preventing more frequent and severe self-harm and even suicide. The most appropriate and effective type of therapy will depend on the motivation of the individual.

Treating underlying disorders
In cases where the self-harming behaviour results from an underlying psychological or psychiatric disorder, it is important to address the disorder directly, in order to effectively reduce self-harm and any other symptoms that may be present. Inpatient psychiatric treatment has been found to be effective for the adolescents suffering from severe depression or psychotic disorders, particularly when there is a high risk of suicide (Hawton et al., 2005). For adolescents suffering from depression and other mood disorders, cognitive behavioural therapy has found to be effective in reducing self-harm behaviours as well as improving the overall disorder (Hawton et al., 2005). Similarly, some studies have found the use of antidepressants to be effective in decreasing negative affect in adolescents, and thereby decreasing affect regulation motivation for self-harming behaviours (Hawton et al., 2005).

Targeted interpersonal and social treatments
Where the adolescents self-harm motivation stems from interpersonal relationships and social difficulties such as bullying, a variety of group therapies and problem solving strategies have been shown to be effective in providing the patient with healthy strategies and non-violent outlets for reducing negative affect (Hawton et al., 2005). In circumstances where the patient is experiencing significantly aversive home circumstances or unhealthy familial relationships, it may be necessary to temporarily remove the adolescent to alternative accommodation in order to allow for a full recovery.

Conclusion
What is self-harm?
 * Self-harm is a deliberate and voluntary behaviour which causes significant non-fatal harm to the individual.
 * Less than 15% of individuals who self-harm seek medical treatment.
 * The prevalence of self-harm in adolescents has been dramatically increasing in recent years.

Prevalence
 * Self-harm behaviours are approximately twice as common female than in male adolescents.
 * Adolescents who are members of the LGBTI community are at an increased risk of self-harming and differences has been found between cultures in regard to prevalence.
 * The majority of first incidents of self-harm occur impulsively during adolescence.
 * If left untreated, adolescent self-harm can become a lifetime habit associated with dramatically increased risk of suicide.

Characteristics
 * The most common method of self-harm are cutting or burning of the skin and self-poisoning.
 * Self-harm by poisoning tends to be more serious and can be indicative of high suicide risk and underlying psychological disturbances.
 * Traumatic life events such as physical and sexual abuse and experiencing the self-harm of suicide of another person are risk factors for self-harm in adolescents.
 * Poor relationships and social difficulties are also associate with self-harm in teenagers.
 * Adolescent self-harm often results from psychological conditions such as anxiety, depression and low self-esteem, and is frequently reported to occur during the experience of negative affect.

Motivation
 * The two dimensional model of self-harm suggest two motivations, a cry of pain and a cry for help.
 * Self-harm may be employed as a coping mechanism in response to negative affect and overwhelming feelings of anxiety.
 * The contagion model of adolescent suicide may be applied to self-harm suggesting that the behaviour are the result of modelling.

Treatment
 * It is important to address any underlying psychological disorders which may be motivating the self-harm.
 * For adolescents experiencing depression and anxiety, cognitive behavioural therapy and antidepressant medication may be effective.
 * Where the behaviour is motivated by interpersonal difficulties, group therapies targeting the source of problems and teaching problem solving strategies have been effective.

Revision
Fill in the blanks
 * 1) The most common method of self-harm used by adolescents is ________.
 * 2) Adolescents who self-harm has a _______ risk of committing suicide.
 * 3) Self-poisoning is less common than other methods of self-harm because ________.
 * 4) In the two dimensional model of self-harm, the two key motivations are a cry of ____ and a cry for ____.
 * 5) The modelling theory of self-harm has become increasingly significant in recent years because of ________________.

Answers: fill in the blanks


 * 1) Cutting the skin
 * 2) Increased/greater
 * 3) Overdoses require greater planning and are therefore less impulsive
 * 4) Pain, Help
 * 5) Increased use of the internet and social networks

Multiple choice


 * 1) Self-harm is a ______ behaviour.
 * 2) Deliberate
 * 3) Accidental
 * 4) Fatal
 * 5) The majority of adolescents who self-harm seek medical treatment.
 * 6) True
 * 7) False
 * 8) Females are more likely to engage in self-harm than males.
 * 9) True
 * 10) False
 * 11) Which of the following are associated with increased self-harming behaviours?
 * 12) Anxiety
 * 13) Depression
 * 14) Low self-esteem
 * 15) All of the above
 * 16) It is important to treat any underlying psychological disorders to prevent future self-harm.
 * 17) True
 * 18) False

Answers: multiple choice
 * A
 * B
 * A
 * D
 * A