Non-suicidal self-injury (NSSI) is a type of deviance that refers to the intentional damage to one’s own bodily tissue without suicidal intent and for reasons that are not regarded as socially acceptable. NSSI can take the form of cutting, burning, biting, scratching, and interfering with wound healing. This paper will examine NSSI by focusing on the most prevalent form: cutting. The author will examine the current academic literature on the topic, and expose several of the gaps and shortcomings of contemporary NSSI research. With limited research on NSSI primarily existing in the fields of psychology and nursing, a call to action is given to social scientists in other disciplines to assist in further exploring cutting & self-injury. Brief explanations are provided of how future research and modest policy reform can a) help achieve a more well-rounded understanding of NSSI, and b) enable those who self-injure to receive appropriate care and treatment.
Non-suicidal self-injury (NSSI), also known as deliberate self-harm, superficial-moderate self-mutilation, self-wounding, and parasuicide (Klonsky, 2008) refers to the intentional and deliberate damaging of one’s own bodily tissue, typically resulting in the perception and sensation of pain. Unlike culturally relative forms of self-inflicted pain like tattoos, body piercing, or corrective & cosmetic surgeries, NSSI refers to self-harm that is conducted for reasons that are not deemed as socially acceptable.
NSSI can take the form of cutting, burning, scalding, inflicting blows or banging on the body, scratching, picking, biting, scraping, inserting sharp objects under the skin, interfering with wounds, tying ligatures, pulling out hair, scrubbing away the surface of the skin, or ingesting sharp objects or harmful substances (Inckle, 2010). While the most common form of NSSI is cutting, those who engage in self-injury typically employ multiple methods throughout their lifetime (Klonsky, 2008). While this paper primarily draws data and research on cutting, its application and relevance directly extend to all forms of NSSI.
Relevant Fields of Application
Cutting and other forms of NSSI concern a diverse range of academic and professional disciplines. While the vast majority of academic literature regarding NSSI belongs to the fields of nursing and psychology, the findings and importance of understanding NSSI extend to various other areas. Those in the field of psychology attempt to understand the individual-level corollary and causal factors that lead to NSSI. Nursing and health provider fields incorporate many elements of psychology, but place a significant emphasis on the treatment and patient interactions with nurses and medical practitioners. Nursing and psychology are often intimately tied with the biological sciences, particularly neuroscience. Limited studies have been conducted on how adolescents who self-injure perceive pain, and how their pain threshold is physiologically different from those who do not engage in self-injury (Hooley, Ho, Slater & Lockshin, 2010). Bridging the gap between neuroscience and psychology would give a more complete understanding of the psychology and physiology behind this phenomenon.
Due to the robust association between self injury, psychopathology, and suicide (Klonsky, 2008), research on this topic can create points of departure for sociological inquiry. As the paper presents current literature on the topic, one will be able to recognize the relevance and application to sociology. NSSI and cutting are associated with subcultures, marginalized groups, and a lack of proper emotional outlets for certain groups of people that present spark many sociological questions.
The field of criminology also benefits from further research on NSSI, as the prevalence of individuals with mental disorders is disproportionately higher among incarcerated populations compared to the general population. Correctional facilities, especially juvenile detention centers, would significantly benefit from having a staff that is well educated in the topic of adolescent self injury, so that the most appropriate response can be given when self-injury occurs among detained individuals.
Aspects of Deviance & Control
While it is impossible to categorize any behavior as objectively deviant, NSSI is a form of behavior that is by and large unaccepted and frowned upon by contemporary society. The aforementioned presentation of how NSSI relates to various areas of study and expertise illustrates how NSSI is both a question of establishing how a particular form of deviance arises (psychology), and how to properly treat, control, and minimize it (nursing & psychiatry). Fortunately, the current research on NSSI provides insight on cutting for the sake of understanding the behavior, as well as information and recommendations for how to best treat, control, and respond to individuals who engage in the behavior. In recognizing that NSSI is a phenomenon that has far-reaching applications for a variety of academic and professional fields, we can now survey the limited data that exist on the topic.
Research on NSSI has been published in the following academic journals:
- Advanced Emergency Nursing Journal
- Creative Nursing
- Developmental Psychology
- Issues in Mental Health Nursing
- Mental Health Practice
- Personality Disorders: Theory, Research, and Treatment
- Psychiatry Research
- Psychological Medicine
- Social Work Research
Using the published research from these nine journals, we can gain a comprehensive understanding of cutting and NSSI in general. As one may be able to notice from the list of academic journals, the vast majority are evenly split between the fields of nursing/medical practice, and psychology (four articles each), with the addition of one article that is grounded in the practice and theoretical framework of social work. The conclusions and recommendations of these articles, while very insightful in introducing NSSI and providing a basic examination of the topic, leave much to be desired.
Current Status of the Issue
The existing academic literature on cutting shows that the demographic most likely to engage in this form and other forms of NSSI are adolescent females. The onset age of any form of self injury is averaged at 16 years of age, with range of anywhere between 10 and 24 years old. In terms of lifetime prevalence, the literature shows a variation of anywhere between 4% and 23% of adolescents engaging in this form of deviance at least once in their lifetime. One study cuts straight to the point and asserts that “there are currently no reliable estimates of the prevalence of self-injury among the general US adolescent population” (Whitlock, Powers & Eckenrode, 2006).
There is growing recognition of the multifaceted functions of self injury and cutting as a means of coping with and expressing traumatic issues and experiences (Inckle, 2010). The qualitative data in the studies illustrate how “cutting is a way of releasing bottled up emotions, stress, anger, feelings of isolation and abandonment, frustration, anxiety, and as a way to relive pain” (Lesniak, 2010). Apart from the desire to alleviate negative emotions, self-injury also serves as a method to punish oneself, communicate with others, get attention, or to escape a situation or responsibility (Klonsky, 2011). While there is a tendency for the nurse practitioners to view cutters as attention seekers (Reece, 2005), the primary motive behind cutting and other forms of NSSI is to alleviate internal tension and personal turmoil, typically when there is no alternative conventional method of doing so.
Findings also show that cutting is associated with individuals who have experienced intense emotional trauma or an emotionally- difficult life circumstance. The lack of a conventional outlet in which to vent negative emotions (like a caring adult who would be able to listen and give positive advice) is a significant factor in contributing to the likelihood of adolescent self-injury (Walls, Laser, Nickels & Wisneki, 2010). Having a death in the family at an early age, experiencing or witnessing domestic violence, low self-esteem, negative perceptions of body image, lack of peer groups or social networks, and lack of familial bonds to others within the household have been labeled as factors that create these negative emotions that cutters seek to relieve.
In terms of viewing cutters and those who engage in NSSI as a marginalized group with shared characteristics, some of the literature did allude to the subcultures or micro-communities that form among those that practice cutting. One article presented an academically rigorous picture of how cutters can come together in online communities to provide much needed support for each other. The functional value of these online message boards and chat-rooms is that online communication may encourage more truthful exchanges; many people report a greater willingness to share thoughts and feelings online than they would in face-to-face situations (Whitlock, Powers & Eckenrode, 2006). This form of communication can be especially advantageous for shy, socially anxious, or marginalized youth, allowing them to exercise their social skills without the perceived risks associated with face-to-face interactions.
With more than 80% of American youth (ages 12 to 17) using the internet and nearly half of them logging on daily, this understudied phenomenon and how it functions in online communities deserves increased attention by those interested in studying NSSI.
Because self-injury is typically a private, secretive behavior that is difficult to estimate in terms of prevalence and demographic characteristics of those who engage in it, the internet provides a unique opportunity for academics to study cutters and those who self-injure outside of a clinical setting, which is where a lot of the academic research takes place.
The articles that are more concerned with nursing and medical treatment of NSSI focus on how medical health practitioners are uneducated and ill-prepared to deal with the needs and perspectives of those who self injure. Often miscategorized as suicide risks, some medical professionals improperly subject self-injurers to inappropriate, often punitively-perceived methods of “treatment”, like being placed on suicide watch or referred to a mental health institution (Reece, 2005). While nurses are federally mandated to report suspected abuse or neglect of an adolescent to child-protective authorities, they are not properly trained in how to recognize the needs of a self-injurer and how to properly care for them when they need treatment for their wounds (Lesniak, 2010).
The perspective taken by current research in the nursing and medical practitioner fields generally emphasize a more individualized, compassionate, destigmatizing approach to handling self-injurers so as to prevent them from feeling like outcasts or inconveniences for the nurses and medical facilities that they visit. One article acknowledges that while some medical practitioners feel ambivalent towards this patient group, they must overcome these feelings through continuing education of nurses and empathetic clinical supervision in order to care for them effectively (Benbow & Deacon, 2011), and go on to suggest ways of educating the cutters themselves on how to properly care for their wounds. This exemplifies a harm-reduction approach, assuming that self injury will remain a constant in society and that a positive method of addressing it would be to educate those who self-injure on how to properly care for their wounds and avoid unnecessary complications like infection, permanent scarring, or delayed healing.
Lastly, a valuable feature of the academic articles that were analyzed is that many of them incorporate the view, opinion, and experience of the individual cutter. Qualitative data in the form of extensive interviews allows for researchers to hear directly from the people who engage in the behavior, unlike other forms of deviance where the population that commits the behavior under study is difficult to track down or interview.
Gaps within Current Research
While the nine articles from various journals provide an insightful slice of information regarding cutting and NSSI, there are many gaps in the current research. Notice that while most of the research has been published recently, none of the articles explore to any great extent the different variables and demographic characteristics of cutters and those who engage in NSSI. No study of the American population can be complete without accounting for the diversity of demographic characteristics that exist in the United States. Age and gender are analyzed in most of the studies, but there is no breakdown or analysis of race, ethnicity, or socio-economic status. This leads one to be unable to neither confirm nor deny that cutting and NSSI is predominately“middle to upper-class white girl problem”, as it is anecdotally stereotyped to be. No study explicitly addressed whether individuals “age out” of NSSI in the way that people typically “age out” of crime. Age ranges were only provided in some studies because that was the maximum age range of the clinical sample.
Additionally, there is no explicit reference or allusion to the correlation that might exist between those who engage or identify with cutting and self-injury, and subcultures like the goth, death metal, or grunge subculture. While research has found that cutters tend to be socially isolated and lacking in social support networks, they do not exist in a vacuum, completely disconnected from social groups or subcultures that they may identify with. The goth subculture, which explicitly conveys messages of morbidity and self-inflicted suffering, is large enough that there are relatively “mainstream” stores like Hot Topic that one can find in major shopping malls that cater to the fashion needs of these individuals. Death metal music has a significant following of its own, and a lyrical content analysis would illustrate how the lyrics reference NSSI and may contribute to a subculture that endorses it. The fact that there is little to no mention of the social groups and group-level characteristics of cutters leaves a sociological gap in current academic literature.
In the nursing articles, there is little to no reference for what specific types of scenarios justify one coming into a hospital for treatment, which may leave one with the assumption that ‘it must have been that they cut their wrists too deep”. The articles spend ample time discussing the interactions between nurses and patients, and the expectations and biases of each, but none of articles specify what type of self-inflicted injury “crosses the line” and lands a cutter in the emergency room. This is important because if cutting your wrists too deeply to the point where loss of blood is significant and loss of life may be likely, then researchers who base their studies on clinical samples are largely underestimating the prevalence of NSSI and the forms in which it takes place in private residence. This is why the study concerning the online chatrooms and message boards is valuable; it allows for researchers to capture what would go completely unnoticed since many of those individuals who post about their NSSI activity wouldn’t necessarily ever end up in the hospital or treatment center.
Another gap in the research is the lack of application of NSSI to prison and juvenile detention facilities. Attempted and successful suicide among prison populations have been well documented within the field of criminology, but non-suicidal self-injury among prisoners who may be emotionally unstable is completely ignored in all of the aforementioned studies.
Only one study mentioned physiological differences between those that cut and self-injure and those that don’t. Most of the articles explained the factors that were associated with NSSI, but none of them explicitly specified factors that would lead one individual to choose NSSI over a more conventional method of emotional release like mediation, exercise, creative writing, outward physical aggression or violence. There are plenty of people who have experience negative emotions during adolescence, or may have been raised in extremely challenging and emotionally-provocative circumstances, but do not resort to cutting or NSSI. What makes the differences? None of the studies addressed this question.
Uniformity of Findings
While the several gaps in the existing academic literature on cutting and NSSI might lead one to believe that the topic is severely lacking in empirical analysis, one can say with confidence that the 9 articles actually provide a very comprehensive, but concentrated, view of the topic. Many of the gaps in research could be more readily addressed by sociologists, social psychologists, biologists, neuroscientists, and psychologists that seek to study the issue from a different angle. The topic of NSSI and cutting is certainly in need of further attention and research, but the existing data and studies do serve as a valid preliminary analyses and explanation of the issue.
In terms of whether the findings of the 9 studies are uniform or widely varied, they are by and large consistent in their a) theoretical frameworks, b) methodology, c) conclusions and d) policy recommendations. Most of the articles provide an unbiased description of how NSSI has a functional value for those that practice it. All of the articles provide an explanation of how their study has limitations and methodological concerns. The authors arrive at conclusions that are compatible with one another, and the nursing articles all agree with the assertion that medical health practitioners need to be better educated on self injury and provide more compassion and understanding to adolescents who need emotional help and attention. The ideal way to describe how these articles fit together is to say that each of the 9 articles serve as complimentary rods and pillars that together create the framework and foundation that future research can fill in and cement.
Methodological Flaws of Existing Research
The most obvious methodological flaw of the existing research is the reliance on samples that are unrepresentative of a larger population. Either the sample sizes were too small (one of them being n=4), or drawn from a clinical population where the characteristics of the sampled individuals cannot be attributed to any larger group. Virtually every article suggests that the type of research contained within the article is preliminary and serves as a starting point for future research, although the articles with quantitative data do provide more generalizable conclusions.
Connection to Other Forms of Deviance
In terms of defining deviance down, a concept coined by Daniel P. Moynihan, some of the nursing articles presented cutting and NSSI as a phenomena that is relatively fixed; they certainly do not address it from the perspective of NSSI being something that can be completely eliminated. Benbow and Deacon explicitly state the importance of educating self-injurers on how to effectively look after their wounds, without directly mentioning how society could address the root causes that make people self-inure in the first place. This type of micro-normalization among certain medical health professionals is a form of defining deviance down, which is a concept that describes a type of normalization that occurs when deviant behavior becomes increasingly acknowledged and accepted as more “commonplace” and “here to stay”. The medical community is almost exclusively focused on controlling this type of deviance, not eliminating it, which is a concept that Moynihan emphasizes in his “Defining Deviance Down” article.
NSSI and cutting are forms of deviance that the articles present as a phenomenon that neatly fits Edwin Sutherland’s differential association theory. In this theory, an individual associates with deviant others, which increases the likelihood that the individual (or actor) learns values, motives, techniques, justifications that are conducive to norm violation, which in turns manifests itself into deviant behavior. The articles regarding internet message boards and the phenomenon of social contagion support the notion that informal and marginalized groups form subcultures that may teach potential youth about how to deal with negative emotions in a self-injurious way. Adolescents and adults who are exposed to a cutting/NSSI subculture or who are in a facility where cutting is frequent (as described in the depiction of social contagion in Whitlock, Powers & Eckenrode’s article) are more likely to engage in cutting.
The article by Holt, Blevins & Burkert, Considering the Pedophile Subculture Online draws close parallels to the Whitlock, Powers & Eckenrode, 2006 article regarding NSSI online communities. Both articles explore understudied populations and how their online interactions provide a sociological and psychological window in which to get an insightful glance at the customs, practices, and preferences of a marginalized community. The authors of both articles acknowledge how difficult it is to study these marginalized subcultures, and they all employed similar methods for coding and interpreting the types of interactions that they observed online. Comparing these two articles implies that future research on NSSI could be based on the orientations of producing or contributing to micro-level theories.
John Kitsuse’s Model of labeling theory provides a theoretical framework for how these group interactions and subcultures can come into place. An audience may interpret an individual as socially awkward, unwanted, or as an outcast for being introverted or being associated with some image like being “emo”, “goth”, a “loner”, etc. This individual, who may or may not engage in NSSI, is categorized and treated as a misunderstood individual who is neurotic, overly emotional, and attention seeking. When this labeled deviance or mild and sporadic forms of NSSI cannot be suppressed, over time this individual becomes increasingly isolated from normal others, develops a deviant identity and self-image, and an amplification of deviant behavior takes place. These individuals would then have the inclination to associate with others that have similar experiences, and this is when a subculture starts to emerge. Additionally, the current treatment that cutters receive when they enter medical and treatment facilities contributes to a negative label or low self-worth, shame and embarrassment (Reece, 2005).
Lastly, NSSI is an example of the route that a macro-level theory can take in explaining a form of deviance. None of the articles call into question the socio-cultural composition of American society, or raise questions about the possibility that NSSI is not a ubiquitous feature of human civilization, but rather something is contingent on a certain type of culture or societal system of organization. Sanday stresses the importance of socio-cultural context for the occurrence and interpretation of deviant behavior. While none of the articles raised macro-level questions about NSSI, we still ought to inquire from this perspective. Why does NSSI exist in such high prevalence in Western society but not in other cultures and societies? What is going on in our societal structures and institutions that is contributing to the prevalence of NSSI? How are institutions like the family, schools, social groups, and methods of communication arranged in such a way that gives rise to NSSI? Sanday’s article reminds us of the importance of incorporating macro-level orientations to supplement some of the micro-level orientations that we currently use to account for deviant behavior.
Functional Value vs. Addressing Root Causes
While most of the articles clearly articulate the functional value of NSSI, few of them aspire to understand and tackle the root causes. This academic orientation regarding NSSI represents the opposing perspectives of functionalism versus conflict theory: NSSI can have a valued function, but be born out of conflict-relationships regarding power, control, and affect regulation (Klonsky, 2008). The nursing community is primarily concerned with properly treating and handling cutters and other self-injurers. The literature from psychology gets closer to understanding the root causes and correlations of behavior, but much more research is needed to investigate what makes the difference that leads an individual to self-harm versus choosing another form of emotional expression.
Conclusion: Call to Action for Academics & Health Professionals
As the authors of the existing literature explicitly recommend, additional research is needed, particularly in the areas mentioned in the “gaps of existing literature”. Additional quantitative and qualitative data need to be gathered on the various facets of NSSI in order to gain a deeper understanding of how NSSI develops and functions among various societal groups.
Nurse and Healthcare Field Orientations
To better understand cutters and those who engage in forms of NSSI, there needs to be a transition from treating symptoms and managing self-injurers to understanding the factors that lead people to engage in such behavior. Some may argue that it is beyond the purview of a nurse’s occupation to address root causes of; we don’t necessarily expect nurses to focus on the cultural and societal factors that lead to other types of mental illnesses or detrimental behaviors. But this does fall on the responsibility and job description of the social scientist. As mentioned earlier, the gaps in the current academic literature on cutting and NSSI present inviting opportunities for social scientists to plug in the gaps that leave many sociological questions unaccounted for.
Nevertheless, a harm reduction approach that doesn’t stigmatize or give a feeling of punishment and contempt is needed among nurses and health practitioners so that adolescents who self-injure can feel better understood and less like “undesirables”. They do not need to be treated like delusional, suicide-prone attention seekers but rather as people who have no other outlet in which to vent very personally distressing emotion (Reece, 2005). Modest policy reform in the areas of nurse education and training will allow for health care providers to be better prepared to deal with these marginalized adolescents. With cutting being the most prevalent form of non-suicidal self injury, paired with the fact that NSSI practitioners generally employ multiple methods of self injury, educating nurses on how to properly approach cutters and self-injurers will result in a lesser degree of stigmatization and shame that patients currently experience. The increasing number of stories in the mainstream media, as well as the growing number of anecdotal reports by physicians, therapists, school counselors and social workers, suggests that NSSI may be the next teen disorder (Whitlock, Powers & Eckenrode, 2006). With an estimated 1 out of 10 adolescents engaging in some form of NSSI, a call for further research and professional attention is certainly justified to ensure that adolescents and youth issues are addressed in the most competent manner possible.
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