Self-Harm

By Asst/P Jacqueline Lee Tilley
Psychology and Child & Human Development Academic Group, NIE, NTU
Published: 16 September 2022

What do we know about self-harm amongst Singapore's students?

Self-harm behaviors refer to a range of behaviors in which a person deliberately causes harm or injury to themselves, with or without suicidal intent (Nock et al., 2006; Uh et al., 2021). Such behaviors include cutting, hitting, burning, self-biting or scratching skin, pulling hair, over-dosing or self-poisoning, and deliberate acts of recklessness (Skegg, 2005). While many youth who self-harm do not intend suicide, they are at an increased risk of death by suicide and other unnatural causes, such as overdose and other risky behaviors (Chan et al., 2016; Hawton et al., 2012).

Youth between the ages of 16 and 24 years old are generally at highest risk for self-harm (McManus & Gunnell, 2020); however, research indicates that many youth begin engaging in self-harm in early adolescence (Nock, 2010). Those who start self-harming at a younger age, particularly before age 12, tend to engage in more frequent and more severe self-harm behaviors; hence, early intervention is crucial for this problem behavior (Ammerman et al., 2018).  

Causes & Functions of Self-harm

When asked to describe why they engage in self-harm, youth often report that they use it as a way to obtain release or relief from intense feelings, such as self-hate and self-dissatisfaction, and as a means to control or cope with difficult feelings (Stänicke et al., 2018). For these youth, the physical pain from self-harm serves as a distraction from more distressing emotions and psychological pain. Self-harm is also used as a way to communicate “unaccepted” feelings to others (e.g., by expressing their distress outwardly and obtaining help from others) or as a way to protect others from these “unaccepted feelings” (e.g., rather than take out their anger at others, they hurt themselves) (Stänicke et al., 2018).

These subjective experiences are consistent with explanations from behavioral science research on how self-harm is developed and maintained. Studies suggest that many youths who engage in self-harm have underlying difficulties with regulating their emotions and communicating with others due to exposure to an invalidating or critical home/social environment. Because many of these youth lack adequate coping skills to manage these emotions and communicate effectively with others, they use self-harm as a way to regulate distressing thoughts and feelings, as well as communicate with or influence others (Nock, 2009).

For example, the pain from self-harm behaviors can decrease or distract a person from difficult thoughts or feelings, generate desired self-punishing or dissociative feelings, facilitate help-seeking, and allow youth to avoid difficult social situations (e.g., confronting people with their strong emotions).

Youth also find self-harm to be a particularly effective means of coping compared to other behaviors that serve similar functions, such as the excessive use of alcohol or drugs, because it is more accessible and implementable, and has more rapid effects (Edmondson et al., 2016; Nock, 2009, 2010; Stänicke, 2021).  

Factors associated with Self-harm

In general, female adolescents have a higher tendency than males to engage in self-harm; however, this gender difference seems to disappear in young adulthood (Fliege et al., 2009; Shek & Yu, 2012). Youth who are emotionally sensitive, tend to engage in impulsive, risky behaviors, or have underlying mental health issues, such as depression, anxiety, and aggression, are also more likely to engage in self-harm (Ghinea et al., 2020; Witt et al., 2019; You et al., 2011). Low self-esteem and poor problem-solving abilities also place some youth at a higher risk for self-harm behaviors (Hawton et al., 1999).

A youth’s family and social environment can also place them at elevated risk of self-harm. Youth whose parents have difficulties related to emotion dysregulation, or have lower mental well-being, are at greater risk for self-harm as they are both genetically predisposed and socialized to have poorer emotion regulation (Buckholdt et al., 2009; Morgan et al., 2013; Sim et al., 2009). Exposure to childhood experiences, such as separation from parents, emotional neglect, psychological or physical abuse, or sexual abuse, and pervasively invalidating family climates (e.g., highly critical parents) are other notable risk factors (Adrian et al., 2018; Fliege et al., 2009; Gratz, 2003; James & Gibb, 2019), as are negative interpersonal experiences, such as bullying and discrimination (Fisher et al., 2012; Hay & Meldrum, 2010).  

The Singapore Context

Anecdotal evidence suggests an increase in self-harm behaviors among Singapore youth since the start of the Covid-19 pandemic in 2020 (Gan, 2022); however, prevalence rates of self-harm among Singapore youth are currently unknown. Most self-harm behaviors in Singapore youth manifest as hitting, cutting, biting, and picking of wounds (Shahwan et al., 2018), with cutting identified as the most common type of behavior (Lauw et al., 2018; Shahwan et al., 2018). Singapore youth tend to use self-harm more as a means to regulate their emotions, than as a way to communicate with others (e.g., social function) (Ong et al., 2017). Specifically, they more frequently endorse engaging in self-harm as a means to stop “bad” feelings, to relieve feelings of numbness or emptiness, to feel relaxed or “something even if it was pain,” and to punish themselves, than to avoid social activities (e.g., work, school) or control a social situation.           

Studies have shown that self-harm behaviour is relatively more common among the youth with existing mental health issues  (Lauw et al., 2018).  Consistent with broader global literature, Singapore youth who are females, have existing mental health or substance use problems, and have a history of abuse are more likely to engage in self-harm (Lauw et al., 2018; Loh et al., 2013; Ong et al., 2017). The likelihood of self-harm behaviors is further elevated in the absence of social support and a sense of belonging (Poremski et al., 2017).  

In Practice

Dialectical behavior therapy (DBT) is a well-established evidence-based treatment for youth who engage in self-harm behaviors (Asarnow et al., 2021). DBT focuses on decreasing ineffective coping behaviors linked to pervasive emotion dysregulation, such as self-harm. It does so by improving youths’ ability to regulate their emotions and increasing their repertoire of positive coping, problem-solving, and interpersonal skills. DBT is more effective than treatments, such as cognitive behavioural therapy and supportive psychotherapy, because it specifically targets underlying mechanisms related to self-harm behaviors and emphasizes the importance of self-management.

Singapore youth seeking help and resources for self-harm can contact:

CHAT (https://www.imh.com.sg/CHAT/About%20CHAT/Pages/default.aspx)

Tel: 6493 6500 / 6493 6501

Email: [email protected]

Samaritans of Singapore (https://www.sos.org.sg/)

Tel: 1-767

Email: [email protected]  

Takeaways

• Self-harm is a way some youth manage very difficult emotions; they may or may not have any suicide intent
• Self-harm behaviors should be treated seriously; youth who self-harm are at a greater risk for death by suicide or unnatural causes, such as overdose or other impulsive behaviors
• Early intervention and monitoring is important as those who start self-harming at an earlier age tend to engage in more frequent and severe self-harm behaviors
• Reducing self-harm requires replacing this method of coping with difficult emotions with a variety of targeted, alternative coping skills; dialectical behavior therapy is a very effective treatment for self-harm behaviors  

Acknowledgements

The author thanks Amanda Chia Ching Ling for her research assistance. 

References

Adrian, M., Berk, M. S., Korslund, K., Whitlock, K., McCauley, E., & Linehan, M. (2018). Parental validation and invalidation predict adolescent self-harm. Professional Psychology: Research and Practice, 49(4), 274-281.

Ammerman, B. A., Jacobucci, R., Kleiman, E. M., Uyeji, L. L., & McCloskey, M. S. (2018). The relationship between nonsuicidal self-injury age of onset and severity of self-harm. Suicide and Life-Threatening Behavior, 48(1), 31-37.

Asarnow, J. R., Berk, M. S., Bedics, J., Adrian, M., Gallop, R., Cohen, J., Korslund, K., Hughes, J., Avina, C., Linehan, M. M., & McCauley, E. (2021). Dialectical behavior therapy for suicidal self-harming youth: Emotion regulation, mechanisms, and mediators. Journal of the American Academy of Child & Adolescent Psychiatry, 60(9), 1105-1115.e1104.

Buckholdt, K. E., Parra, G. R., & Jobe‐Shields, L. (2009). Emotion regulation as a mediator of the relation between emotion socialization and deliberate self‐harm. American Journal of Orthopsychiatry, 79(4), 482-490.

Chan, M. K. Y., Bhatti, H., Meader, N., Stockton, S., Evans, J., O'Connor, R. C., Kapur, N., & Kendall, T. (2016). Predicting suicide following self-harm: Systematic review of risk factors and risk scales. British Journal of Psychiatry, 209(4), 277-283.

Edmondson, A. J., Brennan, C. A., & House, A. O. (2016). Non-suicidal reasons for self-harm: A systematic review of self-reported accounts. Journal of Affective Disorders, 191, 109-117.

Fisher, H. L., Moffitt, T. E., Houts, R. M., Belsky, D. W., Arseneault, L., & Caspi, A. (2012). Bullying victimisation and risk of self harm in early adolescence: Longitudinal cohort study. British Medical Journal, 344, e2683.

Fliege, H., Lee, J.-R., Grimm, A., & Klapp, B. F. (2009). Risk factors and correlates of deliberate self-harm behavior: A systematic review. Journal of Psychosomatic Research, 66(6), 477-493.

Gan, E. (2022, 8 May). Social media a double-edged sword for young persons who self-harm, as counsellors see more cases during Covid-19 pandemic. Today Online. https://www.todayonline.com/singapore/social-media-young-self-harm-counsellors-more-cases-covid-19-pandemic-1892156

Ghinea, D., Edinger, A., Parzer, P., Koenig, J., Resch, F., & Kaess, M. (2020). Non-suicidal self-injury disorder as a stand-alone diagnosis in a consecutive help-seeking sample of adolescents. Journal of Affective Disorders, 274, 1122-1125.

Gratz, K. L. (2003). Risk factors for and functions of deliberate self-harm: An empirical and conceptual review. Clinical Psychology: Science and Practice, 10(2), 192-205.

Hawton, K., Kingsbury, S., Steinhardt, K., James, A., & Fagg, J. (1999). Repetition of deliberate self-harm by adolescents: The role of psychological factors. Journal of Adolescence, 22(3), 369-378.

Hawton, K., Saunders, K. E. A., & O'Connor, R. C. (2012). Self-harm and suicide in adolescents. The Lancet, 379(9834), 2373-2382.

Hay, C., & Meldrum, R. (2010). Bullying victimization and adolescent self-harm: Testing hypotheses from general strain theory. Journal of Youth and Adolescence, 39(5), 446-459.

James, K. M., & Gibb, B. E. (2019). Maternal criticism and non-suicidal self-injury in school-aged children. Psychiatry Research, 273, 89-93.

Lauw, M. S. M., Abraham, A. M., & Loh, C. B. L. (2018). Deliberate self-harm among adolescent psychiatric outpatients in Singapore: Prevalence, nature and risk factors. Child and Adolescent Psychiatry and Mental Health, 12, 35.

Loh, C., Teo, Y. W., & Lim, L. (2013). Deliberate self-harm in adolescent psychiatric outpatients in Singapore: Prevalence and associated risk factors. Singapore Medical Journal, 54(9), 491-495.

McManus, S., & Gunnell, D. (2020). Trends in mental health, non‐suicidal self‐harm and suicide attempts in 16–24-year old students and non-students in England, 2000–2014. Social Psychiatry and Psychiatric Epidemiology, 55(1), 125-128.

Morgan, S., Rickard, E., Noone, M., Boylan, C., Carthy, A., Crowley, S., Butler, J., Guerin, S., & Fitzpatrick, C. (2013). Parents of young people with self-harm or suicidal behaviour who seek help – A psychosocial profile. Child and Adolescent Psychiatry and Mental Health, 7, 13.

Nock, M. K. (2009). Why do people hurt themselves? Current Directions in Psychological Science, 18(2), 78-83.

Nock, M. K. (2010). Self-injury. Annual Review of Clinical Psychology, 6(1), 339-363.

Nock, M. K., Joiner, T. E., Gordon, K. H., Lloyd-Richardson, E., & Prinstein, M. J. (2006). Non-suicidal self-injury among adolescents: Diagnostic correlates and relation to suicide attempts. Psychiatry Research, 144(1), 65-72.

Ong, S. H., Tan, A. C. Y., & Liang, W. Z. (2017). Functions of nonsuicidal self-injury in Singapore adolescents: Implications for intervention. Asian Journal of Psychiatry, 28, 47-50.

Poremski, D., Kunjithapatham, G., Koh, D., Lim, X. Y., Alexander, M., & Lee, C. (2017). Lost keys: Understanding service providers' impressions of frequent visitors to psychiatric emergency services in Singapore. Psychiatric Services, 68(4), 390-395.

Shahwan, S., Abdin, E., Zhang, Y., Sambasivam, R., Fauziana, R., Mahesh, M., Ong, S. H., Chong, S. A., & Subramaniam, M. (2018). Deliberate self-harm in psychiatric outpatients aged 14-35 years in Singapore. Annals of the Academy of Medicine of Singapore, 47(9), 360-372.

Shek, D. T., & Yu, L. (2012). Self-harm and suicidal behaviors in Hong Kong adolescents: Prevalence and psychosocial correlates. The Scientific World Journal, 2012, 932540.

Sim, L., Adrian, M., Zeman, J., Cassano, M., & Friedrich, W. N. (2009). Adolescent deliberate self‐harm: Linkages to emotion regulation and family emotional climate. Journal of Research on Adolescence, 19(1), 75-91.

Skegg, K. (2005). Self-harm. The Lancet, 366(9495), 1471-1483.

Stänicke, L. I. (2021). The punished self, the unknown self, and the harmed self - Toward a more nuanced understanding of self-harm among adolescent girls. Frontiers in Psychololgy, 12, 543303.

Stänicke, L. I., Haavind, H., & Gullestad, S. E. (2018). How do young people understand their own self-harm? A meta-synthesis of adolescents’ subjective experience of self-harm. Adolescent Research Review, 3(2), 173-191.

Uh, S., Dalmaijer, E. S., Siugzdaite, R., Ford, T. J., & Astle, D. E. (2021). Two pathways to self-harm in adolescence. Journal of the American Academy of Child & Adolescent Psychiatry, 60(12), 1491-1500.

Witt, K., Milner, A., Spittal, M. J., Hetrick, S., Robinson, J., Pirkis, J., & Carter, G. (2019). Population attributable risk of factors associated with the repetition of self-harm behaviour in young people presenting to clinical services: A systematic review and meta-analysis. European Child & Adolescent Psychiatry, 28(1), 5-18.

You, J., Leung, F., Fu, K., & Lai, C. M. (2011). The prevalence of nonsuicidal self-injury and different subgroups of self-injurers in Chinese adolescents. Archives of Suicide Research, 15(1), 75-86.

Citation

Tilley, J. L. (2022, September 16). What do we know about self-harm amongst Singapore's students? Child and Human Development, Life@NIE SG^®. https://sites.google.com/g.nie.edu.sg/child-and-human-development/topics/at-risk-behaviors/self-harm