Annals of Behavioural Science

Keywords

Self-harm; Online discussion forum; Narrative; Attachment

Introduction

and other technology [1-7]. The Internet has thus become a new everyday arena that in turn has changed the way young people socially interact, communicate, navigate identity and seek information [8]. Furthermore, the Internet has also begun to transform the way young people access help for health issues [9]. Changes in how people live their lives request new areas of investigation. Research has for example revealed that young people increasingly use the Internet to communicate distress to peers [10]. Online discussion forums provide a possibility to meet and receive emotional support from people who share similar experiences [11]. Furthermore, via online forums such connection to others is readily accessible from the comfort of one’s home, at a time when most needed with the possibility to remain anonymous [10].

The term deliberate self-harm can be defined as the act of purposely destructing body tissue without suicidal intent to reduce, escape from or feel in control of intense negative feelings of for example stress and anxiety or to alleviate pentup emotions [12]. Acts of deliberate self-harm encompasses a range of behaviors such as cutting, scratching, burning, scalding, hair-pulling, breaking bones, self-poisoning or hitting oneself. Self-harm has also been referred to as for example “self-injury” or “self-mutilation. However, in the present study the term self-harm will be employed. Mental health concerns and self-harm is prevalent among young adults in particularly Western countries and in Asia and has increased over the past few decades [1,13-19]. The lifetime incidence of self-harm in adolescents between the ages of 13 -18 in the UK was estimated to be around 13% to 15.5% [1,17]. Self-harming is particularly common between the ages of 11-25 years of age [16] and is more frequently occurring in females than in males [20,21].

The phenomenon of self-harm is complex involving multiple reasons. One factor that has been proposed to play a role in the increasing prevalence of self-harm among young people is a new development of a youth culture around self-harming behavior primarily in Western cultures [22]. Self-harming represents a whole way of thinking about expressing emotional distress, marginalization and loneliness in latemodern Western society [22,23]. Self-harm has regularly appeared in movies, in songs and in magazines [24]. Celebrities have confessed to self-harming, such as for example, Johnny Depp, Angelina Jolie, Nicole Richie and Cortney Love [25]. With the explosion of the Internet, a community has been created with several online discussion forums and websites on issues of self-harm [24]. This increased exposure to self-harming behavior may be one reason why self-harming has become more prevalent among young people [22]. Self-harm presentations are thus bound up with history and social and cultural context. However, sociocultural explanations are unable to account for why some people are more at risk of resorting to self-harm than others.

A risk factor that has consistently been found to correlate with self-harm, is childhood maltreatment, neglect or trauma due to for example sexual abuse, physical abuse, parental mental illness or parental substance abuse [26-31]. Developmental theories of mental health have conceptualized how childhood adversities increase the risk of developing maladaptive coping strategies for regulating emotional distress. In the pioneering work of John Bolwby, mental health problems are proposed to be attributed to insecure attachment to caregivers in early childhood [32-35]. Bowlby’s attachment theory is a relational theory. This theory explains how the relationship emerges between a child and the primary caregiver and how the quality of this relationship influences the child’s emotional, social and cognitive development. When young children experience emotional distress, due to perceived physical or psychological threat, their attachment systems are activated which motivates them to seek proximity to their primary caregiver, this has evolutionary gains of increasing the child’s chances of survival [32].

Caregivers who are sensitive and responsive to the emotional needs of the child can help the child regulate emotional distress enabling the child to restore the experience of emotional safety and well-being [35]. This sensitivity and responsiveness fosters secure attachment between child and caregiver. The caregiver provides a secure base from which the child can explore. The child subsequently learns how to take over these self-soothing and comforting emotional regulation strategies and thus gradually learns to self-sooth and selfcomfort to achieve, maintain and restore felt emotional security when facing challenges and stress in life. Learning how to regulate emotional distress emerges over the course of childhood, adolescence and young adulthood. If the caregiver is not available or is insufficiently responsive when the child is experiencing emotional distress, the emotional distress tends to intensify. Such unavailable or insufficiently responsive parenting styles fosters an insecure attachment between child and caregiver. Abuse of the child is particularly detrimental to the child’s development and subsequent ability to deal with emotional distress since the child risks being overwhelmed by emotional distress and the child is by itself, without the comfort and support of a caregiver, unable to self-sooth and thus restore a sense of emotional security [35].

Studies have found that insecure attachment to caregivers is related to self-harm behavior in young people [36-39]. The early experiences that the child has with primary attachment figures are believed to result in an internal working model in the child’s mind comprising of mental representations for understanding the world, other people and the self [35]. These mental representations thus include information about whether attachment figures will be available, responsive and thus trustworthy, and whether the child is worthy of care from the attachment figures. In order to manage the painful emotions of anger, sadness and fear related to an unavailable, insufficient or abusive caregiver, the child develops various strategies to handle these negative expectancies.

Strategies to cope with stress and the regulation of emotional distress are central aspects of development and play a key role in the risk for mental health problems [35]. Throughout life a person’s thoughts, feelings and behaviors are proposed to subsequently be guided by these internal working models formed in childhood. These mental representations will thus shape the nature of emotional reactions and regulation attempts when facing challenges and stress throughout life [40]. Furthermore, individuals tend to seek out relationships that feel familiar and confirm their internal working models and relationship expectancies [41].

Inability to maintain and restore emotional sense of security and calmness is in turn related to inability to use adaptive coping mechanisms when under intense emotional distress, and development of defense strategies [42]. Insecure attachment to parents has been found to be associated with poorer problem-solving skills, in turn increasing the risk of engaging in self-harming behaviors [37,43,44]. Young people with insecure attachment to caregivers are thus proposed to be more vulnerable to self-harm because they lack other more constructive strategies for coping with emotional distress [45]. There has been consistent support for maladaptive patterns of regulating distressing emotions among young people who selfharm [46-49]. When faced with challenges and problems young people who engage in self-harming are unable to selfsooth and tend to blame themselves [50].

Especially detrimental to child development is the most serious form of insecure attachment, called disorganized attachment [51]. If the caregiver behaves very inconsistently towards the child, confusion is created in the child which makes it impossible for the child to form organized strategies to understand and respond to the caregiver. When the child is not able to find an organized relational pattern with the caregiver the attachment relationship is thus disorganized. The caregiver can for example frequently frighten the child, act in a hostile way, miscommunicate feelings, convey helplessness or expectations of parentification. The parent can typically also alternate between contradicting behaviors such as hostility and conveyed helplessness. The child then struggles with the dilemma of both protecting itself from the caregiver but at the same time trying to maintain a relationship with the caregiver. The child may in this process develop multiple, segregated and incompatible internal models of attachment [52]. Confusing experiences with the caregiver can leave the child with multiple, incompatible and hard to reconcile views of the caregiver and in turn the emerging sense of self. This confusion also makes it difficult for the child to generally establish a sense of coherence in life. Experiences that cannot be assimilated because they are so unfathomable and confusing fragment the mind. The child may in heightened states of emotional distress thus not only have difficulties regulating emotional distress and adopt self-soothing strategies but also be forced to resort to hyper-activating strategies such as heightened vigilance or deactivating strategies such as dissociation [51].

Attachment theory can thus help to explain how dissociative processes become wired into the brain in turn resulting in difficulties identifying, expressing and regulating emotions [52]. When exposed to stress and challenges the attachment system is activated but the ability to adequately seek out sources of support or to self-sooth is damaged. When the child has experiences in the attachment relationship of a caregiver who has in separate ways inflicted suffering and trauma on the child, the attachment system adapts to pain and suffering [51]. Self-harm is thus proposed to develop when the child has become attached to caregivers who have inflicted trauma and suffering on the child via the attempts by the child to maintain an attachment. Child experiences of consistently having been met with hostility, dismissal or incomprehensible responses, such as displayed helplessness, from the caregiver when in need of care and comfort are thus proposed to increase the risk of developing self-destructive ways of dealing with emotional distress in dissociative compensatory attempts to meet underlying attachment needs [52,53].

Young people who self-harm tend to avoid seeking care [54,55]. Besides, most people who engage in self-harm tend to harm areas of the body that are easy to hide from others why their self-destructive behaviors may not be detected by family and friends. Research has revealed that one reason for not seeking help is that people who self-harm often feel judged and stigmatized by health professionals [55,56]. Lack of empathy from health professionals can have damaging psychological and emotional impact on vulnerable individuals who self-harm [57]. Research supports that healthcare professionals tend to have a negative view of people who selfharm [57]. Other reasons for why self-harmers are reluctant to seek help are out of fear of being misunderstood and disregarded as manipulative or as attention seekers as well as out of fear of hurting loved ones if their self-destructive behavior become known [2].

Young people engaging in self-harm are more likely to seek support from peers than from family or healthcare professionals [2]. Research has revealed that peer-to-peer advice and support on issues related to self-harm available through online discussion forums is perceived as more trustworthy than advice and support from professionals [3]. Furthermore, self-harmers who do seek help online have been found to be more distressed and suicidal than those who do not seek help online [10]. The Internet may thus provide an important venue for connectivity and social support especially for those most at risk young people. On online discussion forums marginalized individuals can come together and construct equal power relations and talk about self-harm which in society is perceived as a taboo act. In these self-harm community’s online posters are not bound by professionally justified or socially accepted frames.

Considering that the Internet has increasingly become a platform for vulnerable and marginalized individuals there is a need to learn more about communications on these platforms. Individuals who self-harm are often ashamed of their self destructive behaviors why recruiting them for research is difficult. In order to investigate this population an alternative strategy was thus adopted in the present study, by analyzing posts about self-harming behavior on an online forum focused on issues of self-harm. Internet is an ideal tool for gaining access to the often secret and hidden world of self-harmers. Making use of self-harmers narratives, in the form of posts online, is also a way to include the voices of these young people in their attempts to make sense of and explain why they self-harm. An inside perspective can provide valuable information that can be of use to health professionals. The current study is one of the first to directly explore the narratives on an online forum posted by people who selfharm. The primary purpose of the present study was thus to examine how self-harmers construct narrative meaning of their experiences with self-harm. Interpretations of these narratives were made within an attachment based narrative framework [4-6].

Method

Data collection comprised a total of 648 posts involving 475 user names on an International Web site and discussion board of health issues for young people, aged 14-25, in English. This age span was considered appropriate considering that selfharm is most prevalent in young people [16]. When conducting a search for forums on this web site, the term “self-harm” was used. A single message, or conversation, is on these sites called a post. A post can be replied to by anyone and by as many people as so wish. In the present study replies to posts were not analyzed. Posts were in the present study referred to as online narratives. Posts by individuals writing about issues of self-harm were thus sampled in the present study. All the online narratives about self-harm were reviewed. These narratives had been posted between 2013 and 2017.

Ethical considerations

It is important to consider ethical issues when conducting research on online discussion forums. The online forum examined in the present study was not password protected but open to the public. Therefore, in line with other similar type of studies, no consent was perceived necessary [58,59]. This aligns with the practice of several previous studies [60-62]. If a website is in the public domain, using online content for research purposes is permitted since the status of such websites is equated to published material [63]. However, to protect the rights of posters on the online forum examined in the present study their user names were not exhibited and the online forum was not identified. The activity on the chosen online forum was monitored by moderators. Moderators actively monitor for potentially damaging content, such as for example encouraging self-harm and suicide. Such posts deemed damaging are blocked by monitors. The complexity of the narratives demanded preservation of the entire story and therefore the decision was made to conserve large pieces of the narratives communicated.

Data analysis

analysis A narrative psychological method was used in the present study when analyzing narratives, shared as posts, on the online forum for self-harmers [4,5]. The psychology of the narrative proposes that human beings are active in giving meaning to their experiences and behaviors [5]. Sharing one’s story allows an individual to develop insights regarding experiences and behaviors. Storytelling is one of the principal ways in which individuals attempt to make sense of the world around them and of the experiences they have in life. Furthermore, the ability to cope with stress and challenges in life is influenced by the stories people construct about themselves and their lives. By telling stories people bring order and meaning to their everyday life. Scattered and confusing experiences can be arranged in a coherent story [4]. In the present study the striving of individuals who self-harm to create coherency of their experiences related to self-harm was thus traced using an attachment based narrative framework [6].

The Internet presents a useful arena for gaining access to people who self-harm as online forums directed at these individuals offers a unique platform for them to self-express. Their narratives can provide insights to how they narrate meaning of their self-destructive behaviors. Furthermore, storytelling is a reciprocal event between a teller and an audience [5]. The character of a person’s story depends on to whom the story is being told. The act of self-harming is stigmatizing why it may be easier to, protected by the anonymity of the Internet, tell people who share the same self-destructive behaviors about these acts of self-harm. The narrators in the present study chose to post on an online forum for people who share their experiences related to selfharm. The narrators thus chose to connect with others who could understand their suffering.

All narratives were first read closely to become acquainted with the data and establish a general knowledge of the data. Each narrative was subsequently reread and examined closely. Relevant and salient content and patterns that held interest to the researcher considering the research question were identified. Posts conveying information about attempts by posters to narrate meaning of their experiences related to selfharm were thus selected to obtain an inside perspective and learn more about posters meaning making processes. Frequently occurring themes were then identified. The themes were closely examined for their content and clearly defined and named. Furthermore, the tone and the structure of the narratives were examined [4,6].

Results and Discussion

From the narratives, shared as online posts, rich and detailed information was retained. It is possible that the perceived anonymity on the Internet and the sense of online community with like-minded offers a platform perceived safe for self-harmers to present their personal narratives without fear of judgment in turn encouraging especially authentic and disclosing narratives. Narratives reflected construction of meaning from overall experiences with self-harm. The structure of the narratives was generally unstable and reflected chaos where the individuals seemed unable to cope and appeared to be disoriented. The stories conveyed anguish, chaos and uncontrollability. A substantial proportion of posters perceived the urge to self-harm as incomprehensible and they were unable to stop themselves from self-harming despite attempts to do so. The unstable structure suggested absence of sense of coherence. The posts typically started negatively reflecting how distressed the posters were feeling. The general tone of the narratives was thus negative conveying absence of hope for a brightening future. There were several dominating themes that could be found throughout the narratives and the most pronounced was “Out of control”. The urge to self-harm dominated the lives of these individuals despite their efforts to take control over the chaotic situation. Another theme in the narratives pointed to “Inability to understand and deal with emotions”. Inability to understand emotional states seemed to result in difficulties finding ways to self-regulate emotions. Another theme occurring in most of the narratives was “Lack of coping strategies”. These individuals seemed to lack adaptive coping strategies when faced with adversities in life. They were unable to find other strategies, then to self-harm, to reduce emotional distress. Yet another theme that occurred frequently was “Loneliness”. Many narrators lacked social support and experienced difficulties forming relationships and reaching out for help. A common general feature of the narratives was that they conveyed a tragic everyday life story. The tone in the narratives was pessimistic most of the time. Below are examples of narratives reflecting the challenges faced by individuals who self-harm and their attempts to understand and construct narrative meaning of their own experiences related to self-harm. For all posts original spelling, grammar and punctuation were retained.

Unable to cease self-harming

The following narrators below articulated how they struggled with trying to end their habit of self-harm. Several posters described how the acts of self-harming were perceived as impossible to cease, narrators had no control over urges to self-harm. They were bewildered as to what to do to end their pattern of self-destructive behavior:

“I just don't know how to get myself to stop. It's like I get this pressure building up inside me chest, and the only way to do it is to be destructive towards myself. I just want to figure out how to stop this.”

“Hello, I just wanted to ask advice really, I have shy for a few years but lately it doesn’t seem to help anymore but can't stop, I feel I have no control over it, more like it's controlling me. I don't want to do it anymore but aren’t really sure what to do, I tried to stop on my own but just can't”

“I was going really well with the whole not self-harming thing but yesterday everything fell apart again, and I had to get 25 stitches all together. I'm really upset with myself for doing it and I wish I didn't and I just don't know what to do.”

In the post below the narrator described how she had previously received therapy and medication and how she had learned about how to distract herself and find other ways of coping than to resort to self-harm. However, the urge to selfharm had not gone away:

“So, over the past year I have had therapy and medication, and learned a lot about why I wanted to SH and had times over the past year when the urge has gone away completely, but it seems to always come back. I am spending much of my energy fighting it: I know all the tricks of distraction, doing activities I might enjoy, exercise, keeping busy, meditation, writing, or even just allowing myself to sit with the feelings but the urge is just always there, and I am so tired of fighting. I'm not sure what advice anyone can give me that I haven't already tried, but I appreciate the chance to just say how hard this is.”

The posts also reflected the danger of becoming addicted to self-harming. In the first post below, it appeared as if the person was experiencing withdrawal symptoms, such as agitation and shaking. In the second post below the narrator articulated feeling like an addict:

“I know have a self-mutilation addiction. I cannot stop. The people, who know, being my best friend and family, think I am “fine” again, but it couldn't be further from the truth. Like in any issue, drama or problem people get tired of hearing about it– but in my case, it’s not hearing its visually seeing it. So, I now self-harm in places people can’t see. Now the feeling of the self-harm does not satisfy my thirst as such....” “I don't want to do this, I hate having to wear long shirts and cardigans but it’s like a drug.” “I can physically feel when I need to selfharm I get agitated, I can’t focus, I strum my fingers, my hands shake. I just don't know how to push past all of this.”

“I found my tools. I want to self-harm so badly. I feel like an addict I am an addict.”

Disorientation

A substantial proportion of the narratives conveyed inability to attain narrative coherence. The posters were incapable of understanding themselves and of making sense of their urges to self-harm. They were unable to comprehend their own needs behind these acts of self-harm. Their narratives reflected feelings of helplessness and of disorientation. In the narrative below the poster tried to make coherent meaning of why she hurt her leg. She seemed unable to identify the reason for feeling upset, if the experience of distress was triggered externally by factors in the environment or internally from emotional distress. She contemplated various possible explanations such as stress from her old roommate, starting a new job, the fact that she was in a new relationship or the fact that she had been able to sustain from drinking, and thus wasn ´t using drinking as a strategy to cope with feeling upset and overwhelmed. But she seemed unable to come up with an explanation for her act of self-harming.

“I don't know if it was the stress from the old roommate, the fact I started a new job, the fact I'm in a new relationship, the fact I manage not to use or drink or whatever reason. I just remember being scared, not being able to breathe and next thing I knew I'm on the kitchen floor and my leg yea.”

In the post below the narrator tried to understand why she resorted to self-harm. She was unable to find an explanation as there was no pattern that she could detect or no warning that she could identify. The urge to self-harm could come quickly and unexpectedly without identifiable cause. Despite seeing a psychologist, the narrator was finding it difficult to receive help for her urge to self-harm. Unable to understand herself she did not know how to talk about her problem:

“I go through waves of feeling OK and of feeling an emotional mess. There is no pattern, no warning. The change can be quick. Unexpected. Without identifiable cause. I go and see my Psychologist, only I never seem to know what to talk about. Is that stupid? And when I think I do know what I want to talk about I struggle to get the words out. Rarely am I able to talk about anything...”

The poster below connected the need to self-harm to feeling empty and blank:

“I don't understand what I'm feeling...I should be upset. I don't know that I really feel good, but I don't feel that "black cloud" around me now. I feel sort of...empty. Like...I don't know, "blank" kind of empty, not sad. I don't really know if relief is the right word for it either.”

Attempts to end the habit of self-harming could instead lead to new forms of self-destructive behaviors, the techniques of self-harm just changed form. In the following two posts below, the narrators described how they over time gradually realized that they had switched from one way of inflicting self-harm to another, despite believing that they had ceased their habit of self-harm:

“Hello. I've struggled with self-harm now for around 10 years. And for around 2 years I thought I'd stopped (I used to cut) but it wasn't until recently that I noticed that I'd simply changed how I did it. And I'm not sure what I can do to help myself with this one. When I'm upset I will hit my head against walls, or hit myself in the head, or even punch walls (I needed an X-ray once because I was in so much pain I thought I'd broken something) Basically I've gotten used to coping with the urges to cut, but this... I'm not sure how to help myself to stop doing this. I don’t even fully realize at the time that I'm doing it.”

“I first starting out cutting as a form of SH. I haven't in almost 3 years, but I don't think the SH ever stopped. it just changed. Instead I started starving myself. Now I'm hitting myself in the head with heavy objects and punching myself. Has anyone else ever dealt with this? I want to stop entirely, but I don't know how. I don't know how to cope without pain.”

The narratives above were disclosing of serious problems. Narrative fragmentation, incoherence and confusion was conveyed in these narratives. This lack of coherence may mirror fragmented narratives of selves. Many posters were unable to explain for themselves the urge to self-harm. They seemed unable to understand their own needs behind the acts of self-harm. The most serious form of insecure attachment, disorganized attachment, occurs if the caregiver behaves very inconsistently towards the child creating confusion. Experiences that the child cannot assimilate can fragment the mind which in turn renders sense of coherence difficult to achieve [50].

Dealing with emotional distress

Some narrators conveyed more coherence in the sense that they could at least connect the urge to self-harm with a wish to in some way deal with intense negative emotions or have a release of negative emotions such as for example stress, anxiety, depression or anger. The following narratives entailed the words of four narrators trying to narrate meaning of their urges to self-harm:

“I've been through a lot recently and normally I can handle a great deal. Then I just sort of snapped. I started to deal with anxiety, then it was for stress and not it's like a bad habit I can't get out because I’ll have a meltdown, then look down and realize I've done it without thinking,”

“I can remember biting my hands from the age of about 10 (maybe slightly younger) to relieve anger, or sometimes other intense negative emotions. I never thought of it as self-harm, although after I started self-harming in other ways I found that I tend to do it in similar situations.”

“So, I slipped a few days ago and blacked out and cut myself. The past few weeks have been stressful, and I think it finally caught up with me.”

“I had a relapse over the weekend I’ve been really struggling with my anxiety and depression the urges have been unbearable I’m far from okay. I’m tired of fighting. I still want to self-harm i need a release. I want to cut so badly I’m just tired. I’m so sorry I feel I can’t keep fighting this much longer.”

The narratives above conveyed difficulties dealing with stress and challenges in life. By interpreting these narratives within an attachment narrative framework, absence of parental guidance in how to understand emotional states can be understood to resort in inability to deal with emotional distress. Inability to endure and deal with emotional distress leaves an individual at subsequent risk of being vulnerable when faced with challenges and stress in life [50].

Difficulties regulating emotional states

Narrators expressed having difficulties comforting themselves and calming down when upset. They were unable to self-regulate emotional distress. Below is an example of how feeling stressed resulted in becoming overwhelmed which in turn spiraled into a panic attack. The narrator described trying ways to calm herself in order not to resort to selfharming, but nothing helped, and she ended up hurting herself. Suffering appears to have become so excessive that the psyche could not absorb it:

“Last night I was really stressed over just about everything, and sometimes when that happens I get so overwhelmed I get into panic mode and I can get myself out of that using my safety plan etc. but last night it was different. i was thinking of self-harm and no matter what I tried the overwhelming feelings and the self-harm urges wouldn't go away. I felt a bit helpless, I couldn't stop crying. It turned into like a panic attack x 100, I was sitting on the floor crying, I'd hurt myself, I felt like the world was ending, everything was spinning, and I thought I was going to die, it felt like I couldn't move, I was just stuck, I was by myself, but I still felt like about 100 people were screaming at me. I didn't know what to do, I thought it was never going to end.”

For several narrator’s life seemed to be utterly chaotic. In the post below the narrator described how control over the urge to self-harm, after fighting to resist, eventually was lost resulting in major damage to the thigh using a razor. The narrator attempted in the post to narrate meaning of the strong urge to self-harm and concluded that the urge to selfharm stemmed from underlying feelings of anger and shame:

“I just cut very badly I just I didn’t want to fight anymore I just cut up my thigh badly I had to bandage it up, but I also got rid of my razor this has been the worst damage I’ve done and I actually want to keep doing it I just don’t care but, yet I’m so tired idk what it is I need I know I’m not okay. I need to face what’s underneath the anger and shame I feel I just feel afraid.”

The narratives above revealed of behaviors that could be perceived as scary, bizarre, incomprehensible and deviant which in turn may make these behaviors difficult to talk about with other people who do not have experiences of selfharming. The narrators appeared to reach out to others who could understand their destructive behaviors and help them make sense of these behaviors. On online forums posters can open in a way that they would perhaps not have been comfortable doing with family, friends or even a therapist out of fear of being judged. Online forums may thus promote openness and self-disclosure where concerns and worries can anonymously be shared with others who experience the same issues related to self-harm. The potential for embarrassment and stigmatization may be reduced on the Internet.

Unable to cope and solve problems

The posters articulated being unable to find alternative coping strategies than to self-harm. They had difficulties perceiving adaptive solutions to their problems. Below are the accounts of two people expressing how they were struggling to find other ways to cope than to self-harm but how they failed to do so:

“I thought I was doing better. I felt a bit better. I felt happier. Those feelings don't last with me apparently. I feel so lost and numb and nothing I can do can change that or help it. The more I try I still get nowhere. I can't take this anymore. The only thing I know how to help myself is to hurt myself which is known won't solve anything but what else am I supposed to do.”

“I know it's wrong, but I still do it. I don't want it to be my only coping mechanism, but it is. I don't know how to stop. I haven't done it in two weeks, so far so good. But there are times when tiny things upset me, and my mind goes straight to self-harm. Help me please”

Some narrators articulated that self-harm gave them a sense of control. Self-harm was thus used as a mechanism for coping with problems by at least feeling in control of pain. Below is the account of one narrator expressing how she was unable to feel positive feelings and did not have anyone to talk to but at least she could control the pain and in this way, achieve a sense of enjoyment out of self-harm:

“I feel unable to feel positive things and feel so ignored by everyone as I don’t have anyone to talk to and am alone with no one regardless of how much I try. I’ve started to self-harm again as at least I can control the pain and I get a sense of enjoyment out of self-harm.”

Posters could identify how losses and disappointments in life could trigger the urge to self-harm. One narrator articulated how devastated she was about miscarrying and how she did not know any other way to get through such a loss than to self-harm:

“I had a miscarriage this morning. Yes, on Mother’s Day. I was 7 weeks pregnant with our first child. I don't know if I can get through this without cutting. I have been self-injury free for 41 months and it hasn't been easy in the slightest. This has been devastating for both my husband and me. And I don't know how to cope with this kind of loss.”

Inability to reach out for help

Narrators revealed how difficult it could be to ask for help and to reach out to other people. Several narrators seemed to lack social support. They expressed feeling lonely, stigmatized and isolated. Virtual contact can be of significance for those who lack social support. Interactions online may provide instant access to social networks for this vulnerable group. A feeling of connectedness with peers is a critical part of a young peoples’ lives. Belonging to social media communities may decrease stigma and promote meaningful engagement for people and an opportunity to bond online. In the narratives below narrators were struggling alone without social support:

“I feel like I am fighting everything in my head on my own with nobody by my side to help me through it and it's not working anymore I'm not strong enough to keep going I'm becoming so tired (not sleeping tired but mentally tired) I can't keep my fight up much longer I am starting to break down in tears for no reason all the time, the urges to harm myself and to not keep fighting and just give up are just getting too strong. I feel that I am alone with all of this with nobody around to help I have nobody I can talk to, I'm struggling to cope with everything right now and I just can't take it my mind can't take it anymore. I'm sorry I'm an inconvenience to everyone and to the people around me, I'm sorry if this doesn't make much sense, I have never really been good at telling people things so I have just started writing and I'm sorry if this doesn’t make sense, but long story short I really am struggling with everything at the moment and all I feel like doing is giving up and the stuff in my head is really starting to get to me and I can't find a way to escape from it.”

“I haven't got anyone who I can call a friend, I'm on my own. My girlfriend (who I do live with), could not handle me if I opened to her. Plus, it's so hard physically talking about it. It's always been a mental barrier of mine that I seem unable to break down. Yet I could bare all to a stranger through a screen.”

“Ok so last night I rang a hotline and disclosed something that I’ve been holding onto for 2 years now. I’m extremely embarrassed and scared and so ashamed I just can’t think. I’m also struggling with self-harming thoughts”

Narrators could also identify their acts of self-harm as a cry for help, a wish for someone to respond to their behaviors. Below is the account of one narrator:

“I keep giving out these hints, but nobody takes them or understands them. I hurt myself and nobody cares. I say do the court order, they don't do it. I take my stitches out early and pry open my wounds, so they bleed again. I take all my pills and drink the alcohol then tell someone I want to die, and they do nothing. I snort the powder in my baggie. Nobody gets my hints for my cry of help.”

Posters expressed being hesitant to seek health care out of fear of being judged. The poster below articulated feeling unsure about how to bring up the subject of self-harm and fear of being dismissed, ridiculed and not taken seriously:

“Would a doctor be able to help, or would they dismiss me as being ridiculous, how would I bring up the subject? would they tell me it's not serious enough?”

The Internet has become a central element in the lives of young people who self-harm, feel lonely and fear stigmatization. Apprehension about being negatively perceived by others have been identified as a central concern for many individuals who struggle with self-harm increasing the risk of keeping their self-harming behaviors hidden and not seek help [54]. According to the attachment theory, relational experiences early on in life form internal working models comprising information about whether other people are trustworthy and whether one is worthy of care [40]. Difficulties reaching out for help could thus stem from mental representations including expectations of rejection from others and of not being worthy of nurture. Via the Internet these vulnerable individuals are provided a bride to others who share the same problems. In an instant they can access social networks regardless of time and location. The Internet thus provides opportunities for connectivity among vulnerable individuals who self-harm on a scale never previously possible. The narratives above reflected wishes to connect and share experiences with others who also engaged in self-harm to try and make sense of these self-destructive acts that were perceived as shameful and difficult to talk about off line.

Childhood experiences

Posters disclosed of adverse childhood experiences that could be explanations for using self-harming to deal with emotional distress. The online forum thus appeared to be used in a therapeutic way. The use of an online discussion forum could be a source of venting. The narratives reflected how adverse experiences in childhood could make a person vulnerable later in life when faced with challenges, stress, setbacks and disappointments. Below are several accounts illustrating attempts by posters to make sense of their urges to self-harm through connecting their current life situation with earlier experiences in childhood. One young poster below revealed negative experiences with her father and lack of adequate support from her mother. The narrator connected the detrimental upbringing to mental health problems later in life, such as self-harm:

“I'll cut it short, but basically I had a bad childhood with my father. He did a lot of sad things to me and my mum was completely oblivious to most of it. Off course he did things to her too, so she wasn't completely oblivious, but didn't know the details of what was going on with me. Anyway, skip forward to when I'm now fifteen, I escaped my dad when i was nine with my mum and two sisters, and her new boyfriend at the time. In the space between 9 and 15, I've tried multiple times to take my own life, I've suffered from eating disorders (various) depression, self-harm etc. spent months in an institution.”

The next narrative presented below also revealed severe childhood trauma. The narrator described physical and mental abuse from her father. She further described repeatedly ending up in abusive relationships. Attachment theory proposes a model of psychological development in which internal working models of relationships tend to maintain stable due to the inclination to seek out relationships that feel familiar and in turn confirm internal working models and relationship expectations [40]. Early experiences of abuse may further color perceptions of and reactions to relational experiences later in life, increasing emotional distress by reminding of hurt and pain experienced in childhood. In the narrative below a vicious cycle appeared to have been formed of destructive relational patterns fostering emotional suffering and self-harm. The narrator described being in an abusive relationship that showed resemblance to experiences with her father:

“For most of my life have felt confused, alone, scared, angry, lost.... I could go on forever... At an early age my dad was physically and mentally abusive to the females in my family. I can still remember him hitting my mum and sister viciously and chasing me too trying to take a swing at me at the age of 6. Only in the past couple of years I’m also remembering other things that he did to me and don’t know what to do... I’m confused... And angry!! I have lost all ties with my family and my last relationship and now current is an abusive relationship... He tells me he is sorry and loves me and won’t do it again and because I’m scared of being alone, I stay! When I’m around the very few friends I have (because I pushed so many away because of my poor attitude sometimes) they have no idea, I become a different person, when I’m alone I think of bad thoughts and have tried self-harm quite often, I also lay in bed and listen to sad music whilst thinking about my own death and funeral and wonder who would come and if anyone would care or miss me and then cry myself to sleep! I feel like I’ve lost it... I get so angry sometimes I feel like my blood boils and I just snap at whoever is near at the time! I don’t know what is wrong with me....”

The young narrator below had experienced separation from his mother and he never met his father. He was abused as a child growing up and he had been bullied. When trying to confide in other people in the past he had ended up feeling betrayed and he felt that his adverse childhood experiences in life were just dismissed by other people:

“* sigh* ok I don't know how I'm going to do this or where I start with my story, but here is a small piece of it, here we go........... I am 15 I have been cutting and doing other things to self-harm for a while like trying to commit suicide... including tonight.... and very few people know about it. I’m scared to let anyone know since every time I trust someone I end up getting hurt, but I'm trying one last time with this.... I've been abused as a child growing up, never met my father, and my mother left me for drugs, I've been bullied if I can remember. and when I do tell someone about it, they just say '' suck it up it's nothing, man up and deal with it.'' There are only two people why I am honestly still breathing today, I don't want to hurt them, and I just don't know what to do”

In the narrative below the narrator connected her childhood experiences with her inability to cope adaptively with disappointments in life, such as failing in becoming pregnant. Feelings of failure to achieve something longed for seemed to hook into previous feelings and memories of as a child being in a situation with no empowerment:

“Hi, I would like to tell my whole story. So I grew up in a household where my dad was a drunken and violent person hitting my mum and us girls. My mum was always drunk. As a teen I began to drink and self-harm even got put in hospital for drinking too much and taking medication. Was suicidal as well but never actually tried. When I was 18 I moved out of home with my sister and meet my husband. We moved out together about 5 years later and I stop self-harming. We got my mum to leave my dad. I got married and became an aunty. Life was great. Trying for a baby this year this all came crashing down. I wasn’t succeeding and became very depressed and suicidal and myself harm, drinking and suicidal thoughts came crashing back. I never thought I would do self-harm again. It’s so different this time I did try to commit suicide. This time it’s hard to get over coz there is nothing I feel there should be wrong about and I knew I needed help this time so I am seeing a psychologist”

Interpreting the narratives presented in the current study within an attachment narrative framework entails perceiving responsive and accessible parenting as a key protector against experiencing unbearable emotional distress in combination with lack of ability to restore a sense of emotional security. Serious disadvantages in childhood such as abuse and neglect by caregivers have been found to increase the risk of developing the most serious type of insecure attachment, disorganized attachment, by confusing the child to an extent that renders it impossible for the child to perceive sense of coherence in relational patterns [51]. The narratives above can thus be interpreted in line with attachment frameworks of mental health emphasizing the interpersonal foundations of affectivity proposing that dysfunctional caregiving environments and consequent insecure attachment representations increase the risk of developing maladaptive coping strategies for regulating emotional distress [51]. Abuse or neglect by primary caregivers inflicts pain and suffering on a child motivated to seek proximity with caregivers when in emotional distress. Such experiences may result in subsequent patterns of associating emotional distress with pain and suffering. The need for comfort when under emotional distress, which in turn activates the attachment system, can then be dealt with by inflicting pain on oneself. The need to be cared for has been associated with pain and suffering why selfharm becomes a way to deal with underlying needs of care. Emotional distress may thus be dealt with by replacing such suffering on the inside with physical pain by inflicting selfharm. Individuals who lack the ability to self-sooth and calm themselves when facing challenges in life may thus be more vulnerable to developing destructive ways of coping with emotional distress. The experience of being a victim may cause young people to become victims of themselves where experiences that are incomprehensible, and therefore unspeakable, are played out as a psychodrama in the form of self-harm [52]. Incomprehensible psychological suffering can in this way foster repetition compulsion of reenacting suffering and self-punishment [52]. Self-harm may thus be a way to communicate early relational trauma primarily through wounding the body, disguising early unmet needs of care and nurture.

Summary and Conclusion

The current study examined how individuals who self-harm narrated meaning of these self-destructive acts in their posts on an online forum. The online forum examined in the present study appeared to have taken a therapeutic form for marginalized adolescents and young adults seeking practical and emotional support. Narrative fragmentation, incoherence and confusion was conveyed in the narratives analyzed in the present study. Many posters were unable to explain for themselves the need to self-harm. They were not capable of understanding their own needs behind the acts of self-harm. The posters expressed wanting to cease self-harming, but they nevertheless consistently found themselves doing so when experiencing emotional distress. The stories were often centered on decreased ability to tolerate emotional distress and deficits in problem-solving skills, in line with previous research [36,42,45-47]. Emotional distress was experienced as overwhelming, impossible to bear, to take control over and to reduce. Self-harm was a way to handle such emotional distress and internal pressures.

Furthermore, the inability to calm and self-soothe using constructive coping strategies made these individuals vulnerable to repeating their self-destructive behaviors when facing stress, set-backs, losses and disappointments in life. When facing such challenges, they appeared to experience emotions that hooked into memories of previous experiences that reminded them of feeling the same way. They would then be vulnerable to habitual destructive ways of trying to cope. Some narrators on the online forum connected their use of self-harm as a coping strategy and their inability to selfregulate negative emotions with being maltreated, abused and traumatized in childhood. There were thus narratives disclosing experiences of being victims of their families. The role of insecure attachment as a risk factor for developing selfdestructive behaviors, such as self-harm, is well-established [25,28,29]. When attachment needs have been met with dismissal or hostility the child may associate needs of care with pain and suffering, causing the child to develop selfdestructive ways of dealing with emotional distress [50]. Selfharm can thus be understood to represent dissociated compensatory attempts to serve self-regulatory functions. When the child has become attached to caregivers who have inflicted pain and suffering on the child, those attachment representations can be maintained by self-inflicting pain. Furthermore, narratives disclosed of how primary caregivers seemed to function as a prototype for relationships increasing the risk of repeatedly ending up in destructive relationships [40].

There are several limitations in the present study. The study was for example limited by its sampling procedure and posters in the present study may thus not have been representative of young self-harmers who use online forums. Hence, although online forums may be important to many people who selfharm, it cannot be assumed that the experiences articulated by posters in the current study can be generalized to all individuals who self-harm. It is further acknowledged that the lack of demographic data about participants in the current study limits the extent to which information about for example age of participants can be confirmed. Furthermore, online conversations differ from conversations off line. The researcher could for example not ask for feedback on interpretations made of the posts to add to the credibility of the data. Neither could follow-up questions be asked to ask narrators to clarify and elaborate their stories in more detail or to review the accurateness of their stories. However, although the specificity of the experiences of the posters in the present study may not be generalizable to all individuals who selfharm, clinicians and other health care professionals may benefit from understanding the phenomenon of self-harm from an inside perspective. Individuals who self-harm can be perceived as members of a particularly challenged group in society that often lack the resources to communicate their own stories. Internet-based social networking on online forums provides an opportunity for the first time in history for marginalized individuals to tell their stories to the public. Their stories are valuable and provide an insight into their often secret and hidden world. Such insights can be educational for clinicians and other health care professionals who meet people that engage in self-harming behaviors. Future research about self-harm is required with diverse populations and contexts with consideration of for example distinct cultures, genders and ages.

Recommendations

Clinicians and health care professionals may need to be attentive to that clients who self-harm could be especially assisted by emphatic, compassionate, supportive, trusting and non-judgmental environments. Compassion could reduce shame which in turn fosters ability to harbor emotional distress [64,65]. By addressing individuals who self-harm from an attachment perspective, the ability to use the therapist as a secure base can facilitate exploration of the underlying issues that contribute to the urges to self-harm [66]. Bringing about a new relational experience of emotional safety with a therapist can facilitate the ability to revisit and reinterpret past experiences. Hence, rather than focusing on the outer symptoms of physical wounds, it may be important for clinicians to help clients process and work towards an understanding of underlying emotional needs behind the acts of self-harm by attuning to attachment history and early life history. Exploring the past can uncover parental, abuse or indifference but if such adverse early experiences can be processed emotional defensiveness may be broken down [65]. Breaking defenses can uncover a desire to belong and to be loved and nurtured, in turn creating a more positive narrative pathway for the future involving hope. Increased understanding of the root to urges to self-harm can facilitate a more coherent self-narrative. Being able to understand emotions and reactions has been found to be associated with greater psychological well-being [64]. Gradually, a new and more meaningful self-narrative can emerge. Selfunderstanding can in turn facilitate self-compassion which is important for reducing shame and learning how to self-sooth [65,67].

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