The Self-Injury Experiences of

Young Adult Women:

Implications for Counseling
Laurie M. Craigen
Tammi F. Milliken
s

Many counselors lack a clear understanding of the phenomenon of self-injury. This article
presents results of a qualitative study examining the experiences of young adult women who
engage in self-injurious behaviors. Interpretation of the participants narrative data offers
insight into the value of a humanistic approach to counseling this population.

s s s
Self-injurious behavior is an emerging phenomenon that affects an increasing number of women in the United States (Adler & Adler, 2007; Nock &
Prinstein, 2005). Because of the privacy associated with this phenomenon,
accurate statistics are difficult to determine. Nonetheless, estimates of
the prevalence of self-injury range from 14% to 39% of adolescents in the
general population, and the numbers are predicted to increase (Gratz,
2001; Gratz, Conrad, & Roemer, 2002; Muehlenkamp & Gutierrez, 2004).
Furthermore, self-injuryin the form of cuttinghas gained attention in
the mainstream media through movies such as Girl Interrupted and Thirteen.
Additionally, the Internet contains numerous message boards and websites
addressing self-injury. Pro-self-injury personal blogs and videos can be
found on popular websites such as MySpace (http://www.myspace.com/)
and YouTube (http://www.youtube.com/). These sites allow women to
communicate, view testimonies, and support one another regarding their
self-injurious behaviors.
Despite the alarming prevalence of self-injury, the field of counseling has
only just begun to pay attention to this phenomenon, and the limited research
available has been quantitative in nature. As a result, the data have failed to
provide an in-depth understanding of the lived experiences of those who
self-injure. To assist counselors to respond in a more humanistic manner with
this population, qualitative research is needed (Craigen & Foster, 2009). The
current study aimed to address this gap. The primary purpose of this research
study was to examine young adult womens overall experiences with selfinjury; thus, a phenomenological approach was best suited. The qualitative
Laurie M. Craigen and Tammi F. Milliken, Department of Counseling and Human Services, Old
Dominion University. Correspondence concerning this article should be addressed to Laurie M. Craigen, Department of Counseling and Human Services, Darden College of Education, Old Dominion
University, 110 Education Building, Norfolk, VA 23529 (e-mail: lcraigen@odu.edu).

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2010 by the American Counseling Association. All rights reserved.

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themes that emerged from this study reflect humanistic perspectives and will
contribute to a more humanistic approach to treating self-injury. A description of these themes and a discussion of their implications for counseling
follow a review of the literature related to the characteristics of individuals
who self-injure and treatment of self-injury.
CHARACTERISTICS OF INDIVIDUALS WHO SELF-INJURE
Researchers have indicated that self-injury is 3 to 4 times more common
in women than in men (McAllister, 2003). However, these findings are not
without controversy. Many have argued that the statistics are much higher for
men yet are minimized because men may be less likely to report incidences
of self-injury and counselors may not be as adept at examining self-injury
among the male population (Shaw, 2002). Moreover, statistics are limited on
the examination of racial and ethnic groups; thus, little is known concerning
this activity in marginalized or nondominant groups.
Individuals who self injure are also commonly given differing diagnoses:
depression, dissociative identity disorder, obsessive-compulsive disorder,
schizophrenia, anxiety disorder, adjustment disorder, borderline personality
disorder, and other personality disorders (Nock & Prinstein, 2005). Women
who self-injure are commonly diagnosed with an eating disorder. An investigation of a study that examined the prevalence rates of eating disorders in the
self-injuring population yielded eating disorder rates of 30% (Paul, Schroeter,
Dahme, & Nutzinger, 2002). These comorbid diagnoses may be valid. On the
other hand, many individuals who self-harm may be diagnosed inaccurately
because no official diagnosis exists for self-harm, and the clinician treating the
individual may not properly understand the phenomenon of self-injury.
Understanding the phenomenon of self-injury is difficult because of the
complex nature of the behavior and the multitude of reasons why an individual may choose to engage in the behavior. We reviewed the literature
and discerned three main influencing factors for self-harm: environmental,
psychological, and biological factors.
Environmental influences to self-injury are often linked to childhood physical or sexual abuse, parental substance abuse, and poor parentadolescent
communication (Hodgson, 2004; Zila & Kiselica, 2001). Frequently cited
psychological motivations for self-injury are to end a period of depersonalization, to ground oneself, to cope with emotional turmoil, to gain
a sense of control, to serve as distraction to ones overwhelming emotional
pain, to communicate a need for help, to release tension, and to self-punish
(Walsh, 2006; Zila & Kiselica, 2001). In addition to the environmental and
psychological motivations for self-injury, researchers are now beginning to
investigate biological explanations for self-injury. Neurobiological researchers
have recently indicated that physiological influences exist that are related to
different neurotransmitters, which may instigate the behavior, resulting in
individuals having difficulties in stopping themselves from self-injuring. For

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example, when individuals harm themselves, they may trigger the production
of enkaphalins, a neurotransmitter that produces a pleasurable effect. This
effect may then motivate the individuals, when they are feeling depressed
or unhappy, to harm themselves to feel better. Empirical studies examining
the role of neurotransmitters in self-injury are limited, and future research,
which may ultimately guide treatment, is needed (Favazza, 1998).
The interplay of the environmental, psychological, and biological influences
suggests that self-injury is a complex phenomenon. Unfortunately, many counselors do not fully understand the intricacies of self-injury and consequently,
do not adequately provide proper treatment to individuals who self-injure.
TREATMENT OF SELF-INJURY
Self-injury presents considerable challenges to the professional counselor
because little empirical data supports specific treatment protocols (Muehlenkamp, 2005). We reviewed current literature on empirically supported
treatment of self-injury. Although studies have yielded mixed results,
researchers have found that cognitive behavior and problem-solving treatment approaches are most effective in reducing symptoms (Muehlenkamp,
2005). However, without a strong and collaborative therapeutic relationship,
treatment is less likely to be successful (Craigen & Foster, 2009). In fact,
many individuals who self-injure have indicated a high rate of dissatisfaction with the treatment they receive (Favazza & Conterio, 1988; Shaw,
2002), suggesting that the therapeutic alliance is necessary for counselors
working with women who self-injure.
Counselors who lack knowledge and awareness of self-injury often do not
provide the treatment that these individuals need. In fact, self-injury has been
regularly identified as a behavior that is time consuming, overwhelming,
and frustrating for the counselor (Nafisi & Stanley, 2007; Zila & Kiselica,
2001). Furthermore, it is not uncommon for counselors to inappropriately
pathologize clients self-injurious behaviors (Nock, Teper, & Hollander,
2007; Shaw, 2002). Clinicians may erroneously categorize self-injury as a
symptom of borderline personality disorder or misidentify the behavior
as a suicide attempt. As a result, they may refuse to work with individuals
who self-injure, labeling them as manipulative and difficult to work with
(Crouch & Wright, 2004; Deiter, Nicholls, & Pearlman, 2000; Nafisi & Stanley, 2007). Counselors reactions, if void of empathy, can have damaging
psychological and emotional effects on self-injuring clients.
METHOD
Participants
Participants were 10 women, 18 to 23 years old, recruited from a small
southeastern public university. Each fit the criteria of being a young adult

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who self-injures; thus, purposeful sampling was used. Regarding their

educational status, 8 women were undergraduate students and 2 were
graduate students. All were single and without children. None were participating in counseling at the time of the study. Of the 10 women, 8 were
Caucasian, 1 was African American, and 1 was Latina. All were no longer
actively cutting. However, because the term actively was not specifically
defined, significant variance existed in their last experiences with self-injury.
Additionally, several of the participants engaged in more than one form
of self-injury. Demographics of the 10 participants are shown in Table 1.
Pseudonyms were used to protect their confidentiality.
Data Sources
Qualitative interview. The interviews for this research study were consistent
with the phenomenological approach. The purpose of a phenomenological
interview is twofold: allowing the researcher to gain a deeper understanding
of the person and existing as a vehicle to develop a narrative regarding a
particular personal experience (Rossman & Rallis, 2003). Before interviews
were performed, we developed an interview guide with a list of subject
areas to be explored. We used two face-to-face semistructured interviews
consisting of open-ended questions:
1.
2.
3.
4.

Tell me about your history of self-injury.

Tell me about your motivations for harming yourself.
What are some factors that contributed to your self-injury?
What, if any, was the role of counseling related to your
self-injury?
5. When I look back at my experiences with self-injury, I think . . .
6. When I look back at my experiences with self-injury, I feel . . .
7. If I could make any changes in my past related to self-injury,
I would . . .
TABLE 1
Demographics of Participants
Participant

Age

Race

Form of Self-Injury

Time Elapsed

Amy
20
Caucasian
Cutting
1 month
Claire
21
Caucasian
Cutting
3 years
Sam
20
Latina
Cutting, Eating Disorder
6 months
Ann
20
Caucasian
Cutting
3 years
Juliana
22
Caucasian
Cutting, Eating Disorder
1 month
Katy
23
Caucasian
Cutting, Eating Disorder
1 year
Calliope
21
Caucasian
Cutting
1 year
Jane
22
Caucasian
Cutting
2 years
Becky
22
African American Cutting, Eating Disorder
2 years
Kylie
18
Caucasian
Cutting, Eating Disorder
1 year
Note. Pseudonyms used to protect confidentiality. Time Elapsed = Time elapsed since last
self-injury experience.

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Conducting two qualitative interviews is consistent with the phenomenological strategy: data collection continues until data reaches a saturation point
(Moustakas, 1994). We conducted two interviews, each lasting 1 hour, with
each participant. The two interviews allowed the first author (hereinafter
the researcher) to gain an in-depth and meaningful understanding of the
young adult womens experiences with self-injury.
Reflexive journal. The researcher maintained a reflexive journal throughout the research process to address the expectations and values that she
brought to the study. The journal enabled her to bracket possible biases
and judgments to enhance the studys credibility and authenticity. The
reflexive journal consisted of several components: the researchers daily
schedule pertaining to the study, a personal diary consisting of reflections
regarding her values as well as conjectures concerning growing insights,
and a methodological log in which decisions and rationales regarding
the methodology were recorded (Lincoln & Guba, 1985; Patton, 2002).
The researcher created the format for the reflexive journal. An audit team
consisting of colleagues provided feedback at specific intervals throughout
the research process.
Demographics. Before beginning the first interview, each participant completed a brief demographics sheet. The women answered questions regarding age, race, and family of origin. They also answered questions relating
to the onset, duration, and severity of their self-injurious behaviors.
DATA ANALYSIS
The researcher conducted all interviews and completed each transcription.
To add to the credibility of the data, the researcher requested feedback
from the participants pertaining to the accurateness of their responses and
the interpretations she made. This feedback was obtained at three points
during the study. First, during each interview, the researcher asked for
clarification or elaboration, when needed. Second, participants reviewed
transcripts and provided corrections as necessary. Finally, the researcher
gave participants a draft Results section and requested their corrections
and clarifications.
We focused our analysis on the responses of the womenhow they
constructed meaning of their overall experiences with self-injury. Adhering to the principles of a phenomenological strategy, we began analysis as
soon as data were generated. We conducted a categorical analysis of the
interviews, identifying similarities and differences among the data and
coding and sorting them into appropriate categories (Rossman & Rallis,
2003). We identified the paragraph as the unit of analysis. Because of the
phenomenological approach of this research study, the case analysis was
indigenous. Indigenous categories are those expressed by the participants;
the researcher discovered them through analysis of how language was
used. Conversely, the across-case analysis was interpretive; the researcher

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made interpretations from the language the participants provided (Rossman & Rallis, 2003).
The researcher searched for themes in the participants experiences by
seeking broad categories with subthemes to elaborate the topography of
meaning expressed by the participants. More specifically, this phenomenological study searched for the deep ways in which people make meaning of
their lives and their self-injury experiences, for example, how they integrate,
differentiate, and so on. While identifying these themes and patterns, the
researcher specifically looked for convergence and divergence across participants. Throughout the study, we conducted the analysis of data alongside
the audit team. After each interview was coded, the audit team members and
the researcher reached agreement through a series of meetings. Themes were
altered, changed, and restructured on the basis of this process. Triangulation
occurred through the use of interviews, participant feedback, the audit team,
and the reflexive journal, thus establishing trustworthiness. Throughout the
entire data analysis process, the researcher was actively involved, continually
making sense of and giving meaning to the data (Moustakas, 1994).
RESULTS
Two primary cross-case themes emerged from the data analysis of womens
experiences with self-injury: important relationships and interwoven elements of self-injury. Each primary theme was composed of subthemes that
were delineated on the basis of participant responses.
Theme 1Important Relationships
Under the theme of important relationships, eight women talked about their
families and seven talked about their friends; thus, we created two subthemes
of family and friends for this primary interpretive theme. Relationships
to family and friends were significant to all participants. These important
relationships are essential to understanding participants identities and to
making sense of how their family and friends may have influenced their
experiences with self-injury.
Subtheme 1afamily. Regarding important relationships, the subtheme of
family emerged from analysis of interview responses. Participants talked
about their parents and specifically about their mothers.
Regarding their parents, six women talked about the reactions of their
parents to their self-injuring behaviors. The women experienced a diverse
range of reactions from their parents. For Ann, her parents pretended it
didnt exist or it didnt happen, failing to address or talk about her selfinjury with her. Only when a school counselor called Anns home to inform
her parents that she was cutting herself did they schedule an appointment
with a medical doctor and eventually bring her to a counselor. In Anns mind,
her parents got her treatment because they were concerned about how her

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behavior would reflect on the family: My dad is like really big on the image
of the family and that was a bad image, so he was trying to take care of that.
Katys parents also initiated her involvement with counseling; however, she
felt like her parents didnt take the time to find a counselor who was good.
She described her parents attempt to get her counseling:
They [her mom and dad] were so desperate to locate somebody, and they both are
very private people. And so they couldnt turn to their friends to say, We need help.
So, it was mostly just looking in the phonebook to find somebody whose schedule
worked with theirs and mine after school.

Calliope shared that when she was harming herself in high school with
safety pins and razors, her parents didnt know because she purposefully hid the behavior from them. Amy and Kylie also initially hid their
self-injury from their parents. For Amy, she didnt want to upset her
parents, hurt them, or let them down. Kylie echoed similar sentiments
and stated, I didnt want to disappoint them. However, for Kylie, she
believed that her parents probably knew about her self-injury, although
they never spoke of it. Claire also felt this way and stated that she never
talked about her cutting directly with her parents.
Regarding their mothers, six women talked specifically about their mothers reactions to their self-injurious behaviors. Two of the six spoke of the
lack of support they felt from their mothers. For example, Beckys mother
learned of her self-injury when Becky was in college, shortly before her
mother passed away. According to Becky, her mother did not understand
her behavior, and they only talked about it briefly on one occasion. Likewise,
Anns mother didnt understand her behavior; she was determined that
it was just a phase.
In contrast to Becky and Ann, Jane, Calliope, Amy, and Katy talked about
the caring support their mothers gave them or the concern their mothers
expressed during the counseling process. For instance, Janes mother was
very compassionate and helped her immediately to get counseling. Additionally, Calliope mother, who learned of her self-injury when Calliope
was in college (long after she started harming herself), took the news of her
self-injury really well. In fact, her mother shared with her that she had
cut herself one time in high school. For Calliope, she preferred to speak
to her mother, rather than her father, about her self-injury. In her eyes, it
seemed like a girl issue. Amys mother was supportive in her reaction
to Amys self-injury and expressed a great deal of concern. In fact, Amy
shared that it was one of the only times she had seen her mother cry. I
felt really bad. . . . I obviously got really upset because she was so upset.
Katys mother reacted in a similar manner:
For a long time after, she couldnt look at my baby pictures because she said . . .
Here was this perfect child who was unblemished in some ways. . . . And she
wasnt just talking physically but also emotionally and how painful it was to not
blame herself.

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Subtheme 1bfriends. Regarding important relationships, the subtheme of

friends emerged from analysis of interview responses. Participants talked
about friends knowing about their self-injury and friends with problems.
Regarding friends knowing about their self-injury, five women talked
about the significance of their friends knowing or not knowing about their
self-injury. For Calliope, only a couple of her close friends were aware of
her cutting during high school, although she didnt talk about it often with
them. She shared, I wanted to have fun, and I didnt want to be a burden
on them. Unlike Calliope, four participants (Claire, Sam, Kylie, and Juliana)
talked openly about their self-injury with friends. Sams friends were upset
when they discovered that she was cutting herself, but they encouraged
her to talk to them about her problems. On reflection, Sam found this approach to be extremely helpful to her. Kylie also experienced support from
her friends. Many of her friends let her know they were there for her, but
never pushed any of their views on her. Likewise, Julianas friends were
supportive, yet she had one experience that was different from that of the
other participants. Juliana had a friend who would take her to a store so
she could purchase gauze and alcohol, the necessary supplies, to cleanse
her wounds after cutting. At the time, Juliana was thankful for this friends
assistance. However, on reflection, she realized that this friends actions
were more enabling than being truly helpful.
Although many of the participants friends offered support, others responded with anger and fear. For example, Kylie shared that some friends
were really up in my face about it. They were like, Why are you doing
this? What is wrong with you? Why are you trying to kill yourself? Why are
you being so selfish? Like Kylie, Claire had one friend she told in college
who was really upset and quickly notified both the school and Claires
parents without her knowledge. This friend was ultimately responsible
for her initial experiences in counseling. Claire explained that her friends
approach was kind of weird. . . . I think it would have been better if it
worked out differently.
Regarding friends with problems, five women talked about having friends
who had problems. For example, Ann shared that many of her friends had
problems and were sketchy. She commented that one of the worst days
of her life was when she learned that a close friend was also cutting herself.
Calliope too had friends who were engaging in self-injury. She shared, I
guess it seemed normal because a lot of my friends were very smart girls,
so I thought it must be kind of normal for smart girls to cut themselves.
Although Kylie and Katy didnt talk about their friends specifically cutting themselves, they did share that many of their friends had significant
emotional problems. For Katy, many of her friends had eating disorders,
like herself. Additionally, Juliana had a close group of friends in college
with a variety of different mental health concerns. She talked about one
friend who had attempted suicide numerous times and another friend
who had very serious chronic depression.

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Theme 2Interwoven Elements of Self-Injury

All participants talked about different elements of their self-injury. They
described their physical and emotional responses to their self-injuring behaviors. They also talked about how they learned to engage in the behavior
and how they worked hard to keep it from others. Finally, the women
spoke about eating disorders as a form of self-injury. As a result, the four
subthemes of describing cutting, a learned behavior, privacy, and eating
disorders were created for this primary interpretive theme. Understanding
these participants perspectives concerning their self-injury helps counselors
develop greater levels of empathy and can contribute to the development
of effective interventions tailored to individual client needs.
Subtheme 2adescribing cutting. Regarding interwoven elements of selfinjury, the subtheme of describing cutting emerged from the analysis of
interview responses. In describing their self-injurious behaviors, nine
participants discussed the relationship between cutting and suicide, pain,
feelings, physical aspects, and coping.
Regarding suicide, four women talked about their suicide attempts or
suicidal ideations and the distinct differences between self-injury and suicide. Ann admitted that she had two previous suicide attempts, yet she
viewed these attempts as different from the times she was cutting herself:
The cutting was more because I couldnt cry. . . [and] the suicide was
just like I couldnt handle it. Jane, on the other hand, shared that she did
not attempt suicide; however, she was removed from school for suicidal
gesturing. For Jane, it was hard to classify this injury: It wasnt that
I want to kill myself, but I was just going to go with it and see where it
went. If I died, fine. If not, it would be more of the same. In contrast to
Ann and Jane, Sam did not exhibit suicidal behaviors. However, she did
express to a friend in college thoughts of overdosing on pills. Despite this
experience, she shared that cutting was not terminal, explaining that
the behavior was never an attempt to end her life but to release her emotional pain. Finally, Kylie provided further clarification on the differences
between cutting and a suicide attempt: Trying to kill yourself by slitting
your wrists is very different than cutting yourself because you are trying
to relieve pain [when cutting].
Regarding pain, four participants shared how the cutting was a physical
representation of the emotional pain that they were experiencing. Amy
stated, The pain inside was so much and I didnt want to talk about it, so
it was just easier to cut and feel some sort of physical manifestation of the
emotional pain. Calliope and Becky nearly replicated this explanation as
they both explained that the act of cutting was about taking the pain emotionally and manifesting it into a physical form. Finally, Sam agreed that
cutting allowed her not to have the pain inside by externalizing it.
Regard feelings, four womenCalliope, Jane, Becky, and Amytalked
about their feelings and how these feelings related directly or indirectly to

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their self-injury. Calliope specified that feeling upset, mad, or disappointed

at herself drove her to self-injure. For example, she stated, I would get
really mad at myself. Id be like, You did really bad on your test. And I
would cut myself when I would get upset. On the other hand, Becky and
Amy talked about how their feelings of depression led them to self-injurious
behaviors. Becky shared, Its not even empty . . . its past empty. Its worse
than empty. Its like an unidentifiable pain that you have. Amy shared that
her feelings of unhappiness and depression ultimately caused her to isolate
herself from other people. As she described, I got into a very, very bad
place in my head. This very bad place served as the catalyst to her first
experiences with cutting.
Regarding physical aspects, three participants talked about various
physical aspects of cutting. Sam often cut herself when she was feeling
stressed, and her cutting allowed her to have a physical release from this
stress. On the other hand, Ann believed that her cutting represented a
physical expression of her feelings. As she stated, I was a girl who instead
of crying, cuts. Kylie was the only woman to explain in detail about the
physical aspects of cutting:
Seeing my own blood was like, a rush for me. That sounds so gross. . . . But seeing
blood like trickle down my leg or something felt really good to me. It felt empowering,
it felt dangerous, I guess, and that gave me a rush and a feeling, almost like playing
God. . . . That is a little extreme. But, and so then, basically, you know, I would let it
bleed and I would watch it, and I would be like, wow, this is intense.

Regarding coping, three womenKaty, Kylie, and Julianatalked

about how cutting served as a behavior to help them cope with other
issues. For Katy, cutting was used as a mechanism for coping with her
problems by giving her a sense of control in her life. She stated, I didnt
have any control in my life and [self-injury] was the only way to exercise
some kind of command over what was happening to me. For Kylie, she
cut because she didnt know how else to cope. Likewise, Juliana talked
extensively about cutting as one of several coping behaviors in which
she engaged. She often switched from one to another. For example, if she
stopped cutting, she started smoking or drinking. She also shared that
when her eating disorder was at its peak, her cutting was at its lowest
point and, conversely, when she recovered from the eating disorder, the
cutting got worse.
Subtheme 2ba learned behavior. Regarding interwoven elements of selfinjury, the subtheme of a learned behavior emerged from the analysis of
interview responses. Five women discussed how learning about cutting
became the impetus for them to try the behavior themselves. Claire first
tried cutting after reading about it in a book:
My senior year in English, they made us read Reviving Ophelia. That talks about like
girls with problems, and I was like, Im a girl with problems. And it was like, Here
is what people do when they have problems.

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Jane and Becky engaged in the behavior after learning about it from
television. For Jane, she got the idea to cut from an episode of 7th Heaven:
I had never heard of it before then. For Becky, she first learned about
cutting from a movie, Secret Cutting, on the USA Network. Shortly after
watching the movie, she shared, I tried it and it was magic.
Both Calliope and Juliana learned about self-injury from other women
who self-injured. Calliope shared, I went to a nerd camp. I loved it. It was
such a great time. I was really happy there. But, I remember my friend
showed me her arm. . . . It was horrible. Despite her initial aversion to
the behavior, she believed the experience at camp later influenced her to
try cutting. Juliana discovered the behavior when at an inpatient treatment
facility for her eating disorder. On reflection, she learned about self-injury
from watching a woman in her group session who would scratch her
hands and pick her cuticles: I essentially picked up [this behavior] from
watching her.
Subtheme 2cprivacy. Regarding interwoven elements of self-injury, the
subtheme of privacy emerged from the analysis of interview responses. Four
women talked about their self-injury being a private matter, which they
often hid from others for a variety of reasons. For Amy, she did not want
her experience of self-injury to be known to others, in fear that she would
be looked at differently. She felt that there was some sort of shame attached to the behavior and, as such, shared, I dont want it to come up
in somebodys conversation with someone else. I dont want it to be spread
around. For Sam, her self-injury was something that she didnt like to talk
about with anyone, including her family, friends, and counselors. She shared,
Im not proud of it at all. Its not something you want to talk about with
other people. Like Sam, Claire and Juliana not only kept their self-injury
from their family and friends, but also hid it from their therapists. Claire
learned that if she told her therapist she had stopped cutting she would
no longer have to attend sessions. Similarly, Juliana learned from others
in the inpatient treatment facility how to minimize her contact with the
therapists. She stated, Everyone in the room teaches you. If you have a
plan [to hurt yourself], you cant . . . you dont say anything. Thus, within
an inpatient setting, Juliana opted to keep her cutting from her therapists
to avoid consequences, such as additional therapy sessions, reports to
parents, suicide assessments, or increased monitoring.
Subtheme 2deating disorders. Regarding interwoven elements of selfinjury, the subtheme of eating disorders emerged from the analysis of
interview responses. In addition to cutting, five women experienced eating disorders. Each perceived her eating disorder as a type of self-injury,
although distinct from cutting. All five womenSam, Katy, Kylie, Juliana,
and Beckyfirst entered counseling because of their eating disorders as
opposed to their cutting, likely because of their abilities to keep many selfinjuries better hidden than extreme weight loss. Kylie shared that her cutting overlapped with her eating disorder. She either cut herself or purged,

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depending on the circumstances. Kylie shared, If I was in a place where

I couldnt throw-up being unnoticed, like a public bathroom or crowded
something, I would cut.
Both Juliana and Becky received inpatient treatment for their eating disorders. When she was 12 years old, Juliana was admitted to an inpatient
center for anorexia and bulimia. Her cutting, which she recognized as a
separate sort of illness, manifested itself in this center after she observed
other patients engaging in the behavior. Beckys treatment for anorexia and
bulimia occurred during two separate periods in college.
DISCUSSION
From the participants extensive discussions regarding their cutting, we
can infer that self-injurious behavior is a multilayered phenomenon, with
emotional, psychological, and physical repercussions. Although the specificity of the experiences of the women in this study may not be generalizable
to all clients, counselors can benefit from understanding the complexity
of the phenomenon and the multitude of variables that can contribute to
self-harming behavior.
Overall, the women in this study wanted to tell their stories and wanted to
be heard, which has direct implications for treatment. Namely, the cognitive
behavior approaches that many counselors use may not be the best fit for
this population. Rather, a humanistic approach may be most appropriate
and may be particularly powerful for these women. A primary tenet of the
humanistic framework is that human beings are all active in giving meaning to their experiences (Mize, 2003). Additionally, a humanistic approach
supports the idea that sharing ones story allows individuals to develop
their own self-capacities, stimulates change, empowers, and transforms
(Rogers, 1986). As opposed to focusing on problem-solving strategies, counselors who address self-injuring individuals from a humanistic perspective
might assist their clients in developing insight regarding their behaviors
by providing them with opportunities to share their stories and explore
their experiences in supportive and empathic environments.
Another implication for treatment that emerged from the results of this
study was in relation to the emphasis the women placed on their relationships with family and friends. They spoke at length about the reactions their
parents and friends had to their self-injury along with the role their parents
and friends played in getting them involved with treatment. Many of the
women shared that their parents did not understand their self-injurious
behaviors, and many failed to communicate openly with their parents regarding their self-injury. This finding strengthens the notion that self-injury is a
systems issue. Thus, it would behoove mental health professionals to add
a family therapy component to treatment with the aim of improving communication, understanding, and support. Family therapy may also provide
a forum for resolving some of the systemic problems that contributed to the

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self-injuring behavior. Furthermore, the addition of a psychoeducational

piece would be valuable in that it could potentially increase knowledge
and awareness about the phenomenon of self-injury. Understanding that,
for many, self-injurious behaviors are rooted in systems, therapists may
consider obtaining consent to contact other helping professionals in the
self-injurers life, such as school counselors. A collaborative approach to
helping that addresses the multiple systems in which the client functions
may allow for a broader reaching influence.
Implications for treatment also stem from self-injury being a very personal
and private matter. The majority of the participants in the study did not want
to talk about their behaviors with others, especially their counselors. Some
went so far as to hide their self-injury from their counselors or manipulate
their counselors into thinking that they were no longer cutting themselves.
Without a trusting, humanistic relationship, clients will likely keep their
self-injury hidden and avoid discussing their behaviors throughout the
treatment process (Nafisi & Stanley, 2007; Walsh, 2006). This reality speaks
to the critical need for counselors to establish rapport, form a connection,
use empathic listening, and provide genuine support to clients who selfinjure (Craigen & Foster, 2009).
The complexity of self-injurious behavior also has implications for treatment. Despite thematic overlap, each participant in this study shared unique
experiences, feelings, and environments. Counselors must understand that
not all individuals who self-injure are the same. Counselors need to look
at each client through a distinct lens. In addition, rather than focusing on
the outer symptoms or physical wounds, it is important for counselors to
examine the root, or underlying issues, that contributed to the clients selfinjury. It is the underlying issues, not the cutting behaviors, that should
guide treatment planning, case conceptualization, and therapeutic interventions with clients who harm themselves.
As mentioned earlier, findings of qualitative research, such as this study,
are only logically generalizable (Rossman & Rallis, 2003). However, they
may still serve as valuable indicators for improving treatment and as
grounds for further research. For this study, the researcher interviewed 10
young adult women, 8 of whom were Caucasian. Future research pertaining
to self-injury, both qualitative and quantitative, is needed within diverse
populations. Specifically, self-injury needs to be examined in the context
of different races, cultures, genders, and ages. Additionally, investigating
counselor and family perceptions of self-injury would add to the research
and provide clinicians with a broader understanding of the phenomenon.
Many of the interviewed women, especially those with a history of eating
disorders, used the term self-injury to describe a range of self-harming
behaviors. For them, anorexia and cutting were both distinct forms of
self-injury. With this in mind, it would be worthwhile for researchers to
compare and contrast different forms of self-injury, in terms of both client and counselor conceptualizations and counselor approaches to these

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distinct behaviors. For example, do counselors approach cutting in the

same manner as they do an eating disorder? Are their treatment plans
similar? Finally, it would be valuable to empirically investigate outcome
studies related to self-injury using different treatment modalities, such as
a humanistic counseling approach.
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