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Credible discusses the overview of moral panic in young people. Therefore discussing the panic and social anxieties of young people in society.

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Credible Sources inquires about the issues of young people and providing an overview of self-harm across Australia.

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Credible source discusses the risk factors of self-harming and likely remedies in young people

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Credible source states young people self-harm with or without suicidal intent. And that self-harm is the leading cause of death among young people

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Credible Discusses young people who commit any form of self-harm, tend not to seek professional help.

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Credible discusses the self-expression of young people in social media

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Credible discusses the danger of social media and how sexting and sexualisation has become an common them in young people

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Credible discusses the suicide facts in Australia in relation to young people

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Credible Source talks about  Young people engage with social media to socialise, to be entertained and, importantly, to share their lives with each other. And how social media presents a probelm

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Credible Source discusses about the power of social media and how it influences young people to make radical decisions of Self-Harming

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Credible Source explaining the media background of self-harming in Australia and Statistics

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ConNetica.(2016). Suicide in Australia:Key Facts Retrived from https://static1.squarespace.com/static/5858b2276b8f5be324ffefff/t/5898ff2f15d5dba05f6c9c9d/1486421825261/media_backgrounder_-_suicide-suicide_prevention_australia_may_24
Australian Human Rights Commission.(201).Chapter 3: Intentional selfharm, with or without suicidal intent, in children and young people under 18 years of age. Children’s Rights Report.

Daraganova,G,(2016). Self-harm and suicidal behaviour of young people aged 14-15 years old.Annual Statistic Report. Retrieved from http://data.growingupinaustralia.gov.au/pubs/asr/2016/asr2016f.pdf

Gabriel, F.(2013).  SEXTING, SELFIES AND SELF-HARM: YOUNG PEOPLE, SOCIAL MEDIA AND THE PERFORMANCE OF SELF-DEVELOPMENT

Healy, J.(2013).Youth Mental Health: Issues in Society:Mental Health Anxiety in Adolescents in Young-Adults.

Mutai, J.(2011). Self-harming among young people: A literature Review. Bachelor Thesis.

Rowe, S.,French, R., Henderson, C., Ougrin, D., M., Slade &Moran, P.(2014). Help-seeking behaviour and adolescent self-harm: A systematic review. Australian & New Zealand Journal of Psychiatry 2014, Vol. 48(12) 1083–1095 DOI: 10.1177/0004867414555718

Miller, K.(2017). 13 Reason Why? Is Not The Force For mental Health Awareness People Say It Is
Retrieved from https://www.self.com/story/13-reasons-why-suicide-and-mental-health

Orygen.(2015).Self-harming and young people:Research Bulletin.The National Centre of Excellence in Youth Mental Health. Retrieved from https://www.orygen.org.au/Research/Research-Areas/Suicide-Prevention/Research-Bulletin-Self-Harm-and-Young-People

Orygen.(2015). Myth-buster Self-Harm Sorting Fact from Fiction. Retrieved from https://www.orygen.org.au/Education-Training/Resources-Training/Resources/Free/Mythbusters/Self-Harm/Orygen_Self_Harm_Mythbuster?ext=.

Odgen, J & Bennet, A.(2015).Self-Harm as meme to manage the public and private serves: A qualitative study of help seeking by adults.Sage Journal.

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However, It talks about the Netflix Show 13 Reason Why and how it discusses of the life of Hannah Baker and why she committed suicide critics. Argue that the show glamorises self-harming and trigger suicidal thoughts in young people

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The buzzy new Netflix show 13 Reasons Why is the streaming site's most popular show on social media (research firm Fizziology told Refinery29 that it generated 3,585,110 tweets during its first week), and many are calling it a force for mental health and suicide awareness. For instance, some people have praised the show, saying the fictional setting (a safe, small-town-ish city) shows this could happen at any school and that sometimes a number of factors lead people to feel that suicide is their only option-it's often not just one. Others have said it helps raise awareness about warning signs to look out for.

The show, which is executive produced by Selena Gomez, is based on the 2011 best-selling Jay Asher book by the same name. In it, teen Hannah Baker leaves behind 13 cassette tapes explaining in explicit detail why she chose to kill herself. Each tape is dedicated to one of Hannah's peers, calling them out for the things they have done to her and ways they've caused her harm. 13 Reasons Why covers a wide variety of serious topics, including bullying, rape, slut shaming, depression, and, of course, suicide.

Asher told EW recently that Hannah lived in his original ending for the book-she was supposed to have overdosed on pills but then was saved at the hospital when her stomach was pumped. But he says he realized that death was necessary to raise awareness of the consequences of suicide. "Once I realized that the message of the story would be stronger and that it would definitely be more of a cautionary tale, I felt that was definitely the way to go," he told EW. In talking about the show's finale, Asher also told EW that they purposefully made the suicide scene in the show graphic-for the purpose of driving home the point that her choice to end her life was a bad one. "We worked very hard not to be gratuitous, but we did want it to be painful to watch because we wanted it to be very clear that there is nothing, in any way, worthwhile about suicide," he said.

But experts are deeply concerned that the book and the show may have the opposite of that intended awareness-raising effect, and may impart viewers with the exact wrong takeaway lessons. Ultimately, the entire premise of the story goes against all accepted best practices for how to address suicide responsibly in the mass media. ReportingOnSuicide.org is home to The Recommendations for Reporting on Suicide, which the authors created by working with with "several international suicide prevention and public health organizations, schools of journalism, media organizations and key journalists as well as Internet safety experts," per their About page.

These Recommendations exist because over 50 research studies worldwide have found the way newspapers and news media covers suicide can have an impact on public health-when journalists discuss suicides in the news in particular ways, it can actually lead to a greater risk for suicides. Per the Recommendations for Reporting on Suicide, journalists are taught to follow certain specific rules when discussing suicide:

Don't sensationalize the suicide.

Don't talk about the contents of the suicide note, if there is one.

Don't describe the suicide method.

Report on suicide as a public health issue.

Don't speculate why the person might have done it.

Don't quote or interview police or first responders about the causes of suicide.

Describe suicide as "died by suicide" or "completed" or "killed him/herself," rather than "committed suicide."

Don't glamorize suicide.

13 Reasons Why effectively violates every single one of those guidelines.

Suicide is the 10th leading cause of death in the United States, according to the American Foundation for Suicide Prevention, and each year more than 44,000 Americans die by suicide. The potential for impact on people who are already at risk for suicide is real. Of course, fiction isn't the same as journalism. But the experts we spoke with said that all mass media has the potential to have this effect on vulnerable people-and that's especially true for teenagers.

John Mayer, Ph.D., a clinical psychologist who works with suicidal teens and author of Family Fit: Find Your Balance in Life, tells SELF that the show is "a sad exploitation of a devastating problem among our youth. I don't see the value in it except to sensationalize teenage suicide," he says.

Media is powerful, especially among younger demographics that are drawn to the show, Miami-area licensed clinical psychologist Erika Martinez, Psy.D., tells SELF. "For millennials and Generation Z, what they see in media is canon," she says. "It can certainly glamorize suicide and lead to this copycat sort of effect."

Phyllis Alongi, MS, NCC, LPC, ACS, clinical director at the Society for the Prevention of Teen Suicide, tells SELF that her organization "does not agree" with many of the aspects portrayed in the show, such as romanticizing suicide, including graphic details or depictions of the suicide, inadequate and ineffective assistance from the school counselor, memorialization of the person who killed herself, and placing blame and insufficient treatment. "Hannah's story is fictional, tragic, and not the norm," she says. And unfortunately, teens might not recognize that by watching it.

13 Reasons Why is essentially one long suicide note that makes it seem as though, by killing yourself, you and your problems will not be forgotten. The show is narrated by Hannah through her tapes, although the story is told largely through the eyes of her friend, Clay. Clay is in love with Hannah and, consequently, she's held up as a "goddess" figure (Clay watches her walk into a party in slo-mo-the kind of moment every girl wants a guy to have about her). Hannah is also a gifted poet, likable and relatable, and deeply misunderstood-and her peers keep doing horrible things to her that get worse and worse as the story goes on.

Hannah uses her suicide and the tapes to get revenge on, and gain control over, those who hurt and violated her. The tapes are like fuel for her power, boosting her posthumous status to become "the girl who completed suicide." Hannah even calls out her guidance counselor, Mr. Porter, for failing to help her find a reason to live-essentially blaming someone else for a decision that she ultimately made for herself.

Teenagers are especially susceptible to seeing suicide depicted in such a way, and taking dangerous and inaccurate lessons from it-such as that suicide is a viable coping mechanism when you feel hopeless or in despair; that it's a glamorous way to get the attention you've been seeking (by never being forgotten) or the revenge you've been dreaming of (by getting back at people who've wronged you); and that parents and guidance counselors are inept, out of touch, and unable to help you when you're in trouble. "When we are [teenagers], our coping mechanisms are not developed, so we are left to rely on primitive defense mechanisms and our most primitive is avoidance," Mayer says. "Suicide is the ultimate act of avoidance-avoiding life." Knowing or hearing about suicide puts the thoughts of it in someone's mind and creates the possibility that it's a real choice, Mayer says, which is why he thinks the show is so exploitive.

The truth is that the show is out there, so if you have a teenager who's watching it (and if you have a teenager, they probably are), the best option is to be super honest and direct with them about how the show is problematic and unrealistic, and also be open about what other more important lessons a teenager can take from it. Lessons such as: Suicide is a really bad way to cope with things that are going wrong in life-and there are more effective ways to solve your problems; that you really hurt people who love you if you kill yourself; and that suicide is final, and the opposite of glamorous. "If teens are going to watch 13 Reasons Why, we need to utilize the experience by focusing on suicide prevention," Alongi says.
If you or someone you know is struggling with suicidal thoughts, please contact the National Suicide Prevention Lifeline at 800-273-8255.
CORRECTION: An earlier version of this story listed the wrong narrator. We corrected this post to reflect that Hannah is the narrator, although the story is portrayed through Clay's eyes as he listens to Hannah's tapes.
Related:

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'13 Reasons Why' Is Not the Force for Mental Health Awareness You Think It Is

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The buzzy new Netflix show 13 Reasons Why is the streaming site's most popular show on social media (research firm Fizziology told Refinery29 that it generated 3,585,110 tweets during its first week), and many are calling it a force for mental health and suicide awareness.

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Non-crediable source presenting why non-suicidal self_harm is maintained and how it is developed.

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Credible source exploring moral pain around youth issues

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Credible source identifying youth as 14-25 year olds.

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Credible discusses the Myths behind young people and stigma towards victims of self-harming

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Credible source containing statistics regarding the prevalence of self-harm.

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Self-mutilation is a more common behavior than generally realized; its prevalence may be 750 per 100,000. From the responses of 250 subjects to a Self-Harm Behavior Survey we have learned that...

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Credible source examining how self-harm effects the brain.

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Credible source explaining how self-harm rates have increased for bisexual people.

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The term self-harm is commonly used to describe a wide range of behaviours and intentions including attempted hanging, impulsive self-poisoning, and s...

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credible resource exploring how social media can have a gratifying impact on individuals.

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Non-credibel source providing a helpline to people in need.

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Credible source displaying the perspective of self-harm through a counsellor, enduring different views of self-harm.

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Enter your email address below. If your address has been previously registered, you will receive an email with instructions on how to reset your password. If you don't receive an email, you should register as a new user

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Non-credible source providing a television series incorporating ideas of self-harm.

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Non-credible source of a documentary following the lives of three self-harmers.

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Cut Up Kids, Series 1, Born Survivors - BBC Three

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Documentary which gives an insight into the phenomenon of self-harming teenagers.

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Non-credibel source outlining how stereotypes are still occurring in Australian society

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Credible - Supported by The Australian Government Department of Health.

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Credible - Supported by The Australian Government Department of Health.

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Statistics on Queensland adolescents about self-harm

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Statistics for adolescents on the reason why they self-harmed. There are statistics for AUSTRALIA as well as Europe

Scoliers, G., Portzky, G., Madge, N. et al. Soc Psychiat Epidemiol (2009) 44: 601

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Findings from the child and adolescent self-harm in Europe (CASE) study

Abstract

The present study examines reasons for adolescent deliberate self-harm. A cross-sectional survey using an anonymous self-report questionnaire was carried out in seven countries (Australia, Belgium, England, Hungary, Ireland, the Netherlands and Norway). Data on 30,477 school pupils between the ages of 14-17 were analysed. Past year and lifetime deliberate self-harm were assessed, along with the self-reported reasons for deliberate self-harm. The results showed that 'wanted to get relief from a terrible state of mind' and 'wanted to die' were most commonly reported. Principal component analysis indicated two underlying dimensions in the reasons for deliberate self-harm, i.e. a cry of pain motive and/or a cry for help motive. The majority of self-harmers reported at least one cry of pain motive ('to die', 'to punish myself', and 'to get relief from a terrible state of mind') and an additional cry for help motive ('to show how desperate I was feeling', to frighten someone', 'to get my own back on someone', 'to find out whether someone really loved me', and 'to get some attention'). Females reported more reasons than males. Only females showed an age difference, with girls aged 16-17 more frequently reporting a cry for help motive. There was considerable consistency in choice of motives across countries and genders. Systematic assessment of the reasons for deliberate self-harm can help clinicians to better understand the meaning of self harming behaviour, select appropriate treatment, suggest alternative coping strategies, and hopefully prevent future suicidal behaviour.

Keywords

deliberate self-harm adolescence reasons cry of pain cry for help

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Reasons for adolescent deliberate self-harm: a cry of pain and/or a cry for help?

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Findings from the child and adolescent self-harm in Europe (CASE) study The present study examines reasons for adolescent deliberate self-harm. A cross-sectional survey using an anonymous self-report questionnaire was carried out in seven countries (Australia, Belgium, England, Hungary, Ireland, the Netherlands and Norway). Data on 30,477 school pupils between the ages of 14-17 were analysed.

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" In other words, people posting these images on the internet might ironically still feel a sense of privacy.”

Social Media, Attention and Self-Harm

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"People often try to keep self-harm a secret because of shame or fear of discovery," says the NHS website, but a growing occurrence is of young people posting images of their cuts online.

Self-harm and social media are in the media spotlight at the moment because of the tragic suicide of teenager Tallulah Wilson, who (it was revealed during the inquest) had had posted self-harm images on Tumblr.

Her mother, searching for reasons as to why Tallulah killed herself, said her daughter's addiction to the internet fuelled her death.

Tallulah Wilson, 15, was found dead on the tracks at St Pancras

Since then, discussions centred on whether social media sites, like Tumblr, should be more responsible in monitoring these types of images and whether or not the internet did indeed play a role in Tallulah's death.

After one of our photo editors highlighted innovative ways users can navigate around social media policing, we were motivated to find out more. For example on social media sites such as Instagram, users replace blocked hashtags (such as #self-harm) with alternatives (such as #blood) - the latter serves up some pretty upsetting images of bloodied wrists and forearms.

When we spoke to an Instagram spokesperson to ask them what - if indeed any - moderation takes place, they said: "While Instagram is a place where people can share their lives with others through photographs, any account found encouraging or urging users to embrace anorexia, bulimia, or other eating disorders; or to cut, harm themselves, or commit suicide will result in a disabled account without warning.

"We believe that communication regarding these behaviors in order to create awareness, come together for support and to facilitate recovery is important, but that Instagram is not the place for active promotion or glorification of self-harm."

Sheri Jacobson Collins, a psychotherapist at Harley Therapy, responded to the stance by saying: "I would avoid chastising those who post these images as in many cases self-harm is not about seeking attention, but a way of dealing with distress. We need to direct our focus on offering support rather than judging."

She added: "I'd like to think that when such images are posted, companies like Instagram didn't just send a message saying their account was closed but sent them a communication with options for help such as the Samaritans, Saneline, their GP and emergency services."

However top photosharing social media sites - Instagram, Imgur and Tumblr - host millions of images, so regulation is bound to be difficult.

But the problem at the other end of the scale, with the heavy-handed moderation of sites like Facebook, is a set of sanctions so prudish and narrow-minded that they often prevent images of gay people and breast cancer survivors from being posted.

In 2011, a study by The Lancet revealed that 1 in 12 teenagers self-harm, but most will stop by early adulthood.

The burning question, however, is whether self-harm images encourage young people to cut themselves.

"It depends on the individual," says Sheri, "For some, it could be a turn-off, as it could hold a mirror up to the behaviour they are engaging in and help foster a willingness to seek help.

"However for many it is unlikely to act as a deterrent since self-harm is purposeful - it is commonly used as a way to deal with negative feelings (depression, anger or guilt for example), which may be ongoing and entrenched."

Sara McCorquodale, editor of MyDaily.co.uk, spoke about her experiences as a former self-harmer.

She says: "When I was self-harming, social media didn't exist and I can't imagine wanting to tell anyone. What I can say is, self-harming is quite a big secret to carry around and as it gets worse, hiding it - and telling no one - is a burden.

"You assume friends and family wouldn't understand because you know it's quite a strange thing to do. I suppose knowing there are a community of people who can empathise could be comforting but even then I'm perplexed about the pictures."

Sara believes, like Sheri, that a person who is self-harming is likely to do so anyway.

"In my experience, the thing that perpetuated self-harming was that it becomes quite addictive and compulsive. More than anything, that's why I found it hard to stop - it's a very instant release. I think blocking sharing pictures of self-harming on social media wouldn't solve the problem it would just hide it. I very much doubt people start this type of behaviour as a result of Instagram /Tumblr," says Sara.

Tumblr, the site used by Tallulah, issued this message after the teenager's death: "Tumblr has policies to address the most harmful of this content, and we have systems in place to direct users to appropriate resources for getting whatever help they may need.

"We are committed to continually improving our ability to act on self-harm content, and also to keeping Tumblr a positive, supportive environment for those individuals dealing with issues of depression and self-harm."

Warning signs that a family member or friend is cutting or self-injuring

Unexplained wounds or scars from cuts, bruises, or burns, usually on the wrists, arms, thighs, or chest.

Blood stains on clothing, towels, or bedding; blood-soaked tissues.

Sharp objects or cutting instruments, such as razors, knives, needles, glass shards, or bottle caps, in the person's belongings.

Frequent "accidents." Someone who self-harms may claim to be clumsy or have many mishaps, in order to explain away injuries.

Covering up. A person who self-injures may insist on wearing long sleeves or long pants, even in hot weather.

Needing to be alone for long periods of time, especially in the bedroom or bathroom.

Isolation and irritability.

But Paul Farmer, chief executive of mental health charity Mind, says that a stronger stance needs to be taken against social media sites. "Websites that promote self-harm and suicide can be incredibly damaging and social media platforms need to look hard at their policies and practice to make sure they are not accommodating content that could encourage users to harm themselves."

Self-harm is a way of dealing with overwhelming situations or negative feelings, and trying to get control at a time when everything in that person's life may be volatile. Certainly for Sara, her self-harming started because her best friend was dying from cancer and she was leaving her childhood home to move in with her step-father.

But while the person self-harming may be doing so to regain control in their life, it can also be quite isolating. Perhaps this may be a reason why some choose to share such images online.

Sheri says: "There may be a wish to connect and soothe loneliness. Often, especially with teenagers, it's about feeling that nobody out there understands or cares, so it could be a move to feel they are not entirely alone.

"Plus over the internet, there is still a sense that you maintain your privacy because of the virtual nature of social connections. In other words, people posting these images on the internet might ironically still feel a sense of privacy."

Samaritans has a comprehensive feature on their stance around self-harm practices and the internet, as well as how it relates to suicide. It is already doing great work in the field - it's currently a partner in research to find out the impact of online interactions pertaining to suicide.

They also believe that search engines should have responsibility, so they now work with Google so that when people search for certain keywords, the contact details for Samaritans pop up.

Instagram also employs a warning message, so certain hashtags trigger warning messages that link to external help resources.

"It's possible that some individuals who are self-harming might get further ideas," says Sheri. "If a person has a personality that is subject to extremes, seeing such images might be more damaging in leading them to 'compete'. But I would argue that it is not likely to cause individuals to self harm unless there was an existing tendency to do so."

The solution - for now - seems to be to provide help to vulnerable people self-harming where possible. Also, to show them that there is hope that they can stop.

Sara says: "I just didn't know how to regulate or handle some quite extreme emotions and panicked quite a lot about most things.

"The thing that changed everything for me was joining the gym - exercise was brilliant for just mellowing out and clearing my head. I felt great afterwards and it made me look at my body very differently. I stopped self-harming when I was 16 thanks to this and haven't since."

HELP: If you need advice on coping with suicidal thoughts, self harm or how to support loved ones, visit mind.org.uk or call our Infoline on 0300 123 3393. Alternatively you can visit the National Self Harm Network here.

For help on suicide prevention or for advice and support, visit the Samaritans website or call 08457 90 90 90.

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'People Who Self-Harm Will Do So Anyway': A Report On The Role Of Social Media In Self-Harming

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"People often try to keep self-harm a secret because of shame or fear of discovery," says the NHS website, but a growing occurrence is of young people posting images of their cuts online.

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Tumblr glorifying self-harm

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Tumblr has over 140 million blogs. Most revolve around predictable topics, such as photography, music, fashion, sports and design. But this popular social space has expanded in surprising and sometimes unhealthy ways.

Tumblr thrives on the emotional, diary-like output from a younger demographic, proving a space where teens can post, share, opine, vent and dwell on their interests-including unhealthy ones. Over the past couple years, self-hate blogs have flourished. According to the research team at SimilarWeb, which studied 1.6 million Tumblr blogs, about 200,000 blogs contained self-harm tags. Many of these post include black and white photographs of mystical and dramatically skinny or scarred girls overlayed with quotes like, "I don't know if I'm getting better or used to the pain" and "I want to die a lovely death."

"When you look at secular trends and epidemiological research completed over the last several decades, there seems to be a slow and fairly consistent increase in levels of depression of each succeeding generation of teenagers," says Dr. Mark Reinecke, chief psychologist at Northwestern Memorial Hospital. Reinekce speculates that this is because the online cultivation of "beautiful sadness" is easy to join. "Anyone can take a picture, turn it black and white, pair it with a quote about misunderstood turmoil, and automatically be gratified with compassion and pity," he says.

Depression has always been a stigmatic topic. However, Stan Kutcher, an adolescent psychiatry expert, notes that "the pendulum, has swung from 'let's never talk about it and let's never educate ourselves about it' to 'let's everyone blab about it."

The term "depression" even appears to be overused. "When we use the word 'depression' for every negative emotional state, the word loses its meaning," Kutcher says of the recent tendency to over-discuss and over-diagnose this condition. This creates a trend of girls becoming "wannabe" depressed. They post images and quotes associated with torment, even though they are not clinically depressed. "You see kids self-identifying as having that depression, but they don't have a depression. They're upset, they're demoralized, or they're distressed by something," says Kutcher.

Teens who confuse depression with everyday challenges are drawn to Tumblr's online hub of self-harm because of the horribly poetic combination of pain and beauty that is advertised. In an interview with The Atlantic, Laura U, a 16-year-old at an international school in Paris, said she believes that Tumblr is the chosen media for this wildfire-like trend because it is "a very easy place for people to feed off of this kind of frenzy because of their 'reblogging' system, [which makes] it very easy to [spread] pictures and gifs." She also theorizes in that the exhibitionism of self-harm, suicide, depression, or self-loathing is considered "beautiful, romantic and deep."

Teenagers seek the satisfaction of being different. Yet they also yearn to be part of a community. Being part of something dark, beautiful and misunderstood makes it all the more appealing. And these Tumblr communities seem to provide the perfect solution for the fragile mind. But to be accepted, teens have to advertise their suffering- they have to prove they belong.

Sophie Moser, a sophomore at SMA, expresses frustration over this trend. She feels that the wannabes "are dramatizing the illness itself; they are also isolating the people with the illness by posting revolting pictures."

And in fact, many teenage girls do suffer from legitimate conditions. In the U.S., 20 percent of women have suffered from a clinically significant eating disorder at some point in their lives, and between 2008 and 2010, 12 percent of teenage girls 12 to 17 suffered from a major depressive episode, according to a 2012 report by the Substance Abuse and Mental Health Services Administration. Reinecke comments that you can sometimes get a "reverberating echo chamber," of girls who are feeding off each other's self-destructive emotions, increasing the effect of the web-wide negative feelings. Moser says, "Girls and boys are trapped in society's bubble their whole life, so they go on the internet to let out everything that they would be judged for in daily life."

Junior Isabella Langhus believes that "hurting yourself should never be a form of self-expression or art." Yet, she says she sees many self-hatred posts with thousands of reblogs. One that stuck with her was a girl bleeding in a bathtub, with 'perfect' carved into her arm. "We do know that exposure to the kind of content that glorifies dangerous behaviors...is a real problem," explains Susie Roman, National Eating Disorders Association's Director of Programs. "It is not healthy, or fair to people actually going through things, to post pictures like that," says Langhus.

The problem is that the teenagers most at risk are those turning to a site like Tumblr in the first place. "Social media sites can further entrench the disorder with those who are viewing the images and message, and it can also delay or prevent them from seeking help or entering recovery programs," worries Roman. For Kutcher, the solution lies in recreating the distinction between normal emotional states and the clinical condition of depression. Perez agrees that the way to go about this is education.

At a time where social media, bullying, depression and suicide are at all-time highs, this topic is highly relevant, especially at SMA, where a majority of the population frequent Tumblr and many girls already deal with diagnosed depression. While there can be beauty in suffering and pictures can convey immense emotion, if art and pain become imbalanced, it can be detrimental. Moser says "You never know who you are affecting, what lives you are changing. With that in mind, post consciously and reblog cautiously."

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Tumblr Blogs Glorify Depression and Self-Harm

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Tumblr has over 140 million blogs. Most revolve around predictable topics, such as photography, music, fashion, sports and design. But this popular social space has expanded in surprising and sometimes unhealthy ways. Tumblr thrives on the emotional, diary-like output from a younger demographic, proving a space where teens can post, share, opine, vent and dwell...

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Blogger's experience with her 'friend' calling her self-harm 'looking for attention'

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Several years ago, I was struggling with self-injurious behavior. It never got to a dangerous point. Yet, it was serious enough for me to worry about myself and to have others worry about me. It was a really big issue for me because a part of me wanted to stop but a part of me craved it.

As this became such a pertinent issue in my life, I reached out to several support people. I would reach out whenever I had urges in an attempt to curb my impulses and get out of crisis. It really worked for me. Calling a friend was a powerful tool.

Until, that is, one of my support people said to me, "You're clearly doing this for attention."

I was floored. In all honesty, there was probably a subconscious part of me that was using self-harm as a way to reach out to people. However, on a conscious level, I was completely in shock at the thought of self-harm being anything more than a destructive addiction that I couldn't shake. I was not using it to manipulate people into giving me attention.

That comment from my friend put a seed of doubt into every conversation I've had with support people since then. What if I am using this for attention? What if this person thinks that about me? What if this is feeding a loop that's only going to make my self-harm worse?

Thoughts like these plague me to this day, and honestly, it has made it more difficult to reach out to people when I'm in crisis. I don't want to use self-harm for attention, and the fear that I might weighs me down enough to not reach out at all some days.

Here's the truth: Self-harm is not for attention. Even if it is, it signifies a deep need for help in an individual. If you know something struggling with self-harm, then never assume you know why they do it. It's different for everyone. Let them tell you why and then support them through it.

If you are someone who struggles with self-harm, then know that getting help and reaching out to others is the strongest thing you can do. Don't let other people's assumptions stop you from getting the help you need. You are worth it.
If you or someone you know needs help, visit our If you need support right now, call the We want to hear your story. Become a Mighty contributor here. Image via Thinkstock. Suicide Prevention Lifeline at 1-800-273-8255. You can reach the Crisis Text Line by texting "START" to 741-741. prevention resources page.

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When a Friend Said I Was Self-Harming for Attention

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Several years ago, I was struggling with self-injurious behavior. It never got to a dangerous point. Yet, it was serious enough for me to worry about myself and to have others worry about me. It was a really big issue for me because a part of me wanted to stop but a part of me craved it.

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A blogger's experience with people thinking that their self-harm was for attention.

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"Oh you know, school was great, except I severed a tendon or something and my hand is numb." I probably say it with a hint of a challenge in my voice. The questions I am really asking are: am I too scary for you now? Are you going to leave me because I am too destructive? Can you still love me even though I am damaged? I only said something because my therapist told me I needed to tell someone. I sounded flip because I did not know how else to say it.

"Well X says you're only doing this for attention anyway," he says. "Look at you, you're proud of what you did."

I am not proud of what I did. But I long ago lost the ability to use words to explain what is really going on. I cannot properly express my emotions, so I cannot explain the real reasons this is happening again. My best friend is tired.

My best friend has been told that cutting is only the manifestation of the deeper issue. My friend knows this, but his friend speaks with such confidence. Someone who barely knows me, who has never had more than a five-minute conversation with me, has succinctly and unequivocally decided my fate. I am a bad person who is behaving badly and will not be seen until I can behave properly.

I wish that person had understood cutting can be a sign of a mental illness. Cutting releases endorphins in your brain. It takes away emotional pain. While physical can be healed, emotional pain lingers. I cannot always handle the emotional pain, so I deflect it to physical pain. Physical pain I can understand. Physical pain is something I can control.

I wish that person knew I am ashamed of being a "cutter." I am ashamed of the way I look. Strangers ask me what happened if they see my scars. My college roommates teased me for always wearing long sleeves. I am constantly asked if I am hot or how I can wear that in the summer. When I don't wear long sleeves children stare and sometimes even point at me. What I am saying is a get plenty of attention for cutting and I would prefer not to have any.

I want that person to know that if someone is seriously harming herself, the best thing is not to ignore her and assume that will motivate her to change. If I could change because someone else wanted me to, I would have changed a long time ago. It is not about love or respect or being a bad friend. Ignoring problems, especially mental illnesses, makes them grow, not go away.

I want that person to know it's OK if your friends make you sad sometimes. If your friend is hurting, it's OK to hurt, too. If your friend is struggling with an illness, including a mental illness, that causes pain, and it is natural to feel sad for them. Avoiding people who have sadness in their lives leaves everyone alone.

In fact, when this person goes through a difficult situation a year later, my friend cries because he is sad for her pain. I do not say, "Well if it makes you sad, just ignore her until she is happy." And had I, people would have been appalled I would suggest something so insensitive.

I have not been able to forgive the person who told my best friend I only cut for attention. I realize it was a comment made of ignorance, not malice, and that I am responsible for not seeking medical treatment on my own. I realize I should not hold a grudge. However, to this day, this person does not feel she was wrong for what she said, and my best friend says she was only trying to help.

This shows how much people who cut are not accepted in society. They are not seen as deserving of help. They are seen as "bad" or "disobedient" or "attention seekers." Punishment is seen as an appropriate response. Cutting is one of the most stigmatized behaviors because people do not even try to understand it. If we look at the history of addiction, we know blaming the individual does nothing and costs us more in the long run. We should learn from this.

The ignorance this person displayed can spill over into insurance companies that will not pay for treatment, funding taken away from mental health programs and research on treatment, and leaves families, friends and those who cut without somewhere to seek help. This attitude can stop people from asking for help and stop people who want to help from giving it. Ignoring a problem rarely makes it better. Usually, it just leaves everyone alone.
We want to hear your story. Become a Mighty contributor here. Image via contributor.

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What I Want to Tell the Person Who Said I Only Cut Myself for Attention

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"Oh you know, school was great, except I severed a tendon or something and my hand is numb." I probably say it with a hint of a challenge in my voice. The questions I am really asking are: am I too scary for you now?

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Skegg, K. (2005). Self-harm. The Lancet, 366(9495), 1471-83.

Statistics on self-harm.

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Credible source - Australian Government - Department of Health

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Credible source - Australian Government - Department of Health

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Overview of Self-harm

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Self-harm can be confronting and hard to understand. When someone self-harms, it is often a sign of deep emotional issues that they are unable to resolve.

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What is self-harm

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People define self-harm in lots of different ways. Usually self-harm is defined as someone deliberately hurting themselves without wanting to die. It is sometimes called deliberate self-injury or non-suicidal self-injury. Engaging in self-harm may not mean that someone wants to die. It is a behaviour that is used to cope with difficult or painful feelings.

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Credible source - The Self-Injury Institute

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Credible source - The Self-Injury Institute

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Difference between cutting for attention and not.

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For me, this has become a relatively new topic. With social media, cutting "parties," graphic Tumblr pages, and Demi Lovato, I find more cases of attention-seeking cutting every day. But is there a difference between cutting for attention and the more clinically recognized rage-based cutting? The long answer is yes. The short answer is no.

Rage-based cutters usually do everything possible to keep what they're doing hidden. They wear sweaters in summer. They make up stories about "accidents." They spend a lot of time alone. They keep secrets. A rage-based cutter has a very difficult time expressing emotion. They avoid interpersonal conflict at all costs, and instead resolve conflicts privately by self-harming in some way. I have found that a rage-based cutter is not what gets glamourized in the movies-they're not typically your gothed-out, emo, druggie high school dropout. They're actually the opposite (usually). They get good grades. They're committee chairs, star athletes, or presidents of social clubs. They maintain a high level of social functioning. They're usually hidden from the world in plain site. We find that a rage-based cutter needs to be freed from rigid and inflexible rule structures about emotional expression. They need to be able to get angry without facing unfair consequences.

With attention-seeking cutters, I see a different picture altogether. Their mood is different. Their actions are different. Their personalities are different. Even the way they think about the world is different. They aren't trying to hide the way a rage-based cutter is; on the contrary, a hiding place is the last thing they want. They tend to either brandish their wounds to their friends, or manipulate circumstances that will "accidentally" reveal their behavior to an unsuspecting bystander. They are not shy about expressing their emotions. They're on social media sites all day long. They're more interested in peer relationships than school, grades, or extracurricular activities. In truth, they are far hungrier for attention than the rage-based cutter, and have figured out how to turn the spotlight.

That's the long answer. Yes, there is a difference-in motivation. But the short answer is there is no difference. And what I mean by that is that within the familial context, a repair needs to be made, no matter what the reason behind the self-harm really is. For the attention seeker, this may mean asking families to spend more time together, maybe adjusting the way a family defines "special," perhaps even adding some good old after-school activities to teens with way too much time on their hands. For the rage-based cutter, this may mean relaxing family rules around communication, confronting a family about inappropriate secrets, sometimes simply educating parents about normal developmental milestones.

Family is everything to us here at KISI and we believe family therapy is vital for teens struggling with the need to self-harm. You can't send a cutter-attention-seeking, rage-based, or otherwise-to their own shrink and expect any real results. From our standpoint, the problem isn't the cutting, it's the family dynamic. Family therapy is about learning to communicate effectively. It's about realigning relationships. It's about resolving conflict. And yes, sometimes it's about confronting attention-seekers and holding parents accountable. We've found that our work brings real change; attention-seekers get a voice and space to grapple with adolescence, and their families are better equipped to support the turbulent journey through the teenage years.
-Brad Horne is a Fellow and the Training Coordinator at the Kahn Institute for Self-Injury

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For me, this has become a relatively new topic. With social media, cutting "parties," graphic Tumblr pages, and Demi Lovato, I find more cases of attention-seeking cutting every day. But is there a difference between cutting for attention and the more clinically recognized rage-based cutting? The long answer is yes.

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Article about the the issue of self harm. Self-Harm Awareness Day

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Three years ago, with her parents and sisters out for dinner, then-13-year-old Lucy found herself alone in her family's Lincolnshire home. Dressed in her pink Tinker Bell pyjamas, she began to make herself a cup of tea. Then she spotted an object on the kitchen counter that immediately diverted her attention. "Shall I do it?" Lucy asked herself. "Will it stop the pain?"

For Lucy, now 17, that evening marked the start of a two-and-a-half year struggle with self-harm. Two weeks before, she had been brutally attacked and raped (which she now describes as "the incident"). At the time, anxious they wouldn't believe her, Lucy never fully revealed to anyone what had happened. In her mind, she tried to repress the rape. She began shutting herself in her bedroom. She told her parents she was feeling unwell. Physical pain, she decided, was the only way to purge her pent-up emotional pain.

"When you keep all your problems in, it feels like you're screaming inside," Lucy says. "But when you cut or burn yourself, the pain is more physical. You feel like you're releasing that scream. After a few months, self-harming became part of my daily routine."

Eventually, both at school or at home, Lucy was self-harming four times a day. She wore black jeans, black tops and even black gloves to conceal her scars. "I pushed everyone everyone away" Lucy says. "I stopped caring about school. My grades suffered. Self-harm became a real obsession. It took over my life."

Today, having made a huge effort to stop, Lucy has not self-harmed for more than six months. But self-harm is still on the rise among the UK's young population. Data published last year by a collaborate study from England Health Behaviour in School Aged Children (HBSC) revealed that up to one in five 15-year-olds across the country self-harm. During the past decade, according to the same study, there has been a three-fold increase in the total number of UK teenagers self-harming.

What drives young people to self-harm? Therapist Jenna Mutlick, who has a personal experience of it, says it is usually some form of "self-punishment". People believe they have done something wrong - even when they haven't - and then feel they deserve the pain. "I know a few people who self-harm because they are bullied and eventually come to believe that they then deserve to be bullied," she says. "When you self-harm, it is so hard to escape from the [mental] space that you are in."

"It's a very heterogeneous group of people who self-harm, and there are a variety of reasons why people might start," says Professor Glyn Lewis, head of psychiatry at University College London. "Clearly, there are people who self-harm because they want to take their own lives, but there are also people who want to self-harm because they are in difficult situations or want to relieve stress.

"As a long-term strategy, of course, self-harm is not very effective," he adds, "but people do report that they get some form of relief from upsetting thoughts or emotions. Some forms of self-harm are obviously very dangerous, but there's a continuum. Some people may only scratch themselves very superficially, for example, which won't do any long-lasting damage."

The causes of self-harm are likely to be complex, even if the person harming does not see the issues in that way. Kieran, from Glasgow, began self-harming after five years of "constant" physical and verbal bullying at school. His parents split up when he was seven, though he says it was the bullying - which still torments him today - that incited his self-harming. "The bullying made me feel really unbalanced," says Kieran, now 23. "I started to self-harm when I was aged 11, and it kind of just snowballed from there. I stopped eating. I isolated myself from a lot of my friends and family. I kept it a secret for almost a decade."

Like Lucy, Kieran says that self-harming became a secret obsession. The bullying made him feel "physically and mentally numb". Self-harm, by contrast, made Kieran feel more alive, and he would regularly self-harm in his bedroom at night. "It brought me out of my slumber," he says. "It made me feel normal, and I became addicted to doing it for that reason." He says that the self-harm was like an "adrenaline shot" that brings everything back into focus."

Kieran admits that he still has a "daily battle" with self-harm. He is significantly better than he was a few years ago, though, when he would harm himself up to 400 times in one evening. "It's a high level of emotional distress that causes people to resort to self-harming," he says. "People sometimes feel like they can't cope with their emotion. It's how they cope with life's daily stresses."

Chris Leaman, from the UK mental health charity YoungMinds, says it is still very much a taboo subject in British society. "Every year, we work with Childline, YouthNet and selfharmUK to try and combat these sort of stigmas for Self-Harm Awareness Day," he says. "There is a definite problem around young men not feeling like they can talk about their issues, which can make self-harm quite a common issue among them."

"Some people do talk about self-harm quite openly, but that's relatively unusual," says Professor Glyn Lewis. "A lot of people conceal self-harming behaviour from their friends and family. There are not necessarily signs to look out for; it's more a case of often asking people how they are feeling, and keeping communication open with them. As a rule, families and friends concerned about someone self-harming always should talk to the person themselves and encourage them to seek professional help."

Statistically, teenage girls are still more than twice as likely to self-harm than young males, and this has helped create another gender-based stigma: that self-harming girls are simply seeking attention. Fiona Brooks, professor of adolescent and child health at the University of Hertfordshire, who led the investigations for last year's HBSC report, identifies this as a prevalent problem. "Nowadays, young people are in a much more uncertain world than before," she says. "Instead of self-harming just being dismissed as attention seeking, it's something that needs to be taken seriously. Equally, if young girls are self-harming for attention, that's a different matter that needs to be taken just as seriously."

Lucy thinks back on that evening she started self-harming, and wishes that she could tell herself to stop - and talk to someone. Talking, like with most former self-harmers, has been a significant part of Lucy's recovery, but she also credits her own determination as a decisive factor. "If you don't want to stop, you won't," she says. "In the end, a lot of it comes down to how you see yourself. I used to feel people were always judging me, but now I feel I don't care what they think. Why should I let them control my happiness?"

Sunday 1 March 2015 is Self-Harm Awareness Day. For more information on the campaigns of UK charities, see YoungMinds.org.uk. If you have been affected by any of the issues raised this article, you can call the Samaritans on 08457 90 90 90. Comments on this article will be premoderated, which means they will be approved by a moderator before appearing on site.

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Self-harm is not just attention-seeking: it's time to talk openly about the issue

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Three years ago, with her parents and sisters out for dinner, then-13-year-old Lucy found herself alone in her family's Lincolnshire home. Dressed in her pink Tinker Bell pyjamas, she began to make herself a cup of tea. Then she spotted an object on the kitchen counter that immediately diverted her attention.

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A blog that talks about how self harm is just more than attention seeking.

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To recognise the forthcoming Self-injury Awareness Day, we revisited Dr Paul McClaren, Medical Director at The Priory Hospital Hayes Grove to explore this behaviour further. In his article, he discusses the common misconceptions of self-harming, explores why people cause injury to themselves, and how best to offer care and management to individuals you are concerned about.

is defined as the intentional injury to oneself, without suicidal intent. However, there is overlap between self-harming behaviour and suicidal behaviour and individuals who self-harm are at increased risk of suicide. A history of self-harm is found in up to 60% of people who complete suicide and the vast majority of people who self-harm have attempted suicide.

The term 'attention seeking' is often used negatively in relation to self-harm. The implication is that the individual self-harms just to get attention but is important to understand this is rarely the main motivation. One of the key aspects in managing self-harm is to understand the individual enough to subsequently understand their behaviour. This takes time and it can be difficult to achieve in a busy practice.

Self-harm can be the first manifestation of a mental health disorder. It is most typically associated with personality disorder, in particular Emotionally Unstable Personality Disorder. There are however a number of other mental health conditions which self-harm can be a symptom of. These include:

If you are concerned about a patient, the most common signs and forms of self-harm to look out for include:

Cutting the skin with a sharp object

Cigarette burning

Scratching

Picking

Banging or hitting body parts

Hair pulling

Swallowing objects or toxic substances

Who self harms?

It has been estimated that about 1 in 10 admissions to UK medical wards are the result of self-harm. While it is most often associated with angst-ridden adolescents, self-harming is known to occur in younger children right through to older age. It can occur at any age however it is more likely to be missed in the elderly.

It is recognised that self-harm is most common in young people, usually between 12 and 24 years but is important to be open minded and understand that anyone presenting in an unusual mental state with an injury, may be self-harming.

Why do people self harm?

In most situations self-harm is a maladaptive coping mechanism used to modify painful feelings or to communicate distress.

Abuse in childhood is recognised as increasing the risk of self-harm, as is early losses and troubled relationships.

In terms of personality disorder, it has been estimated that about three quarters of people who have Emotionally Unstable Personality Disorder (borderline type) will engage in self-harm at some time in their life. Those with Autism Spectrum Disorders will also engage in self-harm, often quite severely, and can include biting and head banging.

Understanding why individuals self-harm

Understanding why people self-harm is key to successful psychological and psychiatric assessment. This may be difficult to do when the individual who self-harms is still in an aroused or agitated emotional state. Attempts to probe or to question too deeply, too soon, risks falling on deaf ears or alienating the patient. This may make it less likely that a meaningful assessment of risk will be completed, to devise an appropriate treatment plan.

In understanding why an individual self-harms, it is important to consider what the motivation is for them. Potential triggers of self-harm are:

Coping mechanism to provide relief from intense feelings

Controlling emotional pain

An attempt to break out of a dissociative state or a state of emotional numbness

Making others feel guilty

Alcohol can be a disinhibiting factor and many individuals who self-harm will do so in association with drinking

While for some self-harm may bring them back into reality from a dissociative state, for others it may take them away from and allow them to distance themselves from emotional pain, which they struggle to deal with in healthier ways. The physical pain supersedes the emotional and allows them to, at least temporarily, free themselves from that state.

We know that our brain chemistry changes in response to physical injury and opioids are released and that could be one of the psychopharmacological mechanisms in which self-harm can modify inner feelings.

Management of self harm

Management of this behaviour can be divided into two main areas:

The immediate management on presentation

The longer-term management and treatment

In the first instance, the key to management is getting a clear understanding of the behaviour and that involves taking the time to ' interview' the individual at a time and place when they are able to give as much information as they can about their mental state.

In the longer term, individuals may only have contact with practice nurses, GPs or A&E departments to simply dress their wounds. It is so important that the opportunity is taken during wound dressing to engage with the patient and show them that you are interested in understanding of why they have self-harmed. Treating your patient with respect, understanding and kindness at this stage will improve their chances of engaging positively in further psychological treatment.

Most effective treatment

For those who present with recurrent self-harm, the most effective psychological treatment is dialectal behavioural therapy (DBT). DBT is a modified form of Cognitive Behavioural Therapy (CBT) which is focused on improving emotional regulation skills. It is usually done in a group setting with elements of individual support and involves helping the patient to understand their subjective state around an episode of self-harm or impulsive behaviour, which ultimately improves their regulation and reduces the chances of it happening again.

Alongside any intervention such as DBT, which addresses the act of self-harm directly, it is also important to assertively treat any underlying mental illness, such as depression or anxiety. This can also be done using DBT, CBT and other therapies such as Mindfulness.

Priory has a nationwide network of hospitals and wellbeing centres that are well placed to support your patients and offer fast access to therapy for self-harming behaviour.
For more information, please call 0800 840 3219 or click here to make an enquiry, or to visit our dedicated GP section on the website, click here.

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Self-harm - more than just attention seeking behaviour

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To recognise the forthcoming Self-injury Awareness Day, we revisited Dr Paul McClaren, Medical Director at The Priory Hospital Hayes Grove to explore this behaviour further. In his article, he discusses the common misconceptions of self-harming, explores why people cause injury to themselves, and how best to offer care and management to individuals you are concerned about.

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Non credibel source explaining the opposing perspectives of self-harm relating to attention seeking behaviour and sui intention.

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Credible source identifying ways in whichillness can be prevented through education.

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Resources for teaching and learning are posted at tinyurl.com/Glanz4e and www.med.upenn.edu/hbhe4. This fourth edition of the classic book, Health Behavior and Health Education: Theory, Research, and Practice provides a comprehensive, highly accessible, and in-depth analysis of health behavior theories that are most relevant to health education.

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Non-credible Youtube video explaining how society misinterprates self-harm as an attention seeking act.

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Stuff Mom Never Told You - HowStuffWorks

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Amanda Marchant,

Keith Hawton,

Ann Stewart,

Paul Montgomery,

Vinod Singaravelu,

Keith Lloyd,

Nicola Purdy,

Kate Daine,

Ann John

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Correction

Marchant A, Hawton K, Stewart A, Montgomery P, Singaravelu V, et al. (2018) Correction: A systematic review of the relationship between internet use, self-harm and suicidal behaviour in young people: The good, the bad and the unknown. PLOS ONE 13(3): e0193937. https://doi.org/10.1371/journal.pone.0193937 View correction

Abstract

Background

Research exploring internet use and self-harm is rapidly expanding amidst concerns regarding influences of on-line activities on self-harm and suicide, especially in young people. We aimed to systematically review evidence regarding the potential influence of the internet on self-harm/suicidal behaviour in young people.

Methods

We conducted a systematic review based on an electronic search for articles published between 01/01/2011 and 26/01/2015 across databases including Medline, Cochrane and PsychInfo. Articles were included if: the study examined internet use by individuals who engaged in self-harm/ suicidal behaviour, or internet use clearly related to self-harm content; reported primary empirical data; participants were aged under 25 years. New studies were combined with those identified in a previous review and subject to data extraction, quality rating and narrative synthesis.

Results

Forty-six independent studies (51 articles) of varying quality were included. Perceived influences were: positive for 11 studies (38191 participants); negative for 18 studies (119524 participants); and mixed for 17 studies (35235 participants). In contrast to previous reviews on this topic studies focused on a wide range of internet mediums: general internet use; internet addiction; online intervention/treatment; social media; dedicated self-harm websites; forums; video/image sharing and blogs. A relationship between internet use and self-harm/suicidal behaviour was particularly associated with internet addiction, high levels of internet use, and websites with self-harm or suicide content. While there are negative aspects of internet use the potential for isolation reduction, outreach and as a source of help and therapy were also identified.

Conclusions

There is significant potential for harm from online behaviour (normalisation, triggering, competition, contagion) but also the potential to exploit its benefits (crisis support, reduction of social isolation, delivery of therapy, outreach). Young people appear to be increasingly using social media to communicate distress, particularly to peers. The focus should now be on how specific mediums' (social media, video/image sharing) might be used in therapy and recovery. Clinicians working with young people who self-harm or have mental health issues should engage in discussion about internet use. This should be a standard item during assessment.

A protocol for this review was registered with the PROSPERO systematic review protocol registry: ( http://www.crd.york.ac.uk/prospero/display_record.asp?ID=CRD42015019518).

Citation: Marchant A, Hawton K, Stewart A, Montgomery P, Singaravelu V, Lloyd K, et al. (2017) A systematic review of the relationship between internet use, self-harm and suicidal behaviour in young people: The good, the bad and the unknown. PLoS ONE 12(8): e0181722. https://doi.org/10.1371/journal.pone.0181722

Editor: Kim-Kwang Raymond Choo, University of Texas at San Antonio, UNITED STATES

Received: March 6, 2017; Accepted: July 6, 2017; Published: August 16, 2017

Copyright: © 2017 Marchant et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the paper and its Supporting Information files. Relevant included studies are all referenced. Searches are available from the authors.

Funding: This work was supported by the Health and Care Research Wales(Grant: SC-14-11; https://www.healthandcareresearch.gov.wales). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: KH is a National Institute for Health Research Senior Investigator and is also supported by Oxford Health NHS Foundation Trust. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Introduction

Internet use has a mixed effect on children and young people's (CYP) well-being, with evidence of increased self-esteem and perceived social support alongside harmful effects such as increased exposure to graphic content and cyber-bullying [ 1]. High profile cases of cyber-bullying and suicide over the past decade [ 2] and reports of suicide clusters facilitated by social media [ 3] have resulted in researchers increasingly focusing efforts on understanding the relationship between internet use and both self-harm and suicide. An early review examining the use of dedicated self-harm support sites in young people found high levels of support available online alongside normalisation of self-harm behaviour [ 4]. A more recent systematic review relating to self-harm and internet use in young people additionally found evidence of information sharing of methods of self-harm and concealment, a reduced sense of isolation and reinforcement of positive behaviours such as help seeking [ 5]. The authors concluded that the internet exerts both positive and negative influences on self-harm and provides an opportunity for intervention, which is supported by several more recent studies [ 6, 7].

While research appears to be beginning to answer some questions regarding the role of the internet for young people who self-harm a number of questions remain unanswered. Authors of the previous review highlighted that research to the date of their review (26 th December 2011) described internet use only in relation to use of forums or general use [ 5]. This is an important limitation since specific internet pathways may represent increased risk. Internet addiction and pro-suicide websites have been suggested as high risk factors facilitating suicidal behaviours, particularly in isolated and susceptible individuals [ 8]. Additionally, a recent study examining changes in online suicide-related content showed that the results of searches for self-harm have changed over time, with an increasing presence of graphic imagery [ 6]. The role of such images has been examined in relation to self-harming behaviours [ 9], as well as relevant content of videos on a popular sharing website [ 10]. A recent study has also showed that the nature of sites returned varied according to the suicide/self-harm-related search terms use and almost half contain video content. Negative influences such as providing information on methods, encouraging self-harm behaviours and images considered evocative by researchers were common. However, more positive influences including advice on how to seek help was given on over half of identified sites [ 7]. Further research has highlighted the positive and negative influences of the internet, the potential benefit of directing individuals to healthier online behaviour and the discrepancy in perspectives regarding online activities between adolescent culture and that of many mental health professionals [ 11].

The previous review also identified a possible relationship between study design and perceived outcome. Qualitative and mixed methods studies tended to report a positive influence of internet use and quantitative designs tended to find a negative impact. Therefore the design and quality of individual studies may have had an impact on perceived outcomes. Following their systematic review [ 5] the authors highlighted the need for more rigorous research to clarify the positive and negative influences and to focus on the mediating and moderating factors in order to optimise the benefits whilst minimising the potential harm of internet use in young people who self-harm.

The primary aim of this study was to systematically review all research relating to the potential influence of the internet on self-harm/suicidal behaviour in young people, with a particular focus on identifying the factors which determine whether the internet is perceived as positive or negative in its potential influence.

Method

Search strategy and selection criteria

This study was a systematic review. The previous electronic literature search, conducted by some of the authors, was up to 26 th December 2011 [ 5]. For the present review, an electronic literature search was conducted (AM) for all articles published between 1 st January 2011 and 26 th January 2015. A range of databases were searched including: CINAHL; Cochrane Library; EMBASE (excluding Medline journals); HMIC; Medline; NICE; Prospero; PsycINFO; PubMed; SCOPUS. Additional searches were conducted in health improvement sources, topic specific websites (American Association of Suicidology, British Psychological Society, CEBMH, Centre for Mental Health, DH, DHSPSS-NI, MFH, NHS Scotland, Royal College of Psychiatrists, Welsh Government) and meta-search engines (Google/ Google scholar) for these dates only.

The search terms employed in the original review (which included 'Self harm', 'Suicid*, 'Internet', 'Children', 'Young People') were updated to account for the rapidly changing nature of the internet and memes (an image, piece of text, idea that spreads rapidly) in young people. The full details of search terms and sources searched are included in S1 Table. Reference lists of all review articles were manually screened for potential eligible papers. The research team included a number of experts in the field who reviewed searches for any potentially unidentified citations. Experts in the field were also contacted to assist in identification of literature. These included those known to members of the team and others identified from existing literature. They were contacted by email regarding any additional studies and, where relevant, data or full text copies of articles were also requested by email.

Articles were included if they examined internet use by individuals who experienced suicidal ideation, self-harm, or internet use which was clearly related to self-harm content. Any type of online media or activity was considered for inclusion. We included articles that presented primary empirical data and were published in journals. Participants had either to all be aged less than 25 years or have a mean age of 25 years or less. If ages were not stated, participants had to be described as children, adolescents or young adults. Where articles examined more than one age group, only data for the age group fitting these criteria were analysed. Results were not restricted on the basis of location; however, only English language papers were included.

In order to be consistent with the previous review [ 5] review articles, news articles, single case studies, editorials, comments, conference abstracts and other grey literature, while searched for (e.g. CINAHL, HMIC), were not included in the final analysis. While the inclusion of grey literature can reduce the impact of publication bias, it may also introduce its own set of biases. These include the absence of peer review and the potential that the availability of data would impact on overall results [ 12]. Included articles from the previous review on this topic 1991-2011 [ 5] were added to the newly identified eligible articles to provide a complete overview of available evidence. Studies relating to cyber-bullying and self-harm from both the new and existing literature were excluded and will be reviewed in a separate report. This decision was taken due to the number of known quantitative studies related to this specific topic and because it would allow for a more thorough discussion of the literature with the potential for meta-analysis (protocol available from http://www.crd.york.ac.uk/prospero/display_record.asp?src=trip&ID=CRD42017056487).

Two independent reviewers (AJ, AM) manually screened titles. Any disagreements were resolved by consensus. Titles that clearly had no relevance, book chapters, case reports, conference abstracts, comments, editorial, journal notes, grey literature and news sources were excluded at title screen, although reference lists were manually screened for relevant studies. A record was kept of all discarded articles, including the reason for exclusion. Duplicates were removed. The remaining titles with abstracts were then screened for eligibility by the same two researchers. Full text articles were obtained where suitability could not be determined based on the title and abstract. Two researchers independently reviewed the remaining citations (AJ, AM). Any disagreements that could not be resolved through consensus were discussed with a third expert reviewer (KH).

A protocol for this review was registered with the PROSPERO systematic review protocol registry ( http://www.crd.york.ac.uk/prospero/display_record.asp?ID=CRD42015019518)

Data analysis

The data extraction sheet from the previous review [ 5] was adapted and used to record specific findings from both newly identified articles and those from the previous review ( S2 Table). Additional fields were added to account for the greater level of detail in more recent research articles and to allow comparison of internet medium, outcome measured and study design. Studies were divided between four reviewers (AM, NP, AS, VS) and pairs of reviewers' independently extracted data for each study. Any inconsistencies in data extraction and quality scores were clarified by consensus with at least two study authors. Articles were amalgamated and grouped according to internet medium studied and perceived influence. Positive influences were defined as results indicating perceived reduction of psychological distress, reduced suicidal ideation and self-harm, advice on how to seek help and encouragement to do so. Negative influences were defined as results indicating: increased psychological distress, self-harm or suicidal ideation; information on methods of self-harm/suicide was provided; self-harm behaviours were encouraged. Mixed influences were recorded where a report included both positive and negative influences. Internet media were grouped according to their stated description within articles. These media categories were inductively generated following initial reading and data extraction of papers and were cross checked by two members of the study team (AM and AJ).

Quality of included articles was assessed according to the Critical Appraisal Skills Programme (CASP) [ 13] as performed previously [ 5]. This tool assesses various aspects of study design including the study sampled, data collection methods, study design and the clarity and appropriateness of results and conclusions. It also includes items related to potential sources of bias such as from the study population or design.

Due to the range of research questions, methods used, populations and outcomes studied there was a high level of clinical and methodological heterogeneity across studies, precluding any meaningful combination of study results through meta-analysis. Therefore, a narrative synthesis was employed. Based on published guidance [ 14] this narrative synthesis examined a number of key aspects. Comparisons across studies were made regarding the way in which the relationship between self-harm/suicide and internet use had been identified and analysed; relationships between study results were examined and compared across the studies; the influence of heterogeneity was further explored including theoretical variables, differences in baseline characteristics of populations, measures employed and outcomes studied.

Results

Fig 1 shows the results of the search strategy and screening process. A total of 51 articles (from 46 independent studies) were included in the review. A summary of included articles by internet medium and perceived influence can be seen in Table 1. Studies were based in the USA (n = 10), UK (5 studies, 9 articles), Canada (n = 5), Japan (n = 3), Korea (n = 3), Australia (n = 2), New Zealand (n = 2), Sweden (n = 2), China (n = 1), Germany (n = 1), Israel (n = 1), Northern Ireland (n = 1), South Africa (n = 1), Taiwan(n = 1) and Turkey (n = 1), with the remaining 7 studies (8 articles) from multiple countries. A total of 192,950 individuals participated. Forty-four of the 51 articles had more than 50% female participants. Eleven studies [ 15- 25] examined content of forum posts or websites in which participants were described only in terms of demographics of site users. One study [ 26] examined rates of suicide by age group with no further description of the number of participants. Using the CASP quality score 17 articles were assessed as high quality, 19 as medium quality and 15 as low ( S3 Table). The quality of articles varied by study design with a greater proportion of quantitative (13/21) than qualitative ones (0/18) rated as high quality. Number of studies, number of articles, study design and quality varied across internet media ( Table 2).

The sampling of participants varied greatly between studies, each introducing potential selection bias. For example, study participants were recruited via dedicated online support forums [ 51- 59, 61]; emergency departments [ 49]; other healthcare settings [ 44- 46]; through digital metrics [ 27]; and through large school-based and community surveys [ 28- 31, 33, 36- 42].

A number of outcomes were assessed in the studies, including levels of self-harm and suicidal behaviours, mental disorders, internet addiction, levels of loneliness and insomnia, the potential to recruit participants for research [ 15] and the nature of online information seeking [ 27] ( S4 Table). Measures ranged from study-specific self-report questionnaires or content analysis themes to validated scales to assess suicidal behaviours, internet use, mental disorders and well-being e.g. Internet Addiction Scale, Beck Depression Inventory, Strength and Difficulties Questionnaire, Suicidal Ideation Questionnaire.

Perceived influences were: positive, 15 articles, 11 independent studies, n = 38,191 participants; negative, 19 articles, 18 independent studies, n = 119,524 participants; mixed, 17 articles, 17 independent studies, n = 35,235 participants. Table 3 summaries the mechanism of perceived influence by internet medium.

General internet use

Twelve studies examined the influence of general internet use [ 3, 20, 26- 35]. Papers were categorised as examining general use if they spoke generally about internet use, did not detail the type of internet use or examined a number of different mediums. Two studies identified positive influences [ 27, 28]. One of high quality utilised digital to metrics to demonstrate high levels of engagement reported in online discussions about mental health by young people [ 27]. The second, a low quality study, utilised a community survey and showed lower levels of depression associated with frequent video game use. No association was found between media use and suicidal ideation [ 28].

Seven studies identified negative influences [ 3, 26, 29- 33]. Studies rated as high quality utilised survey data and showed that high internet users and non-internet users were at higher risk of suicidal ideation and attempted suicide when compared with moderate internet users [ 31]. An 'invisible risk' group of individuals, who spent a lot of time online but did not engage in other risky behaviours (e.g. smoking) and had similar prevalence of suicidal thoughts as the 'visible' risk group, was identified in another high quality school based survey [ 29]. A relationship between internet use and self-harm was reported in several high quality papers. 15% of girls and 26% of boys reported that either the internet or social media had influenced their self-harm [ 33]. Risky online behaviours such as having a close relationship with someone met online (38% of those who reported self-harm compared with 10% of those who did not) was reported in a set of telephone interviews [ 32]. This relationship was further supported by an additional low quality school-based survey where suicidal ideation was found to be significantly associated with accessing suicide or self-injury information online (OR 5∙11; 95% CI 0∙35-0∙75), anxiety about getting email replies (OR 2∙06; 95% CI 1∙33-3∙20) and hurtful experiences online (OR 1∙71; 95% CI 1∙03-2∙84) [ 30]. In addition to the relationship between online behaviours and self-harm it was found that the internet and social media had facilitated the spread of information in a potential suicide cluster, and may have linked suicides otherwise unconnected by school or district [ 3]. Furthermore, a relationship between internet searches for specific suicide methods and the suicide rate in young people was found in one low quality study [ 26].

Three studies showed mixed influences [ 20, 34, 35]. In one small but high quality set of structured interviews participants found some interactive media supportive, while use of violent methods of self-harm were often preceded by viewing suicide related content online [ 34]. In a medium quality study aiming to examine self-harm content across internet mediums, large dedicated self-harm social media groups, 2290 videos related to self-harm on YouTube and high levels of views of videos about self-harm (the top video being viewed 339646 times) were identified. Peer-driven websites were found to contain warnings of triggering content, including stories and image galleries (not always present). These sites were accessed more frequently than professionally-driven websites [ 20]. Participants partaking in structured interviews reported that online sources of information related to suicide were quite common, and while social networking sites were frequently cited as sources these were not linked to increases in suicidal ideation, whereas online discussion forums were [ 35].

Website with suicide/self-harm content

Two articles reported on websites with dedicated self-harm/suicide content. A medium quality content analysis study of websites indicated negative influences, including that dedicated self-harm websites may normalise and reinforce self-harm [ 25]. A large high quality cross-cultural survey reported that individuals use these websites to gain help and support. While some participants reported a reduction in self-harm a small number reported increased self-harm associated with these websites.

Blogs

Two articles reported the content analysis of the same set of pro-anorexia blogs [ 62, 63]. Both were rated as low quality and reported negative influences in the form of sharing potentially harmful information related to self-harm and suicide methods and means of concealment.

Across different mediums several studies focused on groups often hidden from traditional research and service provision. For example, three studies focused on populations of LGBT young people [ 15, 18, 23]. The first was an analysis of the content of YouTube videos raising awareness of the level of suicide in LGBT youth [ 23]. The other two papers showed that online discussion forums had the potential to engage this hard to reach group and to produce novel, unmediated data [ 15]. This approach was utilised to gather data on LGBT young people's perspective on seeking help for suicidal feelings. LGBT individuals found it challenging to articulate emotional distress and seek help from family members or professionals. They were most comfortable communicating online, particularly in dedicated LGBT forums [ 18]. A further two papers focused on young people with eating disorders [ 62, 63]. In these two studies a set of eating-disorder blogs were analysed, which showed that discussion of self-harm and suicidal thoughts was common.

Discussion

This systematic review is an update of a previous smaller review exploring the relationship between internet use and self-harm [ 5] and incorporates previous evidence, thus also updating the field. A total of 51 articles (representing 46 independent studies) were included, with 192950 individual participants, together with some reports of content analytical studies. While a comparable number of articles included positive (15), negative (19) and mixed (17) influences of the internet on self-harm behaviour, articles demonstrating negative influences included more participants (n = 119524) than those with positive (n = 38191) and mixed influences (n = 35235). On balance, considering the quality of studies and numbers of participants assessed, there is significant potential for harm of online behaviour in relation to self-harm and suicidal behaviour, but also potential benefits that merit exploitation.

Results of this review are largely supportive of the findings of the previous review with comparable proportions of studies with positive and negative results [ 5]. However, in recent years this field of research has developed substantially allowing greater examination of details such as medium of internet use and for a greater range of positive and negative influences to be identified. Studies on general internet use, internet addiction and online interventions/treatment presented the strongest evidence, with mostly high or medium quality research. High internet use and internet addiction appear to have largely negative influences. Twelve studies examined general internet use, half of which were of high quality. The latter group of studies demonstrated that high levels of internet use (more than two [ 31] or five [ 29] hours per day) were associated with suicidal ideation [ 29, 31]. Further low and medium quality research suggested that self-harm and suicidal ideation were related to searching online for suicide information [ 30] and that searches for specific methods were related to rates of suicide in young people [ 26]. Online media appeared to facilitate the spread of information, linking otherwise unconnected suicides, making it difficult to recognize and manage a suicide cluster [ 3]. Research examining internet addiction represented the most homogenous group of studies; all employed high/medium quality quantitative methodologies in the form of cross sectional school-based surveys and validated outcome measures. All studies examining internet addiction found a relationship between internet addiction and self-harm or suicidal behaviour. The direction of causality of the negative influence of internet addiction and self-harm/suicidal behaviour was unclear. Positive influences included lower levels of loneliness [ 41] and a potential protective influence of low levels of internet use when compared with no internet use at all [ 31, 42]. Other studies have found that low and high internet use is associated with higher adolescent health risks than moderate use [ 31]. The internet may provide an opportunity to be part of a community online when this is lacking in everyday life. The potential of the internet as a medium to deliver interventions to address suicidal behaviours and self-harm was examined in six studies of medium to high quality, with mixed results but generally being viewed positively by participants.

Studies exploring the other mediums (social media, forums, videos/ images sharing, blogs) were smaller, of lower quality and with more mixed results. Only one paper related to social media was rated as medium/high quality. Distressed online posts were found to be related to suicidal ideation and behaviour, but there was no evidence suggesting that simply using social media presents a risk [ 50]. The remaining low and medium/low quality research found that young people are increasingly using social media to communicate distress, particularly to peers [ 49]. This is in keeping with more recent research showing that self-harm and suicide-related internet use prior to ED attendance is higher among children and young people than in adults, and is additionally related to higher suicidal intent [ 64]. While social media is being utilised here to communicate distress, this does not indicate a causal relationship. Glorification and normalisation of self-harm was found in two of the four social media studies [ 21, 24]. Forums were viewed positively as a source of peer support. There was evidence of a reduction in suicidal thoughts following forum use in one high quality study [ 58] but also evidence of normalisation of self-harm, encouragement to go ahead with suicide plans and discussion of how to conceal self-harm, supported by one high quality and a number of medium and low quality studies [ 16, 17, 19, 50, 58]. The impact of forum use on levels of self-harm remains unclear. Videos were highly viewed/shared, largely factual or educational and often contained graphic imagery, but rarely with warnings of such content [ 10]. One high quality study found that comments on videos may contribute towards the maintenance of self-harm and suggests a strong motivation for sharing experiences online. It remains unclear whether this sharing of experiences has a positive or negative impact on individuals, with its influence likely to vary with individual circumstances [ 22]. In the remaining (low quality) study some participants reported an alleviating effect of images, others a triggering one [ 61]. Sharing of potentially harmful information related to self-harm and suicide was reported in two small low quality studies of the same set of pro-anorexia blogs [ 62, 63].

The variation in results between mediums may be partially attributable to study design and participant samples. Research examining general internet use and internet addiction was largely based on school surveys employing validated outcome measures and found largely negative influences of internet use. In contrast, research examining forum use recruited almost exclusively from online discussion forums, undertook content analysis of forum posts, sometimes alongside questionnaire data, and often found positive influences. The contrasting results between studies recruiting from general population and self-selecting participants are not unexpected. Studies with more diverse participant samples and employing validated outcome measures may assist in clarification of the effects of different types of medium.

Research in this area may be biased towards measuring certain effects and outcomes e.g. a positive effect for interventions, or a negative effect for internet addiction. The choice of outcome measures may reflect the expected effects of the internet and fail to capture the full complexity of the experience of individuals. This is a risk in all research but may be a particular issue in this field. For example, studies examining internet addiction report largely negative results. However one study found that internet addicted individuals reported high levels of life satisfaction and low levels of loneliness that may not have been identified had these measures not been included [ 41]. In future investigations researchers should aim to ensure that outcome measures capture both possible positive and negative outcomes in order to give a complete and unbiased picture. Such steps can be seen in more recent research. For example an online treatment for depression resulted in symptom reduction but examination of possible negative influences demonstrated that individuals with lower education were at higher risk of symptoms becoming more severe [ 65]. Another recent study found both positive and negative influences of websites detailing suicide methods [ 66].

In keeping with the previous review [ 5] the majority of studies finding solely negative influences utilised quantitative methodologies. Mixed methods and qualitative studies tended to report more mixed results. It is unclear if this is a discrepancy between what participants report and actual outcomes or if quantitative data are failing to capture the complexity of the issue. This is further compounded by the mostly low quality of included qualitative studies. High quality qualitative and quantitative research is needed to establish whether differences in the influence of various mediums are partially attributable to study design.

Strengths and limitations

The potential for publication bias exists in any review of literature and should be considered when interpreting the results. Steps were taken to minimise any bias as much as possible including conducting an extensive search of multiple databases including grey literature databases and topic specific websites, reviewing reference lists and contacting experts in the field. However, only English language publications were included. It was noticeable that males remain under-represented in studies. Further examination of any gender differences is a potential avenue for future research.

While the decision to review literature related to cyber-bullying in a separate review will have had an influence on the proportion of articles reporting positive and negative results, it will allow for a more in-depth discussion of this important topic. The inclusion of this large body of research would have created an unwieldy review or necessitated a more cursory discussion of internet mediums. Literature related to cyber-bullying is unlikely to report any positive outcomes and had it been included it would have added to studies reporting a negative influence. This could potentially be viewed as an important bias in this review. However, results of this review highlight that the internet has the potential for both positive and negative influences dependent on the way in which it is used. Identifying both beneficial and harmful mediums and directing individuals towards healthy online behaviour should be considered of greater importance than weighing up whether the internet is simply 'good' or 'bad'.

While this review summarises data from an extensive search, there will be further literature published since the search was conducted. Based on the number of additional articles in the two years since the review by Daine et al [ 5] it is likely that this will represent a considerable body of research. Summarising it is likely to be beyond the scope of one review. Because of the rapidly increasing body of research, authors conducting future systematic reviews on this topic may consider reviewing by specific internet medium (forums, videos etc.) to ensure the task is manageable and the resultant reviews are of sufficient depth in each area to allow identification of key messages for clinicians and policy makers. While a range of internet mediums were included in this review, recent research has expanded even further, for example examining behaviours such as online gambling [ 67].

The quality of qualitative studies in this review appeared mostly to be low. While this may be reflective of quality, the appropriateness of using checklists to assess qualitative research has been questioned due to the diversity of approaches in collecting, analysing and interpreting data [ 68, 69]. This may be particularly problematic with research into internet use where there is considerable heterogeneity in methodology across study designs. It is unlikely that a single checklist would be suitable to capture all aspects of study quality across the range of study designs, populations and outcomes. Authors of future reviews in this area might consider the selection of quality outcome measures that fully capture the quality of various study designs.

It is not always possible in studies examining forum use or comments on videos/photos to accurately determine the characteristics of individuals and young people may misrepresent their age when creating profiles. Therefore ages of participants were not always clearly reported but were inferred by study authors based on demographics of typical users of sites or based on profile information.

It was a challenge to categorise findings as negative or positive in some studies [ 5]. The sharing of experiences online, for example, while therapeutic for some, may be destructive for others. The expression of distress online could be viewed as negative on the one hand, but as an opportunity for intervention on the other. This is an area of research where outcomes are not always clear cut. It was not always easy to understand whether certain factors acted as mediators or moderators of distress, nor the long-term implications. For example, individuals with a history of self-harm were more likely to report discomfort following online questionnaire completion related to self-harm, but it also caused them to think more deeply about their lives which may have been positive [ 48]. While it has been possible here to broadly discuss the influence of various mediums and to identify those that may represent a higher risk, the impact of various aspects of internet use is likely to vary between individuals and over time and should therefore always be assessed on an individual basis.

A wider range of internet mediums was examined than was possible previously [ 5]. This has resulted in a varied pool of participants, including those recruited from discussion forums, schools and healthcare settings. The majority of quantitative studies employed validated outcome measures, in contrast to literature identified in the previous review [ 5], allowing some comparison of results across studies. However, the considerable range in methodology, population and outcomes studied means that, at this time, it is not possible to conduct a meaningful statistical meta-analysis.

Conclusions

Research concerning the internet and self-harm in young people is rapidly evolving in an attempt to keep pace with the continually changing nature of its use. On balance, considering the quality of studies and numbers of participants assessed in this review, there is significant potential for harm to result from online behaviour in relation to self-harm and suicidal behaviour (normalisation, triggering and competition between users, a source of contagion and harmful information for vulnerable individuals), but also the potential to exploit its benefits (a sense of community, crisis support and reduction of social isolation). The focus should now be on a range of internet mediums including social media, video/image sharing, and the potential for the internet to be used in therapy and recovery.

There were a number of innovative suggestions from research teams responsible for publications, including educational programmes in schools to teach young people how to respond to distressed posts/messages on social media and repeated calls for clinicians to be aware of internet use. The internet may also represent an under-utilised setting to access 'hidden' at risk groups, giving them a voice both in research and in practice.

Acknowledgments

KH is a National Institute for Health Research Senior Investigator and is also supported by Oxford Health NHS Foundation Trust.

Author Contributions

1. Conceptualization: AJ AM NP AS VS KD KH KL PM.

2. Data curation: AM AJ NP.

3. Formal analysis: AJ AM KH.

4. Funding acquisition: AJ.

5. Investigation: AJ AM NP AS VS KD.

6. Methodology: AJ AM NP AS VS KD KH KL PM.

7. Project administration: AJ AM.

8. Resources: AM AJ NP.

9. Validation: AJ AM NP AS VS KD KH KL PM.

10. Visualization: AM AJ.

11. Writing - original draft: AM AJ.

12. Writing - review & editing: AJ AM NP AS VS KD KH KL PM.

References

1. 12. Higgins JP, Green S. Cochrane handbook for systematic reviews of interventions: John Wiley & Sons; 2011.

2. 13. Critical Appraisal Skills Programme UK. Critical Appraisal Skills Programme Making sense of evidence. 2012. Available: http://www.casp-uk.net accessed 2015 June 01.

3. 14. Popay J, Roberts H, Sowden A, Petticrew M, Arai L, Rodgers M, et al. Guidance on the conduct of narrative synthesis in systematic reviews. A product from the ESRC methods programme. Lancaster: Institute of Health Research; 2006

4. 34. Collings S, Fortune S, Steers D, Currey N, Hawkton K, J W, et al. Media influences on suicidal behaviour: an interview study of young people in New Zealand. The National Centre of Mental Health Research Information and Workforce Development. 2011.

5. 69. Green J, Thorogood N. Qualitative methods for health research: Sage; 2013.

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A systematic review of the relationship between internet use, self-harm and suicidal behaviour in young people: The good, the bad and the unknown

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Background Research exploring internet use and self-harm is rapidly expanding amidst concerns regarding influences of on-line activities on self-harm and suicide, especially in young people. We aimed to systematically review evidence regarding the potential influence of the internet on self-harm/suicidal behaviour in young people.

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Credible source exploring how social media influences the act of self-harm

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Abstract

To date, research on the role of the Internet in self-harm has focused on young people's interaction via the medium of text, with limited consideration of the effect of images. This qualitative study explores how young people understand and use online images of self-harm. Semi-structured interviews were conducted with a community sample of 21 individuals aged 16-24 living in Wales, UK, with a previous history of self-harm. Interviewees reported the role of the Internet in normalising young people's self-harm. Images rather than textual interactions are the primary reason cited for using the Internet for self-harm purposes. Images invoke a physical reaction and inspire behavioural enactment, with Tumblr, which permits the sharing of images by anonymous individuals, being the preferred platform. Viewing online images serves a vital role in many young people's self-harm, as part of ritualistic practice. Online prevention and intervention need to attend to the importance of images.

Keywords: Self-injury, Self-harm, Internet, Social media, Qualitative research

1. Introduction

Self-harm is a major public health concern in relation to young people. It can be defined as a non-fatal act where an individual engages in a behaviour or ingests a substance with the intention of causing harm to themselves ( Owen, Hansford, Sharkey, & Ford, 2016). The underlying suicidal intent associated with the behaviour has been contested, with increased differentiation between non-suicidal self-injury [NSSI] and acts with an associated suicide intent ( Muehlenkamp and Kerr, 2010, Nock, 2001, Ougrin et al., 2012). However, both non-suicidal and suicidal self-harm share a range of risk factors ( Mars et al., 2014), indicating location along the same continuum ( Kapur, Cooper, O'Connor & Hawton, 2012). Community samples of non-clinical populations estimate the prevalence of self-harm in young people in the UK to range from 6.9% to 18.8% ( Hawton et al., 2002, Kidger et al., 2012, Morey et al., 2008, O'Connor et al., 2008).

A number of risk factors associated with self-harm in young people have been identified ( Hawton, Saunders, & O'Connor, 2012), with research increasingly attending to the role played by online spaces ( Daine et al., 2013). Evidence indicates that 51.3% of young people who report self-harm have previously engaged in related Internet searches for self-harm or suicide related material ( Mars et al., 2015). Positive influences associated with Internet use include the development of relationships with others, with connections offering empathy and support ( Baker and Fortune, 2008, Lewis and Seko, 2016, Smithson et al., 2011). Online forums may reinforce positive behaviours and encourage help-seeking ( Smithson et al., 2011). They have also been cited as a source of stress alleviation and coping ( Harris and Roberts, 2013, Jones et al., 2011, Whitlock et al., 2006). Conversely, Internet use may confer harm due to the normalisation of self-harming behaviours, the sharing of practices and techniques, and the encouragement of concealment ( Dunlop et al., 2011, Eichenberg, 2008, Lewis and Seko, 2016, Smithson et al., 2011). It may promote self-harm enactment, with a community study by O'Connor, Rasmussen, and Hawton (2014) reporting that 18% of secondary school-aged students were influenced to self-harm by social networking sites.

Despite increased empirical consideration of the prevalence of Internet use, and the mechanisms through which it influences self-harm in young people, the evidence-base remains limited. Firstly, existing research is predominantly characterised by online surveys or content analysis of community forums ( Eichenberg, 2008, Harris et al., 2009, Mitchell and Ybarra, 2007, Whitlock et al., 2006), with only a small number of qualitative studies exploring the meanings young people attach to the Internet ( Baker & Fortune, 2008). Secondly, despite emerging evidence reporting on the influence of the range of content hosted by various online media platforms ( Harris & Roberts, 2013), there is a lack of research addressing how young people respond to different mediums of communication within these platforms. Notably, research has focused on the textual interaction of individuals, paying scant attention to imagery. In the small number of studies that have explored user-generated images, these have been said to reduce loneliness, mitigate self-harm enactment, and offer a means to support others ( Baker and Lewis, 2013, Seko et al., 2015). Equally, they have been reported as a behavioural trigger ( Baker & Lewis, 2013). Thirdly, there is a paucity of research on the online sites and platforms utilised as part of self-harming practices, and the perceived strengths and limitations associated with different online spaces ( Lewis & Michal, 2016). The present study further progresses research on the influence of the Internet on young people's self-harming behaviours, reporting qualitative data exploring the distinct appeal of different media of communication, notably the visual medium, and the preferred online platforms that support the use of imagery.

2. Methods

Participants were purposively sampled for the study. The inclusion criteria were: young people aged 16-25; and previous experience of self-harm. The definition of self-harm was not determined a priori, but conceptualised by the participant. Recruitment was conducted through the social networking site Facebook. This website was utilised as the study aimed to elicit the lived experiences of a diverse range of individuals, including those who were not proactively engaged in online self-harm communities. Adverts were deployed to the Facebook pages of individuals aged 16-25, listed as living in Wales, UK, and who presented a specific set of interests or 'likes'. Individuals who had 'liked' pages relating to the improvement of wellbeing and mental health, specifically charities and youth groups based in Wales, were targeted alongside those who had also listed 'self-harm' and 'suicide' as an interest. Groups assembled around particular music subcultures ('Goth' and 'emo') were also targeted due to established associations with self-harm ( Whitlock et al., 2006, Young et al., 2006). An advert was posted on the pages of identified Facebook accounts for a period of four weeks, with the advert containing brief information on the research study and a link to the study website.

A total of 41,988 accounts displayed the advert, with 744 people (1.8%) clicking through to the main study website. Of these individuals, 49 (6.6%) indicated interest in study participation by leaving their contact details. This response is comparable to other studies that have utilised Facebook for recruitment ( Fenner et al., 2012). Whilst the inclusion criteria was up to age 25, twenty one individuals aged 16-24 participated in the study. The mean age was 19, three were male and 18 were female. The mean age for commencement of self-harm behaviours was thirteen. Sixteen participants (76%) had sought professional help for their self-harm and 8 (38%) had presented to the Accident and Emergency department for their injuries. The vast majority of the sample engaged in cutting as the principle means of injury, although a range of behaviours were described including burning, bone breaking, skin picking and overdosing. That said, these practices were not static, with behaviours often presented as evolving and contradictory. Of the remaining twenty-eight individuals who registered interest, communication could not be established with ten young people and communication ended with the remaining eighteen before an interview could be arranged. In most cases, despite initially indicating interest in participating in the study, all further contact was not responded to. Subsequent contact from the researcher was limited to three attempts. In two cases, potential participants misjudged their required involvement, assuming it was an online survey and so declined participation. One further potential participant did not turn up to an arranged interview and did not respond to subsequent contact. Demographics for this group were similar to those recruited; two male and 16 female. In all cases, the researcher expressed appreciation for their interest via email, and also signposted on to relevant services.

Semi-structured interviews were undertaken. Nineteen were conducted individually, and one was conducted in a dyad. Interviews were led by the primary researcher [NJ]. The interview setting was decided through discussion between the researcher and participant. Interviews were conducted at a university, library, or café. The interview topic guide explored young people's lived experiences of self-harm, notably: motivations for self-harm; receipt of formal and informal support; use of the Internet; navigation of the Internet prior to, during, and following engagement in self-harm; perceptions and experiences of different online content and mediums of communication; and the interaction of online behaviour with real world behaviour. Data were recorded using a digital audio recording device and transcribed verbatim by a professional transcription service. Ethical approval for this study was provided by Cardiff University School of Social Sciences Research Ethics Committee.

Thematic analysis was conducted. Textual data were repeatedly read and coded inductively, with open coding being employed. A coding frame was developed by the primary researcher [NJ] and verified by a second member of the research team [RE]. Codes were subsequently applied to the whole corpus of data. A constant comparative approach was used to identify similarities and differences between accounts, with initial analyses of early interviews used to highlight gaps in knowledge associated with varying levels of engagement with the Internet. For instance, whilst analysis commenced with the broad focus of Internet use, as it progressed nuances within participant's experiences and perspectives emerged, particularly with regards to the degree of passive or active engagement online. Analysis was conducted by the primary researcher [NJ] with the remainder of the research team verifying the construct of categories and data interpretation [RE/JS]. Discrepancies in interpretation were resolved through discussion. Data analysis and data generation were conducted iteratively, with emerging themes being used to refine and further develop the topic guide. For instance, the centrality of images quickly became apparent early in data collection and consequently was explored in greater detail during subsequent interviews. NVivo version 10 supported data storage and analysis.

3. Results

Results are presented in three sections. First, they address the motivations for participants' use of the Internet as part of their self-harming practices. Second, they explore the influence of online imagery, including the impact of exposure to these images. Third, they consider the distinct appeal of different social media platforms for young people engaging in self-harm.

3.1. The role of the internet in young people's self-harm

Participants acknowledged the role of the Internet in their self-harm practices. Some cited it as a catalyst in the commencement of these behaviours, where individuals had researched advice or support for emotional distress, but self-harm had ' just come up ' during the search with the retrieval of instructions and images. However, for the most part, self-harm was not an unknown act inadvertently discovered; it was already a part of young people's lives. Many initially engaged with the Internet with a generic search for self-harm in the attempt to make sense of their behaviours, before discovering and being drawn into online communities.

Use of the Internet was perceived to have a discernible impact on participants' self-harm, primarily through the reinforcement or encouragement of behavioural enactment. For a number of individuals, online community exchanges had supported the normalisation of harm, leading to its construction as a routine, everyday activity:

I was in complete secrecy about my self-harm, but then I'd go home and I had all these people on the computer who I could talk to, who would support me, who didn't see self-harm as some weird thing that was a massive problem. They saw, you know, they saw it the same as making a cup of tea in the morning when you wake up, it was completely fine. But the problem with that was my cuts went from scratches to a lot deeper. (I20, female, aged 19)

Online content and communities also afforded opportunities to discover and share practices and techniques:

I would just look at tips, how to hide it you know how to make it, make it hurt more and things like that, and yeah just kind of, I don't know, I don't know. I did go on there for a positive reason in the beginning, but after that I was just looking at negatives so like pro self-harm sites and that was it then. (I13, female, aged 23)

I was thinking if I can do this one way, how can I do it other ways, so then I was thinking, um ... Most of it comes from online, because I spend most of my time on my laptop or on the computer anyway, and erm I was looking for something with no visual scars or anything like that, you just felt completely out of your body, and that you just didn't feel nothing whatsoever, I was looking for that. So then I found people saying "oh yeah sometimes I take drugs because it makes me feel out of my body". (I15, male, aged 17)

Because I saw on the Internet wrist banging, I'd heard the term before, wanted to know what it was and then I was like, oh I'll give that a try" (I2, female, aged 17)

Access to means was a notable feature of online interactions, with the Internet further supporting procurement by permitting young people to circumvent 'real world' restrictions placed on the purchase of self-harming 'tools' on account of their age:

I used to buy razor blades on eBay because they come in the post, you know, no-one would know what they were, um, because I thought oh god, I'm only like 15, 16, I can't go in to a shop and buy all these blades, you know, so I used eBay. (I6, female, aged 24)

Through the increase in knowledge about the techniques of self-harm, some participants discussed the amplification and severity of their behaviour as they utilised more injurious methods. Equally, they became motivated to engage in further harm through investment in the notion of 'not good enough', where exposure to other individuals' severe acts made them want to become better self-harmers:

I'd look for different methods of self-harm, salt and ice burns, bone breaking, and things like that and then I'd share what I did ... Once my self-harm escalated it stayed quite heightened, like I couldn't just make one little cut, it just was impossible. I'd just look at myself in the mirror and laugh, be like, "Get a grip. What are you doing? That's not nearly good enough. (I20, female, aged 19)

3.2. The influence of online imagery on young people's self-harm

While participants cited the importance of textual interaction within online communities, they also considered the move away from the privileging of such discursively driven spaces towards the production and consumption of images. Indeed, nearly three quarters indicated that imagery (notably photographs) were the primary reason for their utilisation of the Internet, due to a powerful and physical reaction that triggered the desire to harm:

I would go on Google and look at the images; because like I've said I get a really fast heart rate and its triggering and it's like a rush and it became this like addictive high and then each picture had to be worse than the one before. (I1, female, aged 22)

The quotes wouldn't, but the pictures would cos the quotes it's just like reading, I can't visually see it whereas when you visually see it you kind of wanna do it then. (I11, female, aged 18)

The power of the image primarily centred on their ability to 'bring back memories' of previous self-harming episodes or the ease with which they allowed the individual to envisage how others experience the act:

But it's not like I saw a picture and then automatically thought 'Oh, I must self-harm' ... it would be like a building thing, like if I saw a particular picture, I don't know, if someone had done like a nice juicy bruise or something, I'd be like oh, I can imagine what that feels like, and even the thought of it kind of makes me feel a bit better. Like makes me feel like I want one or something like that. (I9, female, aged 20)

Participants also spoke of being inspired to recreate certain sets of practices presented by particular images:

I remember I did think once like oh, um, yeah I'm going to ... I'm going to try that next time to see, you know, if I go deeper will I get a better effect. It wasn't so much oh I want to have deeper cuts than them more that I needed to do what they had done. (I6, female, aged 24)

Discussion was further characterised by a sense of competition, with individuals desiring to emulate the depicted harm whilst chiding themselves when they failed to engage with more sophisticated and severe techniques:

Why can't I do it like that? ... Because when I first started to do it, it was like with bits of can and bits of tin and then I started to bite the blades out of razors and just like using them like they did. (I13, female, aged 23)

For many, reliance on images as a trigger had led to them assuming a vital role within their ritualistic practice, with 'sessions' often commencing with the retrieval of an online image:

I realised that I was looking at them so that I could actually do it. I'd look first, then do. I'd look at it and I'd be like, 'That's what I need to do'. And I'd mark with pens on my arms and my legs; it's got to be that wide. If it's not that wide you don't stop and I'd be cutting until I was absolutely exhausted. (I20, female, aged 19)

If I want to harm and I don't think I'll do it bad enough, I go on to, I go online and then I look for triggers and then when I'm triggering I know I will do it worse than what I would have done before. (I14, female, aged 18)

There was some indication that individuals who shared their own images of injuries engaged in more extreme self-harm behaviours. The small minority who did upload their own pictures not only described severe injuries, there was also a sense that they were encouraged by the wider online self-harm community, thus potentially driving forward severe self-harm.

INT: So why did you ... at the point that you started posting them on there why ... like what was going through your mind to make you want to do that?

RES: Maybe I'd get sympathy maybe in a weird of kind of way ... but they were like oh but it wasn't real it was like, yeah. And I started getting ... started self-harming more. (I2, female, aged 17)

There's a picture on there that I uploaded and it was of my self-harm, but it wasn't for attention, it was just for expression and then I got loads of shit for it, that it wasn't deep enough. (I4, female, aged 16)

That said, this finding should be treated with caution as some extreme behaviours were also found amongst participants who only viewed images created by others and did not upload their own. Interviewees who were overtly critical of the sharing of self-harm images appeared to engage in a less severe form of self-harm. Amongst this group the rejection of public displays of self-harm were based upon the belief that it should be a private activity:

It's like; self-harm is like a kind of an intimate experience with yourself. Um, you know, you don't want to share it with the world, you know? You get other people that do it and just put it all over Facebook and Tumblr and stuff. But I'm not the type of person. (I3, male, aged 16)

There was further concern expressed that the posting of images would be interpreted as attention-seeking, a category of behaviour to be avoided:

I didn't think it was shameful or anything like that, I just thought ... I think I thought that if people saw it, it would be attention-seeking and I hate that. (I12, female, aged 22)

Equally, the online display was seen as being the province of the Goth and emo, and participants were inclined to distance themselves from this sub-cultural identity, and so avoided the posting of images of their behaviour in case they were assigned this identity by the online community.

3.3. The use of online media platforms for displaying self-harm imagery

The virtual world is in a constant state of flux with websites regularly being created and deleted. Self-harm sites are no different. It has been noted that the once prevalent self-harm forums, popular with users and researchers alike, are no longer utilised to such an extent ( Harris & Roberts, 2013). Participants spoke of the challenges of finding these online communities due to invisibility and inactivity, with some reminiscing about some online forums that had lapsed:

I'm kind of sad that Psyke is not very active, I mean last time I went on their site it was like last updated 2009 or something. Ages ago. (I9, female, aged 20)

Whilst there has been a propensity within research on self-harm to classify social media and microblogging into one homogeneous category, participants delineated the nuances between different platforms and discussed the distinct appeal of particular sites that had come to replace the older forums.

Tumblr was frequently cited as a preferential online space and was often discussed as synonymous with online self-harm activity; 'all self-harm links to Tumblr mostly'. There were a number of features associated with Tumblr that participants appreciated.

First, identification of relevant blogs and content are facilitated through the simple searching of keywords and tags, which allows for communities to easily assemble around self-harm. Second, it is amenable to the sharing of images. Tumblr is predominantly used as a photo-blogging platform ( Duffy, 2013), with half of all posts being photographs ( Marquart, 2010). Participants stated that they used the platform so that they could share self-harm pictures.

Third, it is perceived to permit an immediate and intimate connection with others, and is not encumbered by the monitoring and intervention provided by other social media and microblogging sties:

So I wrote in like pro self-harm. Nothing came up. Self-harm, nothing came up and like I could look on pictures of self-harm but there was just nothing, it was all, you know, monitored support websites and stuff ... so I thought well this isn't working and I searched it on Tumblr and then I found a hell of a lot like oh my life's over. (I2, female, aged 17)

I can't remember how I found it, but you type in cutting and then everything comes up, all links, most of the things that come up are linked to Tumblr. So you type in self-harm ... And then people share like pictures of self-harm, which is normal, it's Tumblr, that's what people use it for really. (I19, male, aged 16)

The lack of scrutiny and moderation, where you can purportedly "do what the hell you like", together with perceived anonymity, meant that the site was considered to be more authentic than alternative platforms. However, the freedom of access to Tumblr, combined with user discretion to share the most severe and stark images of self-harm, has led to the normalisation and exacerbation of self-harm for participants:

Kids as young as 12 can use it and anybody can look at your blog, nothing is really private and there's a big self-harm community on there that you can get sucked into and I got sucked into it and it did sort of increase the intensity of my self-harm again. Like it went from sort of little gashes in my legs to I just ... I wasn't happy until I could see an artery and I'd cut through it (I20, female, aged 19).

4. Discussion

The present study aimed to progress existing research on young people's use of the Internet for self-harm purposes through consideration of the distinct appeal of different sites within these online spaces and the various platforms that support individuals' needs. Although there has been extensive documentation of the positive and negative impacts associated with utilisation of the Internet ( Baker and Fortune, 2008, Dunlop et al., 2011, Eichenberg, 2008, Harris and Roberts, 2013, Lewis and Seko, 2016, Smithson et al., 2011, Whitlock et al., 2006), including an increased focus on the influence of photographs or computer-generated images ( Baker and Lewis, 2013, Lewis and Michal, 2016, Seko et al., 2015), there remains limited empirical exploration of how individuals interact with imagery as part of their self-harm practices.

While some individuals reported discovery of self-harm through Internet searching for a tangential topic, which led to commencement of the behaviour, the majority engaged with online spaces to support and further develop a pre-existing set of self-harming practices. In alignment with existing research on the role of the Internet in behavioural enactment, engagement with online communities often led to an exacerbation of self-harm due to normalisation and increased exposure and access to new techniques ( Harris and Roberts, 2013, Jones et al., 2011, Whitlock et al., 2006). That said, it should be noted that other research has found a dichotomy in response to the consumption of self-harm imagery, with positive responses including decreased frequency of injuries and increased feelings of support being reported ( Baker & Lewis, 2013). Reasons behind positive associations include images acting as a substitute for engaging in the behaviour ( Baker & Lewis, 2013) whereby uploading content acts as a vehicle for an emotional outlet, quelling the urge to harm ( Seko et al., 2015).

Despite the use of the Internet, it is apparent that not all platforms and micro-blogging sites are endorsed as equally conducive to sharing self-harm related materials or engagement in online interactions. Such a finding challenges the failure of researchers in this field to differentiate the corpus of online spaces, focusing only on the distinction between online and offline self-harm activity ( Lewis & Michal, 2016). Although some individuals in the study lamented the lapsing of previously popular forums, the primacy of Tumblr in supporting young people's self-harming needs was clearly evident.

Reasons for preferring this platform included the simplistic nature of its functionality and the anonymity and privacy afforded users. These notions do appear somewhat problematic, given that the premise of Tumblr is to be an open and visible platform. Yet as Livingstone (2008) suggests, young people operate within a highly nuanced and precise understanding of privacy, one which sees it in terms of limits to self-expression. Consequently, privacy is no longer about the actual disclosure of information, rather about having control over who knows what about you.

For many research participants, the predominant reason for use of Tumblr is its privileging of the image. Indeed, online communities seem to be increasingly assembled around the production and sharing of imagery in an attempt to document their self-harm journey. The purposeful searching of images may be bound up with the changing ways in which individuals use online media more broadly, where the publishing of photographs documenting everyday life is a common practice amongst young people. As Sternudd (2012) comments, the sharing of photographs is such a widespread online activity that it would be more surprising if self-harm was not a part of the practice.

The power of the image as part of the ritualistic practice of self-harm was evident throughout participants' accounts. Indeed it has emerged as a vital element of the behaviour, serving as essential precursor to commencement of the act ( Baker & Lewis, 2013). The importance assigned to images is reflected in young people's tendency to couch discussions in terms of 'addiction' or compulsion. Psychological studies have understood self-harm as most likely to occur when an individual cannot control their impulses, in addition to a need to escape or avoid an effective difficult situation or emotion ( Chapman, Gratz, & Brown, 2006).

Stark and severe images have the capacity to induce a physical reaction that invokes a strong desire to engage in harm. Previous research has highlighted that the visual aspect of self-harm, from dripping blood to the "nice juicy bruise" are as much a part of the act as the physical hurt caused ( Sternudd, 2014). As such, images might fulfil part of this function through the provision of important visual stimuli. They equally reflect some of the relational aspects of self-harm, and the interactions of online communities of self-harmers. Individuals spoke of being inspired to enact the practices of others, whilst simultaneously chastising themselves if they did not engage in the same extent of behaviour.

Whilst the impact of imagery has been previously underexplored and underestimated, we must juxtapose the position of young people who deem it necessary to their self-harm with those who actively resist online visual displays. Rejection of the public display of self-harm online was based upon the belief that it should be a private activity and that publishing images would be viewed as attention-seeking. Other research has found that for some young people, public displays of self-harm undermine the credibility of the act, with such behaviour considered less authentic than keeping injuries private ( Scourfield, Roen, & McDermott, 2011). There was also resistance to the display of images from participants who felt they perpetuated stereotypes of self-harm, conflating it with Goth and emo subcultures. Of note, these individuals had an individualised discourse of their own self-harm journeys and practices, grounded in their agency and choice, rather than the norms prescribed by a group identity.

Population-level and targeted online prevention and intervention approaches for self-harm remain limited ( Jacob, Evans and Scourfield, 2014). As research progresses, intervention development should focus on the place of imagery, whilst also being sensitive to young people's preferred media. Furthermore, given the ever-evolving nature of young people's use of the Internet for self-harm related activity, particularly with regards to the changing preferences for platforms and micro-blogging sites, mixed -methods research needs to continue to understand how individuals and communities interact with online spaces, and the impact these interactions have on self-harm.

5. Limitations

The study was limited by its sampling procedures, and participants may not have been representative of young people who self-harm and utilise the Internet. Recruitment was restricted to individuals who hold a Facebook account, and given the reported gendered uptake of this social media site coupled with the known gendered nature of self-harm it is important to be aware of the potential bias this sample has towards the experiences of young women ( Thompson & Lougheed, 2012). Furthermore, the posting of study adverts on the pages of individuals a priori hypothesised to have a higher prevalence rate of self-harm (e.g. musical sub-cultures), may have led to the exclusion of other socio-demographic profiles that would provide a different sets of encounters with the Internet and online imagery. There may equally have been a selection bias in relation to individuals responding to the advert and proceeding to participate in an interview, with women more likely to volunteer to take part in studies ( Porter & Whitcomb, 2005). That said, over half of those who initially responded did not take part in the study, an occurrence that has the potential for bias given that we have limited data on this group. The final sample included a higher proportion of females with only three males included in the study. However, there was no discernible difference across the sample in relation to gender. Of the three male participants, two used the internet for self-harm and actively consumed images for this purpose. Of the eighteen females, 11 sought out pictures of self-harm, a further three shared their own images and the remaining four were somewhat resistant to this behaviour. Despite these limitations, the sampling and recruitment procedures permitted the study to go beyond the samples included in the majority of studies considering the role of the Internet in young people's self-harm and suicide, where recruitment is conducted through established online community groups.

6. Conclusion

The Internet plays a vital role in young people's self-harm practices, with the present study supporting the negative aspects of this impact, notably through normalisation of behavioural enactment and sharing of techniques. The study has progressed understanding of how young people use online spaces and mediums through exploration of the primacy of images. In particular, images are sought out due to their capacity to invoke a physical reaction that inspires a desire to harm. The primacy of the Tumblr platform for engaging in online self-harm related activities is partly a result of its privileging of the photographic documentation of individuals' lives. Further research needs to continue to move beyond the homogenisation of online spaces and disentangle young people's interaction with different mediums across different platforms. Effective online prevention and intervention approaches for self-harm remains limited, and future development should more closely attend to the complex and ever-evolving interaction of individuals with online spaces.

Conflicts of interest

The authors have no conflicts of interest.

Acknowledgement

The research was funded by the National Institute of Social Care and Health Research (Welsh Government). The work was also supported by The Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer), a UKCRC Public Health Research Centre of Excellence. Funding from the British Heart Foundation, Cancer Research UK, Economic and Social Research Council (RES-590-28-0005), Medical Research Council, the Welsh Government and the Wellcome Trust (WT087640MA), under the auspices of the UK Clinical Research Collaboration, is gratefully acknowledged.

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The influence of online images on self-harm: A qualitative study of young people aged 16-24

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To date, research on the role of the Internet in self-harm has focused on young people's interaction via the medium of text, with limited consideration of the effect of images. This qualitative study explores how young people understand and use online ...

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Non-credible source providing statistics in relation to self-harm and school students. Provides a summary that self-harm is prevalent among students due to high standard academia.

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Updated April 06, 2017 12:39:29

A new study has found levels of anxiety among TAFE and university students are reaching "alarming" levels, with 35 per cent experiencing self-harm or suicidal thoughts in the past 12 months.

The research, by leading mental health group Headspace and the National Union of Students, surveyed 2,600 Australian tertiary students between the ages of 17 and 25.

"We know that self-harm rates are increasing, with one in three experiencing thoughts of suicide or self-harm over the last 12 months," Headspace CEO Jason Trethowan said.

"Relatively speaking, the number is extremely high and its a point of real concern."

Increased workload, looming deadlines, relationship problems and financial hardships are some of the common challenges associated with young people making the jump from high school to tertiary education.

But the latest results show many students are struggling to cope.

"They might have moved out of home for the first time, and might have greater responsibilities financially [or] domestically," Mr Trethowan said.

"The changing external factors compared to the past decade creates an environment, where people need to be more aware of their mental health.

"I just want young people to recognise that you're not alone, mental health is a problem across the country, getting onto of your issues, there is help out there, so seek help."

In the survey, 65 per cent of the students also reported high to very high levels of psychological stress, and more than half suffered panic attacks, had trouble sleeping and experienced feelings of hopelessness and worthlessness.

'I felt completely paralysed'

Amelia Walters, 18, a Brisbane high school leaver who moved interstate to take up a scholarship at Melbourne University, can identify with that challenge.

After starting her studies, it did not take long for Amelia to become overwhelmed by the pressure of keeping her scholarship.

"My life here rested on that academic performance essentially," she said.

"I felt completely paralysed ... At that point I could see it wasn't only affecting me but the people around me.

"I started losing a sense of myself. Feeling like I'd lost myself. I noticed it probably in the first month of my studies.

"[Then] I got to the point where I felt so paralysed by the different responsibilities I felt to myself ... I was no longer able to engage in my studies."

Suffering anxiety and depression, Amelia did not initially feel comfortable talking to other people about her mental state, but eventually sought counselling.

"For the first time I feel like a university student, I finally feel secure and have a sense of where I'm going," Amelia said.

"I now define my sense of success in terms of the fact I feel well within myself rather than achieving a certain grade."

Topics: mental-health, depression, psychology, diseases-and-disorders, education, university-and-further-education, australia, university-of-melbourne-3010

First posted April 06, 2017 10:20:44

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One in three students consider self-harm and suicide: report

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Updated April 06, 2017 12:39:29 A new study has found levels of anxiety among TAFE and university students are reaching "alarming" levels, with 35 per cent experiencing self-harm or suicidal thoughts in the past 12 months. The research, by leading mental health group Headspace and the National Union of Students, surveyed 2,600 Australian tertiary students between the ages of 17 and 25.

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Credible source identifying who self-harms and the issues provoking it.

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Walk into any high school and you can be confident that there are young people who self-harm. Research suggests that around one in ten teens will self-harm at least once. That equates to 2-3 students per classroom. So we know that self-harm is fairly common.
What is self-harm?
The most common form of self-harm in teenagers is cutting, followed by overdose. Other methods include scratching or piercing the skin, banging your head or other body parts, cigarette burns, hair pulling, wound interference, and jumping from heights.
Why is self-harm a concern?
There can be some skepticism around self-harm, and some people dismiss the behaviour as 'attention seeking'. However, there are some very real reasons to be concerned about youth self-harm:
* The most obvious concern is that self-harm involves physical pain and damage, which can leave permanent scars or injury. Young people who self-harm often do not receive medical help for serious injuries.
* While most young people who self-harm do not intend to die, there is still an increased risk of non-fatal and fatal attempts to end their life. It is hard to know which self-harming young people might be at increased risk of suicide, since suicidal thoughts can be ambiguous and transient. In fact, engaging in repeated self-harm can gradually desensitize a person and, over time, make it easier to engage in more serious suicidal behaviour.
* Young people who self-harm are more likely to experience mental health difficulties. This includes anxiety, depression, and low self-esteem. They are also more likely to engage in other self-destructive behaviours, including eating disorders and risk taking behaviour, and to use or abuse drugs and alcohol.
* Teachers often fear that self-harm may spread among students. These fears are valid: self-harm research identifies the occurrence of social modeling in self-harm initiation and continuation.
But do we know which young people are self-harming?
Naturally, teachers and welfare staff are concerned about self-harm among their students. In most schools, staff strive to keep an eye out for young people who show signs of self-harm, in order to provide further support to students in need. While the intention is good, how easy is it to identify young people who self-harm? It might be harder than we first think.

Despite the prevailing stereotype that young people self-harm to receive attention, in reality most young people keep self-harm hidden. When a young person discloses self-harm, it is not usually to a mental health professional. They are most likely to disclose to a peer, and when disclosing to an adult it is more likely to be a parent than a teacher or counsellor.
Identifying a risk profile for self-harm
So what is the best way to keep an eye out for self-harm? What are we looking for?

One way of approaching this question is to produce a list of psychological and social risk factors that are known to increase the risk of self-harm. This research can assist school staff in identifying young people at risk of self-harm, by providing a 'typical' profile of greatest risk. Risk factors include: female gender, depression and anxiety, low self-esteem, parental divorce, being bullied, impulsivity, and difficulty coping.

However, the research I did in Australian high schools with colleagues Jennifer Hudson and Michael P. Jones, found that not all young people who self-harm fit the 'typical' profile. Our longitudinal study involved 326 students (68.1% female) from five Independent high schools (four co-educational and one girls school) in Sydney and the NSW Central Coast. Students completed an online questionnaire as part of the Youth Coping Project which explored youth coping, mental health, and wellbeing. The longitudinal data discussed here were part of a larger baseline sample (n=1,521 from eight schools).

Our study explored whether psychological profile at baseline was related to self-harm rate at six-month follow-up. We found that there were several different psychological groups with an average risk for self-harm, including anxiety, difficulty with coping strategies, and an often overlooked or misunderstood group: students who displayed impulsivity and externalising behaviours. Our research identified considerable diversity in psychological risk factors among young people who self-harm.

In fact, some young people who self-harm did not report any of the typical risk factors for self-harm. This is a key finding: there are young people who self-harm who are not depressed and anxious, and are likely not on the radar of the pastoral care team as 'at risk'.

These findings have critical implications for how we support young people in our schools. How will we identify these young people, in the absence of the usual risk markers? This is particularly concerning given that only around half of those who self-harm will disclose their behaviour.
Implications for practice
How can we apply these findings in schools, families, churches, and youth services?
1. Be aware of less typical risk profiles.
For example, young people who self-harm may be male, may engage in antisocial behaviour, or may not display any psychological or social risk factors.
2. Ask. If in doubt, ask.
Ask young people whether they have thought about or engaged in self-harm or other self-destructive behaviours. Ask with empathy and compassion, and be prepared to hear an honest answer. If a young person discloses self-harm, respond in a calm and gentle way. Listen to their story and journey with them to seek help.
3. Provide a supportive environment that encourages disclosure.
We need to develop supportive environments in which young people are willing to disclose, and people know how to respond in a safe and supportive way. Barriers to disclosure include fearing a negative response, concern that the disclosure would be spread in the community, and not viewing self-harm as problematic
4. Undertake prevention strategies
Since self-harm is often hidden, and yet the consequences are serious, prevention is essential. Prevention should be universal, that is, including all students. Targeting only the students that appear to be at risk is likely to exclude many who are struggling.
5. Educate the broader community
When a young person discloses self-harm, they are unlikely to go straight to a trained mental health professional. The first conversation is likely to happen with a peer, parent, teacher, youth leader, sports coach, mentor, or friend's parent. Providing support for young people who self-harm extends far beyond the counsellor's office. The broader community needs self-harm education.

We can't expect to see self-harm right in front of us. And we can't assume that if there's nothing to see, then there's nothing to be concerned about. There is a critical need for education as we develop supportive communities that can respond to and prevent youth self-harm.
Sarah Stanford is a writer, speaker, and researcher focusing on self-harm and mental health. Drawing on her experience in youth work and Ph researching self-harmD, Sarah is assisting schools to identify self-harm and develop parent and staff education programs. Sarah delivers workshops on understanding and responding to self-harm in schools and churches for parents, teachers, welfare staff, and youth leaders. Speaking with young people, Sarah brings a message of hope to those struggling with self-harm. Sarah completed her Psychology PhD at Macquarie University in Sydney, Australia, where she is an Honorary Postdoctoral Associate. Based in WA, Sarah works locally and interstate.

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Self harm by Australian high school students: latest research on who might do it and how to help

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Walk into any high school and you can be confident that there are young people who self-harm. Research suggests that around one in ten teens will self-harm at least once. That equates to 2-3 students per classroom. So we know that self-harm is fairly common. What is self-harm?

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Non-credible Tumblr page displaying images of self-harmers.

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Find and follow posts tagged cutters on Tumblr

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Find and follow posts tagged self harm on Tumblr

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credible source displaying reasons behind deliberate self harming.

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Is self-harm linked to attention-seeking? | Understanding mental health | ReachOut Schools

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Self-harm isn't just attention seeking. Liesje Donking explains what it is and how to help. Learn more here.

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Non credible source explaining self harming and attention seeking behaviour, correlating to feelings of worthlessness.

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1. Q & A

2. Self-Harm

3. Question

Last Updated: 04/04/2017 at 7:43pm

Top Rated Answers

Anonymous

September 1st, 2015 11:47am

Self Harming for attention is often seen as something people don't do, though it may be more common than we think. If a person is self harming for attention they need just as much help and support as somebody who is not, this is equally as unhealthy. To decipher and understand whether a person is self harming for attention or from a feeling of worthlessness may come down to the way the individual reacts. For attention, the person may not try to lie or hide their self harm as much as somebody who is not, and may feel a 'pleased' sense when somebody does notice. Though it is often looked down upon, it is important to remember that just because somebody does self harm for attention it does not mean that they do not need the equal amount of help.

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Q & A Self-Harm Question Last Updated: 04/04/2017 at 7:43pm Top Rated Answers Anonymous September 1st, 2015 11:47am Self Harming for attention is often seen as something people don't do, though it may be more common than we think.

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Non credible source justifying how suicide rates associating to self harm are increasing.

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Posted September 12, 2017 11:50:36

Following a large group of people over a long time is a terrific way to learn more about life in Australia.

The Growing Up in Australia: Longitudinal Study of Australian Children (LSAC) has been going since 2004, following the lives of thousands of children into adulthood and gathering data from parents, teachers, carers and the children themselves.

The latest LSAC Annual Statistical Report provides a window into how the lives of Australian teenagers are changing.

Many have tried alcohol, but few drink regularly

Just over 40 per cent of teens reported having had a few sips of alcohol by the age of 15, but only 16 per cent had consumed a full serve.

Of those who had tried alcohol, 28 per cent of boys and 15 per cent of girls had done so before the age of 13.

This doesn't mean that young teenagers who have tried alcohol are necessarily drinking to excess, just that they are sampling alcohol at a relatively young age.

For most 14- and 15-year-olds, drinking alcohol was not a regular practice - only 7 per cent had consumed an alcoholic drink in the month before their interview.

Parents' regular, short-term, risky drinking was shown to be a strong factor in influencing their teenage children to try alcohol.

Around 11 per cent of mothers and 30 per cent of fathers reported having at least five drinks on a single occasion at least twice a month.

Most parents did not drink daily; of those who did, more men than women exceeded guidelines for long-term risk.

Friends also had a strong influence.

Almost 40 per cent of those who had at least one friend who drank alcohol had tried alcohol themselves, compared to only 5 per cent of those who had no friends who drank.

Teens were also more likely to have tried alcohol if they were the only child, in the later stages of puberty, or in a single-parent household.

But even after accounting for all these factors, there was still a significant association between parents' drinking habits and adolescents' alcohol use.

Those whose parents drank at a risky level were most likely to have tried alcohol.

Rates of self-harm and suicidal behaviour are high

One in ten 14-to-15-year-olds had self-harmed in the previous 12 months, and 5 per cent had attempted suicide.

Girls appeared to be at greater risk than boys of both self-harm and suicidal behaviour.

However, boys were much more likely to act impulsively and make an unplanned suicide attempt.

Some teens are more at risk of self-harm than others.

Those who were same-sex attracted, bisexual or unsure of their sexuality were at greater risk of self-harm than heterosexual teens.

The risk of self-harm was also higher among teens with more reactive temperaments, depression, anxiety or general feelings of unhappiness and those who reported being threatened or feeling victimised by their peers because of their health, skin colour, sexual orientation, language, culture or religion.

Self-harm can often act as a "gateway" to suicide. Of those who had attempted suicide, two-thirds had previously self-harmed.

Teens were at higher risk of suicide if they were same-sex attracted, bisexual, or unsure of their sexuality; or if they had been involved in so-called "delinquent behaviour" such as crime or property offences.

Of those who attempted suicide, 22 per cent had done so more than once and 14 per cent of boys and 18 per cent of girls had required medical treatment after a suicide attempt.

Teens employed in part-time jobs

At 15, almost 40 per cent of young people had worked in a part-time job. Of those working, around one-third worked informally in a family business or for themselves.

Most worked during the school term, with 18 per cent of boys and 25 per cent of girls working on weekdays.

Compared with teens living in the city, those in regional areas were more likely to be employed.

And while girls were more likely to be employed than boys, in regional areas a higher percentage of boys were working.

This might reflect the types of informal work available regionally, such as farming and labouring work.

Young carers falling behind at school

At least one in ten 14-to-15-year-olds were providing informal care for a household member, with around two-thirds of this group helping with core activities including personal care, mobility and communication.

On average, young carers have lower performance levels in NAPLAN reading and numeracy than their non-caring peers.

Young carers who provided daily care were over a year behind their classmates.

Teens at risk need extra help

While most teens are doing well, some teens would benefit from extra help. Parents, teachers and friends of young people need support and advice to know how to help those at risk.

Programs to assist young carers to participate fully in school would be of considerable long-term benefit. Increasing awareness of risk factors for self-destructive behaviour in young people could potentially reduce this disability burden.
Diana Warren is a research fellow at the Australian Institute of Family Studies. Galina Daraganova is executive manager, longitudinal studies, at the Australian Institute of Family Studies. Jennifer A Baxter is a senior research fellow at the Australian Institute of Family Studies. Originally published in The Conversation

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One in 10 Australians aged 14-15 self-harmed in the last year

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Posted September 12, 2017 11:50:36 Following a large group of people over a long time is a terrific way to learn more about life in Australia. The Growing Up in Australia: Longitudinal Study of Australian Children (LSAC) has been going since 2004, following the lives of thousands of children into adulthood and gathering data from parents, teachers, carers and the children themselves.

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Non-credibel source identifying the cause and effect of self-harm, providing information on how to get help.

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Self-harm and teenagers - ReachOut Parents

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Learn about self-harm and get tips on supporting your teenager who may be self-harming.

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Non-credible source that- discusses the reasons behind self harm and the support helplines available.

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Uses statistics to show rise in self harm and discusses the causes of self harm in relation to mental illness.

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The number of children and young people self-harming has risen dramatically in the past 10 years, new NHS figures obtained by the Guardian show.

The sharp upward trend in under-18s being admitted to hospital after poisoning, cutting or hanging themselves is more pronounced among girls, though there have been major rises among boys too.

Experts say the rise is shocking confirmation that more young people are experiencing serious psychological distress because they are under unprecedented social pressures.

The number of girls under 18 who have needed hospital treatment after poisoning themselves has gone up from 9,741 in 2005-06 to 13,853 - a rise of 42% - figures collated by NHS Digital show. The numbers of boys ingesting a poisonous substance have stayed almost unchanged; 2,234 did so in 2005-06 and 2,246 did so in 2014-15.

Poisonings among girls were 42% higher in 2014-15 than 10 years previously

However, the number of girls treated as inpatients after cutting themselves has almost quadrupled over the same period, from 600 to 2,311 - a 285% rise. The number whom A&E teams have treated after hanging themselves has also risen during that decade, from 29 to 125.

While far fewer boys end up in hospital after cutting themselves, the numbers went up from 160 in 2005-06 to 457 in 2014-15 - a rise of 186%. Similarly, the numbers of boys who hanged themselves also doubled from 47 to 95 over the same period, the figures show.

"This is a depressing confirmation of the clinical experience of child and adolescent psychiatrists' experience on the ground," said Dr Peter Hindley, chair of the Faculty of Child and Adolescent Psychiatry at the Royal College of Psychiatrists.

"It is also shocking because it appears to confirm our clinical experience that levels of distress are rising, though not all young people who self-harm have mental health problems, and [that] mental health disorders are rising, for both girls and boys," he said.

Experts said the rises were likely to be due to a variety of factors, including pressure to succeed at school, the damaging effects of social media, family breakup, growing inequality in recent years, children's body-image fears, a history of abuse, including sexual abuse, and increasing sexualisation.

The NHS's most senior doctor responsible for young people's health said the distressing figures underlined that greater improvements were needed to boost support for troubled children.

"It's clearly distressing that more young people are causing harm to themselves and we know that the problems facing children are growing," said Dr Jackie Cornish, NHS England's national clinical director for children, young people and transition to adulthood.

"In common with most experts, we believe this is due to increasing stress and social pressure on young people, including to succeed at school, and emerging problems with body image leading to eating disorders and self-harm."

Poisoning accounts for 88% of all self-harm admissions among under-18s

She added: "We recognise that vital care for children and young people's mental health is an area where more work needs to be done."

Jeremy Hunt, the health secretary, severely criticised NHS care of troubled young people last week. Child and adolescent mental health services (CAMHS) were the "biggest single area of weakness in NHS provision" and beset by "big problems", including failure to intervene early enough when problems such as eating disorders emerged, which meant that "too many tragedies" were occurring, he said.

Hindley added: "The rise is likely to be as a result of many factors but the most important ones are likely to be: growing inequality in the age of austerity, the negative impact of the digital age, increasing sexualisation - this is particularly important for girls - and the impact of abuse and sexual exploitation, and increased pressure to succeed."

Sarah Brennan, the chief executive of Young Minds, said that troubled young people were harming themselves partly because help for them is so inadequate that some do not receive specialist support once it is obvious they have psychological problems. "It's extremely worrying that the number of young people needing hospital treatment for self-harm has risen so sharply. There needs to be far more investment in early intervention, so that problems are dealt with when they first emerge."

Budget-driven local council cuts to social workers, educational psychologists, parenting classes and mental health services in schools had reduced care and support for under-18s in distress, she said. CAMHS teams were responding to rising demand by rationing care.

"The pressure on CAMHS has forced services to raise the bar for access to treatment. Consequently, about a quarter of young people are being turned away, and this will include many who self-harm. At the moment too many vulnerable children end up going to A&E because no other help is available," Brennan added.

Young Minds is concerned that children who self-harm and then turn to the internet for help could come across unhelpful information about, and even encouragement to continue, their behaviour. Young people who self-harm are most likely to go online for information and few seek their parents' support, according to a survey it conducted in March with Childline, Self-Harm UK and The Mix. While 76% of youngsters said they would search the web, just 16% would look to their mother or father, while 61% would ask a friend, and 27% cited a GP and 17% a teacher.

The government has promised to put an extra £1.4bn into care of troubled children during this parliament to ensure that at least 70,000 more under-18s get high-quality care. However, NHS England chief executive, Simon Stevens, has admitted that even if that target is met, it will still only increase the proportion of young people being helped from a quarter to a third.

Hunt last week pledged to make children's mental health a top priority. Cornish added that NHS England has created 56 extra beds in specialist inpatient units for children and young people in the last two years and is putting £30m into improving services for those suffering from an eating disorder such as anorexia nervosa. Earlier this month, it allocated £25m to help cut young people's waiting time for treatment and reduce the backlogs of those awaiting urgent care.

NHS England collated the figures it shared with the Guardian from those covering self-harm and self-poisoning from its Hospital Episodes Statistics datasets from the past decade.

* In the UK, the Samaritans can be contacted on 116 123. In the US, the National Suicide Prevention Hotline is 1-800-273-8255. In Australia, the crisis support service Lifeline is on 13 11 14.

* This article was amended on 31 October 2016 to correct two percentage figures.

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NHS figures show 'shocking' rise in self-harm among young

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The number of children and young people self-harming has risen dramatically in the past 10 years, new NHS figures obtained by the Guardian show. The sharp upward trend in under-18s being admitted to hospital after poisoning, cutting or hanging themselves is more pronounced among girls, though there have been major rises among boys too.

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4 Myths About Self-Harm We Urgently Need to Unlearn

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4 Myths About Self-Harm We Urgently Need to Unlearn

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Credible Source-
Discusses the main myths surrounding self harm and how to combat them.

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Self-harm is something I learned about at a young age.

In my schooling system, we had a subject - patronizingly called "Life Orientation" - where we discussed issues like sex, peer pressure, health, drugs, and relationships.

Something that was covered in Life Orientation was the topic of self-harm.
When I learned about self-harm in school, I had already engaged in it. But it was taught to us in such a way that it othered those who self-harmed.
In a misguided attempt to discourage us from self-harming, our teacher spoke about how stupid it was to self-harm. That it didn't solve any problems. That it was done to seek attention. That it only ever includes cutting.

We weren't taught how to seek help. In fact, with our teacher shaming people who self-harmed, I felt too ashamed to seek help.

My self-harming tendencies continued for years after that - partially because I internalized so many harmful myths about it. I didn't believe I was being overdramatic or seeking attention, but I knew some people would think I was.

If we want to create a society where people who self-harm feel safe and able to find help, we need to debunk those myths.

Myth #1: Self-Harm Is a Failed Suicide Attempt

A very common myth is that self-harm is a suicide attempt. This isn't true.
It's possible to have suicidal ideations and self-harm, and self-harm is sometimes a predictor of suicide.
But most of the time, "self-harm" refers to inflicting injury without actually intending to kill yourself. Personally, I used to self-harm when I felt myself dissociating because of PTSD, or when my emotions were too overwhelming and I needed some kind of outlet.

A clinical term relating to self-harm is non-suicidal self-injury (NSSI), which is categorized separately from suicide attempts because the intention is different.

People who engage in self-harm often do so to distract themselves from emotional and psychological pain, or to help themselves feel something when they're feeling numb.
Being suicidal isn't anything to be ashamed of, but it shouldn't be conflated with the urge to self-harm.
We need to be able to address the pain that people who self-harm are experiencing, rather than assuming they have the same needs as someone who is suicidal.

Myth #2: Self-Harm Is Done for Attention

Whenever mental health issues are thrust into public spaces by sufferers, we're told we're seeking attention.

When we tweet about mental health, we're told we're seeking attention.

When we write about it, we're told we're seeking attention.

When we discuss it in public, we're told we're seeking attention.

When there's physical evidence that we've been self-harming, we're told we're seeking attention.

Of course, this all feeds into mental health stigma.
We're taught by society that mental health is something we need to be ashamed of, something that's inappropriate to discuss with others.
Shaming people as attention-seeking when they discuss mental health is an integral tool of ableism.

As professionals and experts have told us time and time again, self-harm isn't about attention. Many people who self-harm feel ashamed of it and don't want to discuss it. When self-harm produces physical evidence, such as scarring, many of us try to cover it up.

I hid my struggles with mental health for years and years partially because I didn't know how to ask for help.

For me, self-harm was a way of making my mental illness visible in a world that continually erased my struggles. I didn't want it to be visible to anyone in particular, but I wanted it to be visible.

My scars felt like an acknowledgement that I wasn't okay. I shouldn't have had to resort to self-harm in order to acknowledge that I was struggling, but I did. Maybe, in a way, I was subconsciously looking for some validation from the world - validation that I wasn't okay, validation that I needed help.
And you know what? I deserved that validation. We all do.
When I talk about how suicide and self-harm isn't about seeking attention, I like to remind the audience of one thing: Looking for attention isn't necessarily a bad thing.

Many people need attention in order to feel loved. This doesn't mean it's okay to manipulate and emotionally blackmail people into giving you attention - not at all.

But it does mean that attention needs to be paid. We need to pay attention to the mental health of those who self-harm.

Instead of looking at this behavior as cries for attention, we should look at it as an indicator that someone needs help.

Myth #3: Self-Harm Always Takes the Form of 'Cutting'

When you think of self-harm, what image pops into your head?

Many people think about someone cutting into their skin - especially on their wrists.

This is a common way to practice self-harm, yes - but there are many other ways in which it's done. It's important to be aware of these practices so that we can recognize it as self-harm when we see it.

Other methods include burning, carving words or symbols into the skin, excessive scratching or picking, hair-pulling, and punching oneself. It could also include hitting oneself with objects. This could include banging your head against a wall or hitting a door.

In a much broader sense, certain kinds of self-destructive behaviors can be considered self-harm - not just physical forms of self-injury. This could include excessive drinking, substance abuse, overworking, or engaging in other risky behaviors.
There are many possible reasons for this behavior. For many of us, it's exactly the same reason why we self-injure.
When I stopped cutting, I was incredibly proud of myself - and for a good reason. But I started overworking to the point where I got very little sleep.

Over time, I began to realize that I had simply replaced one form of self-harm with another. Because I associated self-harm with cutting, it took me a while to accept the fact that I needed help.

It's important that we look at self-harm and self-destructive behaviors with an open mind.

Myth #4: Only Teenagers Self-Harm

The mainstream media often represents people who self-harm as teenagers. And yeah, studies indicate that teenagers are more likely to engage in self-harm.

But it's important to bear in mind that there are, indeed, adults who self-harm, and we shouldn't erase them from the narrative. This might mean they don't recognize their behavior as self-harm. It might also lead them to feel too ashamed to seek help.
This myth also feeds into a lot of stereotypes about teenagers and mental illness.
Often, when teenagers ask for help, they're dismissed as being over-dramatic and attention-seeking. They're often told that they'll "grow out" of their mental difficulties.

Similarly, self-harm is seen as over-dramatic and attention-seeking. People are sometimes told that they'll simply grow out of self-harm, a stereotype which is substantiated by the fact that adults who self-harm aren't represented.

The stereotypes about mental health and teenagers go along with myths about self-harm. And to forge a better future for mentally ill people of all ages, we need to fight those stereotypes and unlearn those myths.
***
Learning more about mental health issues is a valuable tool in fighting stigma. For that reason, it's incredibly important that we unlearn harmful myths about issues like self-harm.

By spreading awareness, instead of lies, we can equip people to help themselves and others.
Sian Ferguson is a Contributing Writer for Everyday Feminism and a full-time freelance writer based in South Africa. Her work has been featured on various sites, including Ravishly, MassRoots, Matador Network, and more. She's particularly interested in writing about queer issues, misogyny, healing after sexual trauma and rape culture. You can follow her on Twitter @sianfergs and read her articles here.

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4 Myths About Self-Harm We Urgently Need to Unlearn

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Self-harm is something I learned about at a young age. In my schooling system, we had a subject - patronizingly called "Life Orientation" - where we discussed issues like sex, peer pressure, health, drugs, and relationships. Something that was covered in Life Orientation was the topic of self-harm.

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Is a suicide help site and discusses myths surrounding self-harm.

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Myths about self-harm - Suicide and Self Harm Crisis Centre - Pieta House

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Pieta House is a non-profit organisation providing a specialised treatment programme for people who have suicidal ideation or who participate in self-harming behaviors.

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Credible source - Sane Australia

Discusses what self harm is, behaviours associated with it and how to help someone who is self harming.

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Non-credibel source identifying that the mental illness rates are increasing in Australia.

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More Australian teenagers are in severe psychological distress than five years ago despite growing awareness and initiatives aimed at tackling mental illness, a new report shows.

The alarming statistics, released Wednesday in a report by Mission Australia, show almost a quarter of teens surveyed meet the criteria for probable serious mental illness, with girls twice as likely as boys to be affected.

The latest Mental Health Youth Report reflects five years of annual surveys of thousands of teenagers across Australia.

Mission Australia's 2016 Youth Survey Findings

Almost a quarter (22.8 per cent) of young people aged 15 to 19 show the symptoms of probable serious mental illness, up from 18.7 per cent five years ago

Teenage girls are more than twice as likely as boys to be in severe psychological distress, even though the suicide rate is higher in males

Almost one third (31.6 per cent) of Indigenous Australians affected

The three top stressors for teens are: coping with stress; school and study problems; and depression. Other notable issues include bullying, family conflict and suicide.

Older teenagers (those aged 18 to 19) were more likely to show signs of severe psychological distress, as were Indigenous Australians. Particularly concerning was the significant increase in young females affected, which increased to 28.6 per cent in 2016, a rise of more than six per cent over the five year survey period.

Mission Australia's CEO, Catherine Yeomans, is calling on federal and state governments to do more to address the issue.

"We are talking about an alarming number of young people facing serious mental illness, often in silence and without accessing the help they need," she said.

"The effects of mental illness at such a young age can be debilitating and incredibly harmful to an individual's quality of life, academic achievement, and social participation both in the short term and long term."

The latest report from Mission Australia joins a growing body of research showing an increase in serious mental illnesses in young people.

An American study published in the medical journal Pediatrics late last year showed an increase in teens suffering depression from 8.7 percent to 11.5 percent in just 12 months.

PamelaJoeMcFarlane via Getty Images

A similar study in the United Kingdom showed a dramatic rise in the number of teenagers being admitted to hospital for self-harming in the past decade -- shockingly, the number of teen girls admitted to hospital in the UK for cutting themselves quadrupled in that period. Another British study shows rates of mental illness in young women aged 16 to 24 is at an all-time high.

And the issue is not confined to teenagers in developed nations. Last month, the World Health Organisation (WHO) announced that depression is now the leading cause of ill health and disability, having risen by more than 18 per cent worldwide since 2005.

So experts agree that it's a major problem -- and that it's getting worse. What is less certain are the reasons behind the rise.

Is it the pressures of modern day living -- the 'always on' mentality? Is social media to blame? Are we putting too much pressure on our young people to 'do it all', with school, exams, extra-curricular and social life? Or is it simply a growing awareness of mental illnesses that is encouraging more people to speak out?

While a rise in awareness and a decrease in stigma could well play a part in the visibility of mental illnesses, there are other factors involved, says Helen Christensen, Director of the Black Dog Institute, which partnered with Mission Australia in producing the report.

If you know that you can prevent skin cancer by using protection, you would do it. Then why wouldn't you be using these [mental health] programs, when we know they work?"

A leading theory in mental illness suggests that everyone has a different level of vulnerability to mental ill health, called your "stress diathesis", Christensen explained. Essentially, this is the level of stress that you can deal with before developing a mental illness.

Teens are going through a transitional period which exposes them to a lot more stressors than they've previously experienced, which means in those with a lower "stress diathesis" are at risk of mental illness.

"The rates in young people are higher because what happens in adolescence is you go through a period of developmental change, your body changes with puberty, you're taking on more responsibility, your relationships with your peers are increasing and you're letting go of your stronger relationships with your parents," she explained.

Mission Australia's report indicates the biggest sources of severe psychological distress for young people are coping with stress, school and study problems, and depression -- although other factors such as family conflict, bullying and emotional abuse and suicide also added to the emotional toll.

So what can be done about it?

While the solutions are no doubt as complex as the many illnesses young people face, the fact that mental illness is still on the rise shows that current intervention programs are not doing enough, Mission Australia and the Black Dog Institute agree.

The Black Dog's Christensen applauded the NSW Department of Education for taking steps to introduce Youth Aware of Mental Health (YAM), a school program developed in Sweden which has been shown to reduce youth suicide, but said more needs to be done at a national level.

Mental illness was just as serious as cancer or HIV, but wasn't receiving the same attention, she said.

"If you know that you can prevent skin cancer by using protection, you would do it. Then why wouldn't you be using these programs, when we know they work?" she told The Huffington Post Australia.

What's needed, Christensen said, is a coherent strategy for tackling mental health to be introduced in all schools around the country.

"We should be looking at particular types of programs that target a particular risk, like suicide or anxiety, not just doing general programs to increase wellness," she said.

One of the major causes of psychological distress in young people is an inability to cope with stress, according to the Mission Australia report. That means that evidence-based programs to teach teenagers coping skills and emotional awareness could play a key part in addressing the issue.

This would not only play a part in reducing teen mental illness but equip young people for the rest of their lives, Christensen explained.

"Stress is a normal part of life, but you immunise yourself by being exposed to it," she said.

"These school-based programs teach children how to cope -- it's providing the skills that everyone needs in life, at the time that they start to appear."
If you need help in a crisis, call Lifeline on 13 11 14. For further information about mental illness contact beyondBlue on 1300224636 or talk to your GP, local health professional or someone you trust. ALSO ON HUFFPOST AUSTRALIA

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Mental Illness Is Still On The Rise In Australian Youth, Study Shows

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More Australian teenagers are in severe psychological distress than five years ago despite growing awareness and initiatives aimed at tackling mental illness, a new report shows. The alarming statistics, released Wednesday in a report by Mission Australia, show almost a quarter of teens surveyed meet the criteria for probable serious mental illness, with girls twice as likely as boys to be affected.

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Non-Credible

However, it discusses the rise of self-harm in young males for an early age and how that impacts the development from early childhood.

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AUSTRALIAN children as young as six are ending up in hospital after intentionally harming themselves, with rates increasing in younger boys, a new report shows.

Research covering children aged under 17 in all States shows 1600 are admitted to hospital each year for self-harm, with rates higher in boys aged six to 10, while girls are more likely to self-harm in the 11 to 16 age group.

The report comes only weeks after WA doctors warned of an alarming increase in the number of children and teenagers presenting with self-harm to Perth emergency departments.

They said there had been a 400 per cent increase in the past five years, including a downward trend in the age of patients.

The latest figures, in the Australian and New Zealand Journal of Public Health, tracked the number of children admitted to hospital from intentional self-harm and assaults over 10 years.

Researchers from Macquarie University and the University of Sydney found there were 18,223 self-harm and 13,877 assault hospital admissions in under-17s between 2001 and 2012, costing more than $124 million to treat.

The researchers said self-harm was increasingly becoming a major public health issue among children.

"In Australia, the hospitalisation rate following self-harm was found to be increasing in males and was already high for females," they said. "The current study found that the highest proportion of self-harm was among children aged 11 to 16 years, particularly females.

"These self-harm hospitalisations represent just the tip of the iceberg ... because many children who self-harm do not seek treatment from hospitals."

The researchers recommended support services for children who self-harmed, parent education measures and training for children to de-escalate conflicts to address assaults.

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AUSTRALIAN children as young as six are ending up in hospital after intentionally harming themselves, with rates increasing in younger boys, a new report shows. Research covering children aged under 17 in all States shows 1600 are admitted to hospital each year for self-harm, with rates higher in boys aged six to 10, while girls are more likely to self-harm in the 11 to 16 age group.

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International Article. Creditable- source

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Non-credible source exhaling how self-harm is a plead for help, not an attention seeking act.

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A recent storyline on TV soap Hollyoaks has been praised as a "masterpiece of televion" after focusing on the issue of self harm in young people.

The show, which worked with charities Samaritans and Mind on the episode, broadcast a special edition, which looked closely at the journey of the character Lily Drinkwell, and her friends Peri Lomax and Yasmine Maalik - as well as their parents and guardians - and explored themes of self harm and cutting among teenage girls.

It came as a recent report showed there had been a steep rise in incidents of self harm among teenage girls. The findings, based on data from GP practices across the UK, show that self harm among girls aged 13 to 16 has risen by 68% in the past three years.

The study by researchers at the University of Manchester found that self harm was three times more common among girls than boys - and that those who self harm are at much greater risk of suicide. Self harmers are 50 times more likely to try to take their own lives.

The research also revealed that it is socially deprived areas where the greatest increase of self harm is seen. These children are also less likely to be referred to mental health services within a year of their first incident compared with those children living in more affluent areas.

The UK now has the highest rates of self harm in Europe. And the NSPCC's ChildLine Annual Review lists it as one of the top reasons why children contact the charity.

A cry for help

Working directly with adolescences in therapeutic communities, I have seen self harm used by children time and time again as a form of communication - about their state of mind and inner world. They cannot always tell you, but they can show you their pain.

In this way, Armando Favazza, the US writer and psychiatrist has explained how self-harm can usefully be thought of as "a morbid form of self-help".

And research has shown that the main function of self harm is "affect regulation" - in others words, to manage chaotic and frightening feelings.

There is also a lot of evidence that suggests early traumatic memory from childhood is held in the right brain hemisphere, and cannot be accessed symbolically through language because of the immaturity of the infant brain.

The theory goes that memory of these traumatic experiences then tends to be become "somatised" or experienced within the body. So for children who have experienced abuse and mistreatment, self harm can be a method of externalising internal wounds by showing this on the surface of the body.

Troubling times

The fact that more of these harming behaviours are seen in teenage girls is of course concerning. But as the psychoanalytical psychotherapist, Fiona Gardener explains:

Self harm typically begins in adolescence, and is characterised by an adolescent state of mind.

Adolescence itself is transitional, a period of uncertainty, and its duration has lengthened in recent years - with some girls experiencing their first period as young as nine years-old. At the other end, adolescence may be extended with many teenagers staying longer at home because of poor job prospects and rising rental and housing prices.

This means that children remain dependent on parents for longer and are instead compelled to explore their independence in the virtual world - and this of course has consequences.

Anxious culture

Children and parents now spend increased amounts of time online, which has led to a more disconnected style of parenting. And one of the other issues with more time spent online in chatrooms is that self-harming behaviours can be "normalised" by peers. Previous research has shown a "strong link" between using online forums and self harming teens.

Then there is also the highly pressured and image obsessed world many teenagers are growing up in - which is most acutely felt by girls. Children these days live in an age of selfies, online status, updates and instant communication - with sites such as Instagram and Snapchat emphasising appearance over content.

The proliferation of self-images on these sites breeds a deeply competitive and anxious culture among teens. And as any teenager can tell you, more images are posted by girls.

Bullying and pressure on social media is also an ever present threat. This is a threat that doesn't just follow you home, but comes into your house with you, goes to bed with you and even on holiday with you - it is inescapable.

Fighting the feelings

What all this shows, is that children are being given too much of what they don't need and very little of what they do.

This comes at a time that child and adolescent mental health services are inadequately resourced. If children get access to help they are often placed into short term cognitive behavioural therapy (CBT). But this isn't always the answer, because self harm tends to be more about emotional difficulties than cognitive processes - which is what this type of therapy focuses on.

Ultimately though, this rise in self harm needs to be seen for what it is, a cry for help, and a way of communicating the pain and upset these teenagers are feeling. And given the scale of the problem, these heartbreaking figures speak volumes about the experience of growing up as a girl today.
If you have been affected by any issues in this story, or you need support and information, you can visit Mind's website or call their confidential helpline on 0300 123 3393.

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More teenage girls are self harming than ever before - here's why

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A recent storyline on TV soap Hollyoaks has been praised as a "masterpiece of televion" after focusing on the issue of self harm in young people.

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Creditable Source- Surveying people in the community on the truths and myths about self-harm