Cognitive and Social Experiences and Support-seeking among Individuals engaging in Non- suicidal Self-injury

doi:10.21203/rs.3.rs-1438650/v1

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Cognitive and Social Experiences and Support-seeking among Individuals engaging in Non- suicidal Self-injury

https://doi.org/10.21203/rs.3.rs-1438650/v1

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This study explores the cognitive and social experiences that underlie non-suicidal self-injurious behavior as well as attempts to understand how individuals seek support after harming themselves. In-depth, semi-structured interviews were conducted with five young adults who had engaged in some form of self-harm in the past six months. The cognitive experiences provided a greater insight into the inner functioning of the individuals while the social experiences provided evidence of how the environment influences self-harming behaviors. There is also a great variety of support-seeking behaviors.

Psychology

self-harm

cognitive

social

friends

families

emotions

thoughts

feelings

Non-suicidal self-injury, henceforth referred to as NSSI, refers to the act of intentionally destroying one’s own body tissues with no suicidal intent and for purposes that are socially sanctioned (International Society for the Study of Self-Injury, 2020). Some common examples of NSSI might include cutting, burning, scratching, banging, and hitting.

In India, the rate of NSSI in 2013 was found to be 31.2% among college students, with the mean age of onset being 15.9 years. (Kharsati & Bhola, 2014). These behaviors are often performed in secret, and the most prominent reason behind the performance is to induce a feeling of calmness and relaxation. (Bhola, Manjula, Rajappa, & Phillip, 2017).

Understanding the causes behind NSSI requires consideration of the complex interaction of the cognitive and social forces. Individuals who engage in NSSI feel negative emotions, and performance of the act provides results in reduced negative emotions and a feeling of calm and relief (Klonsky, Victor, & Saffer, 2014). Self-injury is also a result of self-directed anger or self-punishment, caused by extreme amounts of self-criticism (Hooley & St Germain, 2013). In a study conducted over 2640 high school students, it was found that adolescents who experience a greater level of psychological distress, receive poor social support from family, and have poor self-esteem are more likely to start indulging in self-injury. (Andrews, Martin, Hasking, & Page, 2013).

Individuals indulging in NSSI might have a different way of perceiving and making sense of the world around them. Hankin and Abela (2011) found that a negative cognitive style predicts NSSI in adolescents. Unfortunately, not much research has been conducted to understand the underlying cognitive factors that contribute to NSSI behaviors.

A number of social factors can contribute to engagement in NSSI. These include low family support, high dysfunctions within the family (Prinstein et al, 2000), negative parenting practices (Ying, You, Liu, & Wu, 2021) and low family cohesion. Peer support also plays a role in NSSI (Prinstein et al., 2000).

Social support, especially support from family and parents, is important as a preventive factor against NSSI as well. Individuals who perceive their parents as dependable and have better communication with them have a greater foundation for developing adaptive coping skills than the ones who rely on peers for developing such skills (Wolfe et al., 2013). Social support plays an important role in dealing with NSSI. Individuals engaging in NSSI have comparatively less social support and fewer people they seek support from compared to those who don’t engage in NSSI. People who engage in NSSI might find it difficult to form relationships (Levesque, Lafontaine, Lonergan, & Bureau, 2021) and develop adaptive interpersonal skills (Muehlenkamp, Brausch, Quigley, & Whitlock, 2012).

One cannot talk about social factors that contribute to NSSI without talking about the cultural factors that underlie every society. Xu et al. (2019) recruited 4799 students from two medical colleges in the Anhui province of China and found that physical, emotional, sexual, and overall childhood abuse is positively associated with NSSI frequency and. There is also a negative correlation between social support and frequency of NSSI, which means participants who had more social support were less prone to engage in NSSI. Brown and Witt (2019) found that in non-Western cultures, family factors are not associated significantly with NSSI, probably because of the stigma and misconception surrounding mental illness. However, in the Western context, negative parental and peer variables are closely related to the onset of NSSI. Relation with siblings is also an important predictive factor.

Very closely related to the social factors is the immediate reaction that individuals who engage in NSSI receive upon disclosing their act. In a meta-analysis of 10 studies, Park, Mahdi, and Brooke (2020) found that people who disclose their NSSI behaviors are often met with negative responses, which often cause them to withdraw from seeking further help. While peers may not have as significant an impact as family on acts of multiple NSSI (Adrian et al., 2011), whenever peers respond positively to the disclosure of NSSI, it leads to a feeling of comfort in the disclosing individual, and might also offer them an opportunity of receiving instrumental help. It might also strengthen the friendship, as was found by Gayfer, Mahdi, and Lewis (2018) in their study. Surprisingly, individuals who disclose their NSSI to health professionals rate the conversation as being ineffective compared to when they disclose it to peers or friends (Baetens et al., 2011). Based on the previous trend, the first impression of the therapeutic setting might influence therapeutic attendance and compliance.

While a lot of studies have been conducted to understand more about this behavior, most of them have been focused on the Western world, where the social factors might be completely different from those in the non-Western world. Hence there needs to be more research in the context of Indian society which would take into account the various cultural typicalities which might often be omitted in research conducted in the Western world.

Thus, this study aims to bridge the gap that exists between the Western and Indian society regarding the psychosocial experiences that contribute to NSSI and the support-seeking behaviors of individuals who engage in NSSI so as to develop a rich and concise account that might be helpful for addressing the problems that force people into NSSI and develop a proper support system to help them deal with the difficult times. As such, this article focuses particularly on two research questions: (1) what are the cognitive and social experiences of individuals that lead to engagement in NSSI? and (2) what are the support-seeking experiences of individuals who indulge in NSSI and how do they perceive the immediate reaction of others upon disclosure?

2.1 Participants

The participants for this study were five individuals with an average age of 22.8 years recruited through purposive sampling. This age group was selected as globally, on average, the mean age of onset for NSSI is 17.25 years and the age by which it is stopped is 26.74 years. The highest incidence of NSSI is during this timespan (Plener et al., 2016). The inclusion criteria were: (i) has to be between 18 and 25 years of age, and (ii) must have engaged in at least one form of NSSI in the past six months. Anyone who was outside the mentioned age bracket and had harmed themselves with the intent of suicide was excluded.

2.2 Procedure

Ethical approval

to conduct the research was sought from the Research Conduct and Ethics Committee, Centre for Research, CHRIST (Deemed to be University) prior to conducting the research. Participants were recruited through an online survey where they had to answer some basic questions for screening purposes. Although almost 10 individuals had shown their interest initially, only five participants actually consented to participate in the interview.

Although the initial plan was to conduct the interviews in person, the rise of the second wave of the COVID-19 pandemic meant that the interviews had to be conducted through an online platform instead. The interviews lasted for an hour on average. These were semi- structured in nature with multiple open-ended questions and the use of appropriate prompts whenever required. All the interviews were audio-recorded with prior consent from the participants and later transcribed for data analysis. The first author transcribed each interview verbatim. To maintain the confidentiality of the participants, the audio recordings and transcripts were coded with numbers and all possible identifiers were removed. Given the minimal number of participants, there remains some doubt whether data saturation was achieved.

2.3 Data analysis

After the interview had been transcribed, qualitative data analysis was conducted. As the researchers wanted to explore the cognitive and social experiences and perceived support, thematic analysis from a realist ontological position was found to be the most suitable data analysis method. The thematic analysis was employed to serve the exploration of the particular phenomenon in order to capture its intricacies. The qualitative analysis software NVivo was used to help in the analysis process. The first author created the initial codes and themes. These were reviewed by an external researcher experienced in qualitative research. The final thematic structure was arrived upon through mutual agreement and discussion between the first author and the external researcher. This structure was further cross-checked and approved by the second author of the paper.

Five participants contributed to the study (three females and two males). The ages of the participants ranged between 22 and 24 years. The average age was 22.8. The participants were found to engage in a wide variety of self-injurious behavior- cutting, hitting, drowning, pinching, and biting. Among these, cutting was found to be the most common (n = 4), followed by hitting (n = 3). Drowning, pinching, and biting occurred sporadically. The analysis yielded 18 basic themes. The basic themes could be classified under eight organizing themes. The organizing themes themselves were grouped under three global themes.

Table 1

The themes from the interview
Global themes	Organizing themes	Basic themes
Cognitive experiences	Precipitates	Internal
		External
	Pre-NSSI thoughts and feelings	Self-directed
		Outward-implicated
	Post-NSSI emotions	Positive
		Negative
		Detached
Social experiences	Family dynamics	Adaptive, cohesive, supportive
		Maladaptive, antagonistic, disruptive
	Dynamics of friendship	Emotionally distant
		Emotionally fulfilling
	Dynamics of extended social system	Close-knit
		Withdrawn
Support-seeking	Primary source of seeking help	Social-oriented
		Therapy-oriented
	Perceived immediate reactions	Supportive
		Berative
		Suggestive

3.1 Global theme 1: Cognitive experiences

The global theme of cognitive experiences explores the situations in which the individual engages in NSSI, what they were thinking before engaging in the act, and their emotions after they had committed the act.

3.1.1 Organizing theme 1: Precipitates

Precipitates are the internal or external conditions or events that led to the individual engaging in the act of NSSI. The internal precipitates refer to the internal psychological conditions that predispose the individuals to engage in NSSI. One participant reported feelings of helplessness and loneliness which led him to engage in NSSI in order to bring other’s attention to his suffering: “...I was feeling very lonely. I was feeling very alone...So I thought if I do something like that, maybe people will pay some sort of attention towards me.”

Another participant reported feelings of hopelessness coupled with extreme anger which led her to engage in NSSI in order to distract her mind: “...if I feel helpless…I feel, to switch off that emotional rage and emotional thing that's going in my head by resorting to something physical, because that will distract my mind.”

For yet another participant, NSSI becomes a way of punishing herself for her feelings of guilt: “...it's not just my anger against the people who I have fought with, but it's even the anger that is like, basically I'm feeling for myself…That means I need to be punished.”

Finally, being overwhelmed by extreme emotions was also identified as a psychological precipitate of NSSI. In such a situation, NSSI becomes a tool to displace the emotional pain to a more tangible, physical target- the own body: “…whenever I feel too overwhelmed by emotions. I really feel like you know, letting out the pain by harming my in some other way.”

External precipitates incorporate the situations that predispose an individual to engage in NSSI. One participant mentioned that she had used NSSI as a form of motivation since she had the “pressure to achieve something”: “...you have the pressure of achieving something…I had this iron wire on my wrist…just remind me that I have something to achieve.”

Stress from family and relationship conflicts emerged multiple times across multiple participants, and was the most common situation precipitant of NSSI: “So it was usually something related to my family…spiraling...Once or twice, it's been because of my relationships as well, like, the fights and all.”

I've got several family problems. I find different pleasures to escape them, which is why I chose to participate here because one of those escapades is NSSI.

3.1.2 Organizing theme 2: Pre-NSSI thoughts and emotions

The theme of pre-NSSI thoughts and feelings attempts to explore what the thoughts and feelings leading up to the act of NSSI were and whether they were directed towards self or towards an external target. The theme of self-directed captures events where the target of harm was the participant themselves.

Most acts of NSSI were directed towards the self than to an external target as all the participants shared experiences where the primary target of harm was themselves, for a myriad of reasons. One participant said that he engaged in NSSI because he had withdrawn himself from others and did not want to feel worthless anymore: “There were times when I was not feeling like talking to anybody. I kind of withdrew myself to my own space... it, I didn't want to feel worthless.”

Another reason for which participants harmed themselves was to gain control over their emotions. This was either done to calm themselves down or to let the painful emotions out in some way, as reported by a couple of participants: “…something that, that things happen that you can't control…I just put around this wire in my hand, just to remind me that I can't control this. So I have to, you know, keep my calm, so that I can think properly and make decisions.”

So self harm is kind of like, cutting myself kind of like leaves, it's kind of a way for me to let out my emotions...I get really overwhelmed.

The theme of outward-implicated refers encompasses situations where the participant engaged in NSSI in order to either communicate something to another person or the emotions towards the other person was displaced towards own self: “I would say that I do it because I am hurting. And that is caused by some someone else. So just because I can't hurt that person back. I chose to hurt myself even further, so that I can, you know, get out of it”

Compared to the self-directed acts of NSSI, engaging in NSSI which was actually directed to an external person was relatively rare.

3.1.3 Organizing theme 3: Post-NSSI emotions

The theme of post-NSSI emotions capture how the participants felt after they had engaged in a particular act of NSSI. The emotions were not mutually exclusive, but sometimes overlapped.

Most participants reported feelings of positive emotions after they had engaged in an act of NSSI. Satisfaction came up in the experiences of a participant as a reaction to engagement in NSSI: “...when you are hurt, like you have an urge to do something and then you finally do it, and then you just have that calm feeling. You could call that satisfaction, I guess.”

A feeling of relief was also another positive emotion that was reported: “…it's similar to that, in the sense like something is let go off. So it's like, let go of a heavy burden that you have secretly, like, you feel like to feel light, and then you feel relaxed.”

I feel relieved, like, it's kind of like a very good feeling. It feels like, you know, how all my emotions are going out of that

However, not always the emotions were positive. The participants reported negative emotions as well. These emotions were overwhelmingly of guilt and regret: “But mostly, there was also a feeling of guilt. Like, I was like, “What have I done?” Like, you know, “I shouldn't have done this”.

...in the very second minute, I think I regretted it. And I was very concerned as to whether I have I had hurt myself to an extent

However, one participant reported feeling detached as NSSI was a regular occurrence for her: “I don't feel pleasant. And, like, I don't feel pleasant, or I don't even feel like the pain. I don't regret it either. Like, I just forget that part...once it's done, I neither regret nor do I, like feel good about it. It's just like a neutral feeling.”

3.2 Global theme 2: Social experiences

The global theme of social experiences explores the dynamics of families, friends, and extended social systems of the participants

3.2.1 Organizing theme 1: Family dynamics

The theme of family dynamics tried to explore the relationship between the participants and other family members, but mostly between them and their parents. At least one participant reported her family to be an adaptive, cooperative, and cohesive one, where everyone would take care of and look out for each other despite having differences in personalities and thoughts and where her parents were emotionally available: “...my father was a very, I could say, a very kind, compassionate...he always had time for his family. My mother, on the other hand, was she was a very hardworking person, she took care of everybody...my parents were always supportive, and they never stopped me from doing anything...”

A more common occurrence among the participants was maladaptive, antagonistic, and disruptive family dynamics, riddled by conflicts between the parents as well as between the parents and their offspring, which would sometimes lead to parental abuse. Such a pattern was identified from the accounts of the rest of the participants: “…the family that I live with, we don't really get along that well...from the emotional point of view are not very sure how things are all kind of work. Maybe there we can observe some form of lack...”

I'm not close to our family and I, we have like a lot of differences. And there have been times like, so I was abused as a child...my father, and he sexually abused me from age seven, I guess, 6–7 to 14, like almost six, seven. So and for some reason, he like he denies it, obviously

They're monstrous and inhuman and abusive and torturous and they'll end up destroying your self-confidence and, you know, make you question your existence...

3.2.2 Organizing theme 2: Dynamics of friendship

Dynamics of friendship explore the relationship the participants share with their friends. Emotionally distant friendships are those in which an individual might enjoy spending time with friends but is not much emotionally attached. Thus, the relationship exists only on the surface level and the individual is emotionally distant from his friends: “…friends are mostly for me, it's mostly having fun. But I don't really express my feelings with them, to be honest.”

The other participants, however, expressed deep, satisfying friendship on an emotional level. Such experiences have been captured as emotionally fulfilling: “I do consider friends is very close people to me, I like to invest myself emotionally, physically, mentally into any kind of shape that I may”

…those two friends were the only people with whom I can I could be myself like as free as funny…very, very good friends, and whom I can call up at any point of time

...my support system is entirely dependent on my friends and my peers... I trust them enough that if something bad goes down, they will be there for me.

3.2.3 Organizing theme 3: Dynamics of extended social system

The theme of dynamics of extended social system explores the quality and nature of relationship the participants share with people who are not a part of their immediate family or friends, but still might share significant amount of time with. This theme explored the relationship with neighbors, relatives, and teachers. Few participants reported that they are close-knit to their extended social system:“Relatives, yes. We have had quite helpful relatives and nice people around in our family, friends and peers they've always been around, giving, like support in all kinds. So that's, that's kind of there.”

Oh, my teachers, they have been a great support. So especially my HOD during my undergrad. He was a person who actually like I wanted someone...he has helped me a lot…

However, the majority of the participants are detached from their relatives, teachers, or neighbors: “I prefer minimal interactions with my neighbors because she used to be my best friend for the past 11 years but she was very pretentious because she has been she has been one of the most significant contributors towards my family tormenting me”

I just believe that relatives neighbors, they are they are they can be as obnoxious as they can be, you know, some it's not I wasn't fortunate enough to have well relatives who were very understanding of the situation.

3.3 Global theme 3: Support-seeking

The global theme of support-seeking explores the primary sources of support the participants use and how they perceive the immediate reaction they face while seeking support.

3.3.1 Organizing theme 1: Primary source of seeking help

The theme of primary sources of seeking help captures the how individuals are likely to seek help to deal with NSSI. They can be broadly divided into social-oriented and therapy-oriented with participants often adapting both options simultaneously.

Social-oriented approach are those where participants sought out help from friends or family or relatives or any such comparable social relations. There was found to be a wide variety of help-seeking behavior in this regard. People usually seek out someone who would non- judgmental listening ear without berating the actions: “...after I do it, I usually tell someone who I trust, who would not like blame me…”

While others do want to seek out social support, but they do not find appropriate people who would convey the empathy and care: “So I never sought help from anybody because I was harming myself. I could not bring myself to narrate whatever was happening to me…we never really got talking”

Therapy-oriented behaviors are those where participants attempted to seek out support from mental health professionals in the aftermath of NSSI engagement. However, not all sought out therapy for the reason. One participant reported seeking out therapy for reasons completely unrelated: “...there was professional help that I was undergoing, and was not definitely on that topic. But then yeah, it was like, that did come up in the, the discussions that we had...”

Fortunately, the therapeutic experience was reported to be positive by another participant: “I am currently you know, I am currently going through therapy sessions. So I guess I am working on myself in that manner.”

Unfortunately, not everyone had good experience in therapy, as narrated by a couple of participants: “I have gone to think 1-2-3-4-5 different therapists. But like, sadly…none of them were able to help me out.”

No, no, I don't want I don't feel like actually a met a therapist once, but I only went for a session. That's it. But I really didn't like the therapist.

3.3.2 Organizing theme 2: Perceived immediate reactions

This attempts to capture to capture the participants’ perception of the reaction they faced from people around them- mostly friends and family- when they sought help. The reactions were supportive, berative, or suggestive.

Supportive responses were those in which the participants received emotional validation and reassurance from their friends: “The most important point here is all of these friends are very, very supportive… They were very loving in expressing themselves”

Unfortunately, not all participants had such supportive friends. One participant reported being berated by his friends for engaging in NSSI: “...people were sad people were, some people were angry that I did that... They were they were also reactions from some of my peers who were into religious circles. And there was a sense of praying and all that. But I mean, the way they received is mostly in a negative way...”

However, both the supportive and berative responses were at the extreme end of the spectrum. Most participants received suggestions to deal with the problem and their behavior: “Some people wanted me to, like, get admitted to a hospital.”

I have a few friends like that, you know, they always push me to take to go to a psychiatrist but I really don't. I really don't. I tried, but I didn't like that's it.

4.1 Cognitive experiences of NSSI

The analysis pointed out a myriad of cognitive experiences that might lead to NSSI. Negative emotions were found to be one of the most prominent precipitates. The relationship between negative emotions and NSSI was reported by Victor & Klonsky (2013). The researchers found that individuals who engage in NSSI are more likely to report negative emotions like sadness, anger, shame, nervousness, anxiety, irritability, and dissatisfaction with self and less positive emotions compared to individuals who do not engage in NSSI. Guilt was also found to be highly correlated to NSSI behaviors among young adults and adolescents (VanDerhei, Rojahn, Stuewig, & McKnight, 2013). Anger, specifically, was found to be an important precipitate of NSSI among veterans (Cassiello-Robbins et al., 2021).

Stress is also one important precipitate. In a study on adolescent girls, researchers found that peer stress, academic stress, and mother-child stress lead to an increase in incident of NSSI among the participants over a three-month period. However, the incident of NSSI decrease over time (Miller et al., 2019). Liu, Cheek, & Nestor (2016) conducted a metanalysis of 23 studies and found that the odds of engaging any form of NSSI is 80% higher after experiencing a life stress than when life stress is comparatively absent. Thus, stress really is an important indicator of NSSI behavior.

Similar to the distinction between the self-directed and outward-implicated distinction that has been made here, Klonsky et al. (2015), distinguished the functions of NSSI as intrapersonal-self-focused, which encompasses NSSI for the purpose of emotion regulation or self-punishment. NSSI may also be committed to cause a tangible, physical sign of an intangible, emotional pain (Klonsky, Victor, & Saffer, 2014). The other function of NSSI they labelled as interpersonal- other-focused wherein the acts are committed for influencing other people, for communicating something to the other person etc.

While the functions of NSSI were varied, the emotional repercussions were too. Most participants reported feeling a sense of calm and relief. In non-clinical population, NSSI results in feelings of calm and relief, and even satisfaction (Muehelenkamp, 2005). The feeling of satisfaction following NSSI was also reported among a sample of adolescents (Selby, Nock, & Kranzler, 2014). Thus, the positive emotions reported by the participants of this study seem to be common across multiple sample groups.

Feelings of regret and guilt as a response to the physiological damage caused by NSSI was reported in a phenomenological study involving 12 individuals (Buser, Pitchko, & Buser, 2014). Gandhi, Luyckx, Goossens, Maitra, & Claes (2018) warns that NSSI may lead to feelings of shame, guilt, and regret which can lead to social isolation and further NSSI engagement.

However, the apathy that one participant reported following NSSI engagement is a rather atypical pattern, and no research corroborating such a finding could be located. Overall apathy is an indicator of increased suicide risk among individuals who engage in NSSI and have also attempted suicide (Muehlenkamp & Gutierrez, 2007).

4.2 Social experiences of NSSI

The social experiences of NSSI are those that are present only in the external environment of the participant. The analysis led to grouping of these experiences under the themes exploring the dynamics of family, friends, and extended social system.

With the exception of one participant, others described their family as maladaptive, antagonistic, and disruptive, where they either faced neglect or abuse from their parents. Research provides evidence for family dysfunction being directly or indirectly being related to NSSI through emotional dysregulation (Adrian, Zeman, Erdley, Lisa, & Sim, 2011). In a clinical sample, it was found that engagement in NSSI was highly correlated with maternal antipathy and neglect (Kaess et al., 2013). From a non- clinical sample of adults, it was found that experiencing physical abuse and neglect increased the chances of women engaging in NSSI while physical abuse alone increased the chances for men (Swannell et al., 2012). Child sexual abuse is a significant risk factor for NSSI as was revealed by a meta-analysis of 65,851 participants across 177 studies (Demirci, 2018; Maniglio, 2010).

Moving a bit outside the family, the research found that most participants enjoy a fulfilling relationship with their friends. Interestingly, the nature of friendship of people who engage in NSSI is not really conclusive. Schwartz-Mette & Lawrence (2019) reports that the quality of friendship has no significant correlation with NSSI behavior. However, Wang, Wang, & Liu (2020) suggest that individuals who engage in NSSI feel lonely, and they use their loneliness as a motivation to make deep, meaningful friendships. Close friendship as a predictive or protective factor for NSSI has not been investigated much, and more research needs to be done on this topic.

Since the study was conducted on participants living in India, and since India is a very collectivistic society, the theme of dynamics of extended social system explores the quality and nature of relationship the participants share with people who are not a part of their immediate family or friends, but still might share significant amount of time with. Most participants did not share amicable relationship with their neighbors, and the relationship with teachers and relatives were mixed.

Considering most of the research on NSSI have been conducted in Western cultures which are mostly individualistic in nature, not much research has been focused on exploring whether relationship with people in the extended social system like teachers, relatives, and neighbors have any influence on people’s NSSI behaviors. More research needs to be conducted in order to give a definitive answer on their association with NSSI.

4.3 Support-seeking

All participants reported that they had sought help at one point or other. However, most did it from their friends. Friends are indeed the most common source for seeking out help among individuals who engage in NSSI, followed by family (Fortune, Sinclair, & Hawton, 2008).

Social support does act as a partial mediator for NSSI (Christoffersen, Møhl, DePanfilis, & Vammen, 2015) and it also moderates the relationship between NSSI and adverse social experiences (Wang & Liu, 2020; Xin et al., 2020). Another form of social support that is emerging in recent times is support communities on social media sites like Facebook, Reddit etc. Kingsbury et al. (2021) report that private use of social media leads to decreased odds of NSSI whereas comparisons lead to increased odd. Thus, seeking out social support and receiving the same might protect individuals from engaging in further NSSI activities. Furthermore, people who engage in NSSI often delay seeking help, and this pattern has been found to be significantly correlated with the development of severe psychopathology (Lusting, Koenig, Resch, & Kaess, 2021).

The reactions that individuals receive after engaging in NSSI might be crucial to their further health. People who disclose their NSSI to others are often met with negative responses, which deters them from seeking further support (Park, Mahdy, & Ammerman, 2020). They may also face harsh judgements, disapproval, and the “silent treatment”. (Simone & Hamza, 2020). Negative reactions to NSSI also increases the risk of suicide through depression (Park & Ammerman, 2020).

4.4 Limitations

Despite the findings, the study has some significant limitations. One major limitation of the study was its number of participants. Although the initial number of participants was decided at 10, due to participant atrophy owing to the sensitive nature of the study, the final number was five. The second wave of the pandemic prevented approaching clinics and hospitals for participants as well. Thus, the final study has only five participants and therefore the data might not be descriptive enough.

Another limitation also is an effect of the pandemic. Keeping in mind the safety of both the participants and the researcher, the interviews were conducted over calls. While this provided the opportunity for individuals to participate from various parts of the country, this also made it difficult to understand and assess their body languages. Thus, some important cues and related cues were missed which could prove to be of importance to the study.

A significant limitation is the narrow definition of family used in the research. Since this research is situated in the Indian society, as indicated by the incorporation of extended social system, the research explored only the relationship between the participants and the parents. Considering Indians mostly stay in a joint family and nuclear families are a comparatively recent phenomenon, this overlooks the delicate intricacies of relationships that exists between the members of Indian families.

Conflict of interests. No potential competing interest was reported by the authors.

Funding details. This study was not funded by any external organisations or grant bodies. All costs, whatsoever, were borne by the researchers.

Data availability statement. Due to the nature of this research, participants of this study did not agree for their data to be shared publicly, so supporting data is not available

Ethical approval. Ethical approval to conduct the research was received from the Research Conduct and Ethics Committee, Centre for Research, CHRIST (Deemed to be University).

Consent to participate. The consent to participate was obtained from each participant prior to conducting the interview.

Consent to publish. The involved authors had provided their consent to publication of the research.

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Cognitive and Social Experiences and Support-seeking among Individuals engaging in Non- suicidal Self-injury

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Abstract

1 Introduction

2 Methods

2.1 Participants

2.2 Procedure

2.3 Data analysis

3 Results

3.1 Global theme 1: Cognitive experiences

3.1.1 Organizing theme 1: Precipitates

3.1.2 Organizing theme 2: Pre-NSSI thoughts and emotions

3.1.3 Organizing theme 3: Post-NSSI emotions

3.2 Global theme 2: Social experiences

3.2.1 Organizing theme 1: Family dynamics

3.2.2 Organizing theme 2: Dynamics of friendship

3.2.3 Organizing theme 3: Dynamics of extended social system

3.3 Global theme 3: Support-seeking

3.3.1 Organizing theme 1: Primary source of seeking help

3.3.2 Organizing theme 2: Perceived immediate reactions

4 Discussion

4.1 Cognitive experiences of NSSI

4.2 Social experiences of NSSI

4.3 Support-seeking

4.4 Limitations

Declarations

References

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