Abstract

Self-injury among young women is a public health problem that is still little known and understood by parents, educators and health professionals. We sought to understand selfinjurious behavior in young women from a perspective of the meaning, actions and interpretation of the experienced situation. This qualitative research used semi-structured interview for data collection from January to March 2020. The data were organized by the MAXQDA software and analyzed based on Symbolic Interactionism. The five interviewees are young people educated by their mothers, with little or no contact with their fathers. They narrated stories of sexual abuse, parental rejection, bullying and low acceptance in the school environment. They established a pessimistic perception of themselves arising from their own interpretations and their social interactions. They saw self-injury as a refuge. They practiced self-injury when they were under unbearable negative feelings. They lived in a cycle of substituting psychological suffering for physical suffering. All admitted having anxious temperaments, low self-esteem and socioemotional disabilities. Self-injury is directly linked to the meanings these young women give to themselves. At schools, the incorporation of knowledge about well-being should be encouraged to train people who are more effective in solving problems.

Keywords:
Nonsuicidal self-injury; Self-injurious; Women; Youth; Mental Health

Introduction

Nonsuicidal self-injury (NSSI) is an emotional problem that denotes deliberate behavior involving direct aggression towards one’s own body (SILVA; BOTTI, 2017SILVA, A. C.; BOTTI, N. C. L. Comportamento autolesivo ao longo do ciclo vital: Revisão integrativa da literatura. Revista Portuguesa de Enfermagem de Saúde Mental, Porto, n.18, p. 67-76, dez. 2017.). The pretext for self-injury is to relieve some emotional suffering, feelings of anger, sadness, anguish and inner emptiness, emotions felt in such an intense and unbearable way that leads the person to self-injury in an attempt to mitigate negative feelings (ARANTANGY ., 2018ARANTANGY, E. W. et al. Como lidar com a automutilação: guia prático para familiares, professores e jovens que lidam com o problema da automutilação. 2. ed. São Paulo: Hogrefe, 2018.).

NSSI is expressed in the form of mild injuries, such as scratching the skin with nails or burning oneself with cigarette butts, going through moderate forms, such as superficial cuts on the arms, or reaching more serious forms, such as self-enucleation and self-castration (GUERREIRO; SAMPAIO, 2013GUERREIRO, D. F.; SAMPAIO, D. Comportamentos autolesivos em adolescentes: uma revisão da literatura com foco na investigação em língua portuguesa. Revista Portuguesa de Saúde Pública, Lisboa, v. 31, n. 2, p. 204–213, dez. 2013.). Generally, such behavior appears in adolescence and lasts for a period of 10 to 15 years or more, lasting decades if not treated adequately (ARATANGY et al., 2018).

The probability of self-injurious behavior is significantly higher in females, in people living in non-nuclear systems and in those with increased school failure (GUERREIRO, 2014GUERREIRO, D. F. Comportamentos autolesivos em adolescentes: características epidemiológicas e análise de fatores psicopatológicos temperamento afetivo e estratégias de coping. 2014. Tese (Doutorado em Medicina) – Universidade de Lisboa, Lisboa, 2014.).

According to Guerreiro and Sampaio (2013), Portuguese-written scientific studies on the subject are still modest, which makes it difficult to carry out further research and compare results in similar realities. It is possible that this lack of knowledge interferes with the performance of Primary Health Care professionals, parents and teachers.

Public policies targeted at children’s and adolescents’ mental health are inexistent in 90% of the countries, as reported by WHO (2002). In Brazil (2019)BRASIL. Lei n.º 13.819, de 26 de abril de 2019. Institui a Política Nacional de Prevenção da Automutilação e do Suicídio, a ser implementada pela União, em cooperação com os Estados, o Distrito Federal e os Municípios; e altera a Lei nº 9.656, de 3 de junho de 1998. Brasília, DF: Congresso Nacional, 2019a. Disponível: https://bit.ly/32a5nob. Acesso em: 5 abr. 2019.
https://bit.ly/32a5nob... , the recent Law 13.819, of April 26, 2019, established the National Policy for the Prevention of Self-Injury, but was restricted to pointing out notification actions. Thus, it did not indicate means of prevention, nor how to approach it, nor treatment modalities for NSSI.

According to the Pan American Health Organization (2018), 10% to 20% of adolescents in the world experience mental health problems but remain undiagnosed and inadequately treated. Failure to address the mental health conditions of adolescents has consequences that extend into adulthood, harming physical and mental health and limiting future opportunities (PAHO, 2018).

With the aim of deepening knowledge about nonsuicidal self-injury, the following research question was formulated: what are the meanings given by young women to self-injury? How do young women interpret self-injury and how do they intend to change?

To this end, we sought to understand nonsuicidal self-injury in young women from the perspective of the meaning, actions and interpretation of the situation experienced.

Methods

A qualitative approach allowed understanding the problem, both in terms of the meaning and the intentionality inherent in the acts of young people with NSSI, and the relationships and social contexts involved in the studied phenomenon, as noted by Minayo and Costa (2018)MINAYO, M. C. S.; COSTA, A. P. Fundamentos teóricos das técnicas de investigação qualitativa. Revista Lusófona de Educação, Lisboa, v. 40, n. 40, p. 139–153, 2018..

Symbolic Interactionism (SI) was used, specifically the assumptions of Herbert Blumer (1969), to support the study. IS principles made it possible to achieve the research objectives, that is, to analyze and understand the meanings that the interviewees gave to themselves and to self-injury based on their social interactions and the way they acted based on the interpretations they made of the situation. The opportunity to redefine themselves and things and, consequently, the NSSI through more optimistic intrapersonal and interpersonal interpretations guided the analysis of the young women’s motivation to change behavior (BLUMER, 1969BLUMER, H. The methodological position of symbolic interactionism. In: BLUMER, H. Symbolic Interactionism: perspective and method. Berkeley: University of California Press, 1969. p. 1-60.).

The study took place in the city of Picos, state of Piauí (PI), Brazil, within the scope of Primary Care and specialized mental health care: at the Family Health Support Center (Núcleo de Apoio à Saúde da Família – NASF) and the Type II Psychosocial Care Center (Centro de Atenção Psicossocial – CAPS), respectively. Picos has six NASF teams that support the 35 Family Health teams in Primary Care, providing 100% coverage of the population (BRASIL, 2020aBRASIL. Ministério da Saúde. E-gestor atenção básica. Brasília, DF, 2020a. Base de relatórios públicos dos sistemas da Atenção básica. Disponível em: https://egestorab.saude.gov.br/paginas/acessoPublico/relatorios/relatoriosPublicos.xhtml. Acesso em: 08 jun. 2020.
https://egestorab.saude.gov.br/paginas/a... , ^2020bBRASIL. Ministério da Saúde. E-gestor atenção básica. Brasília, DF, 2020b. Base de dados de informação e gestão da atenção básica. Disponível em: https://egestorab.saude.gov.br/paginas/acessoPublico/relatorios/relHistoricoCoberturaAB.xhtml;jsessionid=J0Hbj7kkQpFkSZVNTf6P3fXG. Acesso em: 08 jun. 2020.
https://egestorab.saude.gov.br/paginas/a... ).

The study was carried out according to the following steps:

1^st) Choice of theme, bibliographic survey and prior observation of the empirical world involved in the study.

2^nd) We visited the NASF psychologist and the CAPS II team in order to show them the Authorization duly signed by the manager allowing the research to be carried out. We also explained the objectives and data collection methods, and identified young women assisted by the Psychology Department with a history of one or more self-injury episodes to compose the research sample.

3^rd) In this phase we examined the medical records of the potential interviewees, setting the following inclusion criterion: women aged 10 to 24 years. This age range is considered by the Ministry of Health of Brazil the period of adolescence (EISENSTEIN, 2005EISENSTEIN, E. Adolescência: definições, conceitos e critérios. Adolescência e Saúde, Rio de Janeiro, v. 2, n. 2, p.1–2, abr./jun. 2005. Disponível em: http://www.adolescenciaesaude.com/detalhe_artigo.asp?id=167. Acesso em: 02 jun. 2019.; SAWYER ., 2018SAWYER, S. M. et al. The age of adolescence. The Lancet Child & Adolescent Health, Cambridge, v. 2, n. 3, p. 223-228, mar. 2018.) and corresponds more adequately to the adolescent’s growth and self-injurious behavior and self-reported psychological distress. We excluded girls with borderline personality disorders: although nonsuicidal self-injury has the potential to arise as a symptom of borderline disorder, these two conditions differ. People with a personality disorder express aggressive and hostile behaviors, while those with nonsuicidal self-injury express more collaborative attitudes and positive relationships (AMERICAN PSYCHIATRIC ASSOCIATION, 2014AMERICAN PSYCHIATRIC ASSOCIATION. Manual diagnóstico e estatístico de transtornos mentais. 5. ed. Porto Alegre: Artmed, 2014.). Women with psychotic disorders and those whose self-injurious act was initiated during delusional episodes or mental confusion were also excluded from the study (AMERICAN PSYCHIATRIC ASSOCIATION, 2014AMERICAN PSYCHIATRIC ASSOCIATION. Manual diagnóstico e estatístico de transtornos mentais. 5. ed. Porto Alegre: Artmed, 2014.).

4^th) First individual contact was made with the young women and their mothers (in the case of interviewees under 18 years of age) to introduce ourselves and manifest our interest in the topic and emphasize the importance of the adolescents’ participation in the study. In this opportune meeting, we sought an empathetic approximation with the future interviewees and obtained the signatures of the Terms of Consent and Assent. Then, the purposes of the study, the methods for data collection, confidentiality of information, risks and benefits of participating in the interview were explained. After agreeing and signing the aforementioned Terms, the interviews were carried out only with the young women, some at Primary Health Care Centers and some at Picos Psychosocial Care Center.

Nonprobability sampling was determined by convenience, consisting of five interviewees who experience or have experienced NSSI and are assisted at Picos Family Health Support Center and/or Picos CAPS II. None of the young women refused to participate in the study or withdrew from it. The sample size is within the recommended by Polkinghorne (1989)POLKINGHORNE, D. E. Phenomenological research methods. In: VALLE, R.S.; HALLING, S. (eds.). Existential-phenomenological perspectives in psychology: exploring the breadth of human experience. [S.l.]: Plenum Press, 1989. p. 41-60., which is from 5 to 25 people who have experienced the phenomenon.

5^th) With the purpose of privileging the participants’ points of view and interpretations, the interviews were conducted by one of the researchers: a nurse who was a student in the Public Health Master’s program at the University of Fortaleza (Universidade de Fortaleza) and specialized in mental health at the Federal University of Piauí (Universidade Federal do Piauí), with 20 years of experience in psychosocial care.

The data collection instrument contained 28 open-ended questions and was developed with the purpose of knowing: the meaning given to NSSI by young women; the reasons that led them to self-injury; the influencing and protective factors; the existence or not of desire to stop self-injury; intended strategies for changing self-injurious behavior among young women who, perhaps, consider this possibility and what sorts of support they received to face self-injury. The participants’ sociodemographic and temperament data were collected to create their profile.

A pilot test of the interview was carried out before data collection, and the information derived from this assisted in adjusting the final research instrument. Data collection took place from January to March 2020.

The recordings of the interviews were transcribed after careful listening, and phrases and statements considered relevant to the study were highlighted considering what Moustakas (1994)MOUSTAKAS, C. E. Phenomenological research methods. Thousand Oaks, CA: Sage Publications, 1994. calls “horizontalization”.

The meeting took place in reserved rooms at the health service, where the participant was alone with the researcher and felt comfortable to speak freely about her life situation. Each interview lasted approximately one hour and 30 minutes, and none of them had to be repeated. The interviews were recorded, transcribed and returned to the young women for approval or objection. Once approved, they were filed by us in a confidential manner. Field observations were noted after each interview. Saturation was observed by the two researchers after transcription of the third interview.

6^th) We analyzed the collected data; a first reading was carried out in order to identify the first impressions and possible projections of Symbolic Interactionism on the reported information, which Bardin (2016)BARDIN, L. Análise de conteúdo. São Paulo: Edições 70, 2016. calls “floating reading”. This step followed the phases of material exploration and treatment of results, inferencing and interpretation (GOMES, 2016GOMES, R. Análise e interpretação de dados de pesquisa qualitativa. In: MINAYO, M. C. S.; DESLANDES, S. F.; GOMES, R. Pesquisa social: teoria método e criatividade. Petropólis, RJ: Vozes, 2016. cap 4.).

The interpretation of the results was based on scientific evidence and theoretical frameworks on understanding the meaning of self-injurious behavior correlated with the three assumptions of Blumer's Symbolic Interactionism (SI) (1969) as follows.

• Basing ourselves on the first assumption that establishes human beings as guiding their actions towards things based on what they represent for them, as well as on the fact that self-injury is an aggression directed at themselves, we identified the meaning that young women give to themselves.

• The second principle of SI says that the meaning of things arises as a consequence of the social interaction that each one maintains with their peers. Thus, the motivating and protective influences of self-injurious behavior arising from the participants’ social interaction with their environment were investigated.

• The third assumption governs the possibility of transformation through an interpretative process developed by individuals themselves as they are faced with certain elements. With that, we examined their mobilization to change self-injurious behavior.

Content analysis allowed us to organize the statements into 33 categories and these into five analysis themes: 1) How did young women with NSSI build their self-perception? 2) What sociodemographic characteristics and life experiences led them to the perception they have of themselves? 3) Interaction of protective and motivating factors involved in NSSI; 4) Support received by the young women for coping with the NSSI; and 5) Perception of the need for changing self-injurious behavior by the young women themselves, considering, mainly, the understanding of self-perception and changes in behavior regarding self-injury (GOMES, 2016GOMES, R. Análise e interpretação de dados de pesquisa qualitativa. In: MINAYO, M. C. S.; DESLANDES, S. F.; GOMES, R. Pesquisa social: teoria método e criatividade. Petropólis, RJ: Vozes, 2016. cap 4.).

The results obtained were presented to the interviewees and we obtained their approval for publication.

Due to the Covid-19 pandemic, it was not possible to collect data on a larger sample. The research was approved by the Ethics Committee of the University of Fortaleza, under Approval No. 3.773.916.

Results

The organization of the data presents: the sociodemographic characteristics of the young women with NSSI; the interaction of motivating and protective factors for NSSI; how badly they hurt themselves; self-perception, changes in behavior; and the support received by the young women.

In Chart 1, we indicate the sociodemographic and temperament profile as well as the companion of the participants for most of the day.

As depicted in Chart 2, which was based on the findings of Bone, Lewis and Lewis (2020), all young women have all the internal influencing factors considered by the study. As for the environmental or social factors that can predispose someone to NSSI, we address those verified throughout the analysis of the young women’s statements, such as sexual abuse, food insecurity, bullying and unwelcoming school environment, parental rejection, peer pressure and social media influence.

Chart 4 shows that the women involved in the research have exacerbated and negative self-critical perceptions, see NSSI as an escape or refuge (I1 and I3), relief from suffering (I2 and I4) and a cry for help (I5). All intend to abandon self-injury, channeling the need for self-injury (I1), with professional support (I1, I2 and I3), expressing contained feelings (I3), acquiring maturity (I4) and perceiving the ineffectiveness of NSSI for problem solving (I5).

Support for young women with NSSI is offered by other women in the family, such as mothers (I2, I4 and I5) and sister (I1). Only I2 mentioned having been approached by an educator who noticed her self-injury. I5 reported having been helped by a lecture on mental health at school. I1, I2, I3 and I4 are already followed up by professionals, mainly psychologists, or have demonstrated their intention to seek professional help (I5). Seeking help on digital platforms was mentioned by interviewees I2, I4 and I5.

Discussion

The young women with NSSI interviewed are between 14 and 24 years old, an age range prone to the occurrence of both common mental disorders such as anxiety and depression (LOPES ., 2016LOPES, C. S. et al. ERICA: Prevalence of common mental disorders in Brazilian adolescents. Revista de Saúde Pública, São Paulo, v. 50, Supl 1, p. 1s-9s, 2016.) and NSSI (REIS et al., 2019).

Although NSSI occurs in different age ranges, studies on the subject expose data that show the highest prevalence of NSSI among adolescents, with the onset of the act occurring between 12 and 14 years of age (REIS et al., 2019a). The increasingly precocious onset of self-injurious acts among adolescents requires knowledge about NSSI by the entire community and a watchful eye to recognize the behavior soon after the last years of childhood.

With regard to education, four young women were in high school and, of these, two had a history of school failure. An investigation by Reis et al. (2019) revealed that young people in primary and secondary school engage in NSSI more often than those who are in higher education, with significant differences across grades.

Educators have a natural and everyday proximity to their students, thus becoming unique observers of possible signs of NSSI, such as depressed mood, poor school performance, little or no belonging to the group, and even the use of inappropriate clothing for the environment in order to hide self-injuries.

All participants reported engaging in some religious belief, a fact that, according to MihaljevicMIHALJEVIC, S. et al. Do spirituality and religiousness differ with regard to personality and recovery from depression? A follow-up study. Comprehensive Psychiatry, New York, v. 70, p. 17–24, 2016.et al. (2016), has the potential to improve the ability to have hope, faith and purpose in life in the treatment of depression. In view of these findings, it is understood that spirituality is a protective factor for young women with NSSI as its practice gives rise to more optimistic feelings about themselves and about life.

Ethnic differences in the occurrence of NSSI should be noted. Authors believe that certain factors, such as cultural pressures and the prevalence of mental disorders in each ethnic group, interfere with self-injurious behavior, with Black women being more prone to self-injury (AL-SHARIFI; KRYNICKI and UPTHEGROVE, 2015AL-SHARIFI, A.; KRYNICKI, C. R.; UPTHEGROVE, R. Self-harm and ethnicity: A systematic review. International Journal of Social Psychiatry, London, v. 61, n. 6, p. 600-612, 2015.). Contrary to Al-Sharifi, Krynicki and Upthegrove (2015), for whom Black people are more prone to NSSI, the interviewee who declared herself to be Black showed less need to engage in NSSI and greater ability to face the problem than young White and Mixed-race young women.

As previously shown, all the interviewees were from low-income families. Household income is an important indicator of a person’s psychosocial and sociocultural environment, so it is likely to contribute to the creation of adverse situations during childhood and adolescence (GALOBARDES ., 2006GALOBARDES, B. et al. Indicators of socioeconomic position (part 1). Journal of Epidemiology and Community Health, London, v. 60, n. 1, p. 7–12, jan. 2006.). Jebena JEBENA, M. G. et al. Food insecurity and common mental disorders among Ethiopian youth: structural equation modeling. PLoS ONE, San Francisco, v. 11, n. 11, p. 1–20, 2016.et al. (2016) attribute a greater probability of mental disorders to people who have grown in conditions of food insecurity.

Agreeing with MokMOK, P. L. H. et al. Family income inequalities and trajectories through childhood and self-harm and violence in young adults: a population-based, nested case-control study. The Lancet Public Health, Oxford, v. 3, n. 10, p. e498–e507, oct. 2018.et al. (2018), who report increased risk of self-injury among people who grow in low-income families, we believe that the poor economic conditions of I3’s family represents a food insecurity condition and a chronic stressor that increase the risk of psychic suffering, including NSSI. Four interviewees come from families headed by women, a condition that, according to Jebena et al. (2016), increases the socioeconomic risk of psychic disorders.

All interviewees admitted having a temperament that leads them to a socio-affective inability to face life situations. The temperaments self-reported by young women who engage in NSSI coincide with those demonstrated by Guerreiro and Sampaio (2013) as the most prevalent among self-injurious adolescents.

The interviewees demonstrated loneliness. Despite having the company of their mothers (I4 and I5) and father (I3), they feel like the young Portuguese in the study conducted by ReisREIS, M. et al. Comportamentos autolesivos nos adolescentes: resultados do estudo HBSC 2018. Revista de Psicologia da Criança e do Adolescente, Lisboa, v. 10, n. 1, p. 207–217, 2019.et al. (2019) – mostly alone. The few spaces dedicated to promoting leisure, culture, sports and social interaction for young people contribute to the feeling of loneliness among these women.

The conclusions drawn by Stanford, Jones and Hudson (2018)STANFORD, S.; JONES, M. P.; HUDSON, J. L. Appreciating complexity in adolescent self-harm risk factors: psychological profiling in a longitudinal community sample. Journal of Youth and Adolescence, New York, v. 47, n. 5, p. 916-931, May 2018. that there is a wide variety of factors that motivate NSSI, and that they interact, contribute to the understanding that the self-injurious behavior of the participants in this research is complex and is not related to one or the other cause alone. As shown by Hawton, Saunders and O'connor (2012)HAWTON, K.; SAUNDERS, K. E. A.; O’CONNOR, R. C. Self-harm and suicide in adolescents. The Lancet, New York, v. 379, n. 9834, p. 2373–2382, 2012., NSSI in young women results from a combination of genetic, biological, psychiatric, psychological, social and cultural factors.

Bone, Lewis and Lewis (2020)BONE, J. K.; LEWIS, G.; LEWIS, G. The role of gender inequalities in adolescent depression. The Lancet Psychiatry, Oxford, v. 7, n. 6, p. 471-472, 2020. explain women’s predisposition to depressive disorders, highlighting internal and external factors. Those of an internal nature are related to biological or psychological characteristics, such as sex hormones or differences in emotional vulnerabilities; and those of an external nature are environmental or social. They express, however, that such factors are not easily distinguished, since the external ones modify individual vulnerabilities and, thus, also become internalized.

Sexually abused adolescents were 60% more likely to engage in NSSI than their non-abused peers (BAIDEN; STEWART; FALLON, 2017BAIDEN, P.; STEWART, S. L.; FALLON, B. The role of adverse childhood experiences as determinants of non-suicidal self-injury among children and adolescents referred to community and inpatient mental health settings. Child Abuse and Neglect, Oxford, v. 69, p. 163-176, 2017.). Thus, these researchers agree with HailesHAILES, H. P. et al. Long-term outcomes of childhood sexual abuse: an umbrella review. The Lancet Psychiatry, Oxford, v. 6, n. 10, p. 830-839, out. 2019.et al. (2019), who associated childhood sexual abuse with psychosocial problems. We transcribed I2’s speech:

With regard to the economic status of the participants, although I3 does not directly link food insecurity to NSSI in her speech, the scarcity of food caused, concomitantly, by the family’s low income and her father’s illness seems to increase her level of stress, with which she does not know how to deal.

It is also known that bullying and peer rejection increase the likelihood of a young person engaging in NSSI (ESPOSITO; BACCHINI; AFFUSO, 2019ESPOSITO, Concetta; BACCHINI, Dario; AFFUSO, Gaetana. Adolescent non-suicidal self-injury and its relationships with school bullying and peer rejection. Psychiatry Research, v. 274, p. 1–6, 2019.). I4 started cutting herself after being intimidated through bullying. I5, on the other hand, does not mention bullying, but says that the self-injurious behavior started when she changed schools and did not find a supporting environment.

Unsatisfactory paternal care was correlated with higher rates of NSSI. On the other hand, parental overprotection is not a risk factor for self-injury (JOHNSTONE ., 2015JOHNSTONE, J. M. et al. Childhood predictors of lifetime suicide attempts and non-suicidal self-injury in depressed adults. Australian and New Zealand Journal of Psychiatry, Carlton South, v. 50, n. 2, p. 135-144, 2015.). Paternal rejection and low involvement with the father certainly contributed to the formation of low self-esteem, a low sense of protection among young women and a greater predisposition to NSSI.

It was observed that I3 coexists with episodes of intrafamily violence in a conflictual environment to which she started to develop an aversion. MagalhãesMAGALHÃES, J. R. F. et al. Repercussões da violência intrafamiliar: história oral de adolescentes. Revista Brasileira de Enfermagem, Brasília, v. 73, n. 1, e20180228, 2018. Disponível em: https://bit.ly/3292Lqp. Acesso em: 05 jun. 2019.et al. (2018) mention that intrafamily violence leads to physical and mental illness, causing a feeling of deep sadness, self-injurious behavior and suicidal ideation.

Having contact with actions of self-injury and suicide in other people, including friends, predisposes to the development of NSSI (O'CONNORO’CONNOR, R. C. et al. Self-harm in adolescents: Self-report survey in schools in Scotland. British Journal of Psychiatry, London, v. 194, n. 1, p. 68-72, jan. 2009.et al., 2009), which is corroborated by the excerpt from I2’s speech:

Only I4 revealed participating in an online group of people who deliberately hurt themselves and taught strategies for self-injury. The others have already attended support groups. Contact with NSSI stimuli on the internet leads to the normalization of behavior and constitutes a self-injury contagion tool (MARCHANT ., 2017MARCHANT, A. et al. 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, San Francisco, v. 12, n. 8, e0181722, 2017.).

Protective factors are understood as those that strengthen the healthy aspects of a person. They are developed at individual, family, school and community levels and are exemplified, respectively, as skills to learn from experiences, positive family life, school fostering the student’s sense of belonging and leisure opportunities (BRESSAN ., 2014BRESSAN, Rodrigo Affonseca et al. Promoção da saúde mental e prevenção de transtornos mentais no ambiente escolar. In: ESTANISLAU, Gustavo M.; BRESSAN, Rodrigo Affonseca (org.). Saúde mental na escola: o que educadores devem saber. Porto Alegre: Artmed, 2014. p. 37-47.).

In this study, we found a disproportionate exposure of young women to risk and protective factors. The research participants seem to rely only on their precarious individual protective factors constituted in their unique unfavorable contexts.

Fox FOX, K. R. et al. Self-criticism impacts emotional responses to pain. Behavior Therapy, New York, v. 50, n. 2, p. 410-420, mar. 2018.et al. (2018) are more concerned with the study of unintentional self-injurious behaviors. The authors found that NSSI is related to high self-criticism and that increased self-criticism interferes with adaptation to physical pain. Their research found that highly self-critical people see themselves as deserving of pain and punishment and that physical pain improves the mood of self-critical subjects. These findings lead both to a better understanding of the engagement of people in nonsuicidal self-injurious behaviors and to the verification of the unpredictability of the severity of the injuries even when they are planned to have low lethality. Following the observations of these authors, we note that the search for the improvement of negative feelings through pain, as well as the increase in tolerance to it in favor of immediate well-being, increase the risk of sequelae and death among the young women in the study.

People interpret each other’s actions rather than simply reacting to them. Such reactions are not simply responses to the other’s attitudes, but also to their interpretations of those actions. That is, people’s actions and reactions are based on the meaning they give to other people’s behavior (REIS; FREHSE, 2018). They consist of a continuous motion of repetitive actions, interpretations and reactions, not just stimuli and responses (BLUMER, 1969BLUMER, H. The methodological position of symbolic interactionism. In: BLUMER, H. Symbolic Interactionism: perspective and method. Berkeley: University of California Press, 1969. p. 1-60.). The recognition that human beings interpret each other’s actions as instruments to act reciprocally has implications for human behavior.

Gaspar et al. (2019) point out that adolescents deliberately injure themselves because they feel useless and/or because they think they have failed at something. These pessimistic conceptions that the participants have of themselves do not just result from their own temperaments. They have been formed since long. In a sense, they were led to learn through their social interactions (e.g., sexual abuse, parental rejection, peer rejection, bullying, unwelcoming school environment) to see themselves as others made them think they were, as Blumer (1969) says in his first assumption.

In fact, the analysis of the speeches allows us to infer that the fragility of the social structures in which they are inserted contributed, along with other factors, to make them susceptible to a misinterpretation of themselves, to attribute a low value to themselves and to adopt a problem-solving behavior (in this case, NSSI) based on these meanings. Corroborating the ideas of Reis et al. (2019), young women with NSSI express low confidence in their potential.

The self-reports of the interviewees demonstrated engagement in NSSI with the purpose of mitigating negative feelings, such as anguish, anger and sadness. Klonsky and Lewis (2014)KLONSKY, E. D; LEWIS, S. P. Assessment of nonsuicidal self-injury. In: NOCK, M. K. (ed.). Oxford Library of Psychology: The Oxford handbook of suicide and self-injury. New York: Oxford University Press, 2014. p. 337-351. also refer to anxiety, stress, frustration, guilt, shame, feelings of emptiness and hopelessness as emotions leading to NSSI. After deliberate self-injury, a sense of relief is reported by the young women, a kind of emotional pain reliever, as mentioned in the study by Reis et al. (2019). Finally, after the relief comes guilt, producing new negative feelings and causing acts followed by self-injury.

Since it enables understanding the empirical world under study, SI, especially its third assumption, allows the redefinition of these meanings and, thus, the change of self-injurious behavior in women with NSSI. That said, it is important that the interviewees have access to instruments that favor the transformation of this interpretive system that is so cruel to them.

When questioned about other means of coping with NSSI, I5 pointed out perhaps one of the most effective and which coincides with Blumer’s third assumption (1969): the perception of one’s own behavior and the ineffectiveness of the self-injurious act in solving problems:

The mothers of the research participants, heads of households, accumulate overloads that possibly make it difficult for them to look more closely at the young women who, undoubtedly, do not have parental involvement to cope with self-injury.

Kutcher, Wei and Estanislau (2014)KUTCHER, S.; WEI, Y.; ESTANISLAU, G. M. Educação em saúde mental: uma nova perspectiva. In: ESTANISLAU, G. M.; BRESSAN, R. F. (org.). Saúde mental na escola: o que os educadores devem saber. Porto Alegre: Artmed, 2014. p. 63-80. believe that schools are the ideal loci for mental health education because they constitute centers for the formulation of knowledge and because they are the environments where young people spend most of their day. In this study, however, the school environment sometimes proved to be unwelcoming (I4 is bullied, and I5 feels bad at school). Sometimes it seemed not to notice the self-injurious behavior of the young women (I3 and I4). The exception was I2’s educator who was able to see the change in the teenager’s mood and, empathetically, listen to her.

Given NSSI growth trend, including within schools, the training of educators and other employees is essential for the early recognition of signs of self-injury, referral to health services, and deployment of preventive actions.

The promotion of well-being, self-acceptance, resilience, empathy and respect for differences must be continuously developed in all public and private schools. Much better will be the incorporation of subjects that promote well-being and socio-emotional skills from young people’s first years of study.

Despite the professional support found by the participants in this research, it is important to emphasize that the largest number of young people who deliberately injure themselves are hidden in the community, as reported by Hawton, Saunders and O'Connor (2012). A mental health promotion and NSSI prevention policy should be established considering these data.

A WHO report points out an intense use of social media by young people, especially women (INCHLEY ., 2020INCHLEY, J. et al. ed.). Spotlight on adolescent health and well-being: findings from the 2017/2018 Health Behaviour in School-aged Children (HBSC) survey in Europe and Canada: international report. Copenhagen: World Health Organization, 2020. (Key findings, v.1).). There is evidence that social media are a source of informal support sought by self-injurious adolescents (DYSON ., 2016DYSON, M. P. et al. A systematic review of social media use to discuss and view deliberate self-harm acts. PLoS ONE, San Francisco, v. 11, n. 5, e0155813, 2016.), as was the case with I2, I4 and I5.

In view of the evidence that adolescents who deliberately injure themselves seek help on the internet, the inclusion of means on such platforms to facilitate the contact of these young people with sources of professional help should be carried out.

Final considerations

Understanding the characteristics of each of the interviewees and the contexts in which their social interactions took place, based on their biopsychosocial and cultural profile, facilitated the perception of the meanings that they give to themselves. They are low-income women, educated by their mothers, students from public schools who have been subjected to some type of violence (sexual, physical or emotional) since childhood. From the study participants’ reports we could identify the main feelings involved in the practice of NSSI, in which emotional pain is replaced by physical pain in a pain-pain trade-off. Generally, this cycle begins with some negative and unbearable feeling, which leads the interviewees to engage in NSSI followed by guilt for having committed a self-injurious act.

The study’s findings show the disproportionate presence of motivating and protective factors for NSSI in the daily lives of young women. Protective factors proved to be fragile, scarce and discontinued, both within the family and at school.

We highlight the emerging need to train parents, educators, peers and health professionals at all levels of care in an effective intervention approach for young people who deliberately injure themselves. Socioemotional skills, within the interactionist scope of this research, are likely to be learned and modified as the person’s interpretive process also changes. In that regard, the incorporation of subjects addressing well-being and socioemotional learning in schools, whether private or public, should be considered as a robust instrument not only for the prevention of NSSI, but also for the development of a more effective being in the face of the adversities of today and those to come. However, the formulation of prevention plans and policies must be conceived involving the family, the school, the community, health professionals and managers and education, culture and leisure.

Despite the limitations of the study related to the impossibility of collecting data from other women with NSSI caused by the closure of health services and schools during the critical period of the Covid-19 pandemic in Brazil, we believe that the results proved to be robust and will contribute to sensitizing health and education professionals to attentive listening to adolescents with NSSI. New studies with a more significant sample that considers NSSI in the context of the current pandemic are recommended.

Ignorance of the severity of the problem or the possibility that, in some cases, NSSI is underestimated due to superficial scratches on the skin represents serious risks of death among young people and the persistence of intense psychic suffering, with marks much deeper than those seen over the body.

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