Literature Review



A doctoral project submitted to the faculty of the
Graduate School of Psychology
in partial fulfillment of the requirements for the degree of
Doctor of Educational Psychology at
Alliant International University, San Diego, California

Laura A. Dorko


A review of the literature was conducted regarding self-injury, including a historical overview, its definition, prevalence, etiology, and the knowledge and understanding of educators about self-injury. The first focus of the literature review was to discover the most current research regarding self-injury especially concerning its prevalence, phenomenology, and treatment among middle and high school students. The second focus of the review was to discover whether or not educators are knowledgeable about self-injury and confident in their ability to respond to it appropriately.

Overview of Self-Injury
Self-inflicted injury is referred to using various terms throughout the literature including self-harm (Best, 2005; Gratz & Roemer, 2008; Hawton et. al., 2007, McAllister, Creedy, Moyle, & Farrugia, 2002), self-injury (Duperouzel & Fish, 2007; Giebenhain, Anderson, & Keller, 2006; Hodgson, 2004), self-mutilation (Favazza, 1998), and nonsuicidal self-injury (Klonsky & Muehlenkamp, 2007; Ross, Heath, & Toste, 2009; Yates, Tracy, & Luthar, 2008).  The behavior will be referred to as self-injury (SI) in the current work. Favazza wrote a seminal definition of self-mutilation in his 1998 work, “The Coming Age of Self-Mutilation:” “Self-Mutilation (SM) refers to the deliberate, direct destruction or alteration of body tissue without conscious suicidal intent.” (Favazza,1998, p. 260). Many researchers further clarify this definition to exclude socially acceptable forms of SI such as ear piercing and tattooing (Walsh & Rosen, 1988) and SI which can accompany autism or other developmental disorders (Ross, et. al., 2009). In this work, SI will refer to these deliberately destructive acts resulting in tissue damage that are not intended as an act of suicide, are not widely socially acceptable, and are not due to intellectual disability, autism, or other developmental disorders.

It is important to note that while acts of self-injury as defined in this work are not suicide attempts, those who self-injure are far more likely to commit an act of suicide than the general population.  Research indicates that between 55% and 85% of those who self-injure will attempt suicide at least one time (Dulit, Fryer, Leon, Brodsky, & Frances, 1994; Favazza & Conterio, 1989; Gardner, A.R., & Garnder, A.J., 1975; Muehlenkamp & Gutierrez, 2007; Rosenthal, Rinzler, Walsh, & Klausner, 1972; Roy, 1978; Stanley, B., Winchel, Molcho, Simeon, & Stanley, M., 1992).

Historical Roots
References to self-injurious behavior can be found as far back as the writings of Herodotus. He describes a Spartan leader as publicly mutilating himself over most of his body (Favazza, 1998). In the bible, a man is described as crying aloud among the tombs and was said to “cut himself with stones.” (Mark 5:5). While we can find such archaic references to SI, the behavior has not been understood and has only begun be a focus of psychiatric and psychological research over the past 20 years.  Favazza (1998) states, “Despite those early references [as noted above], self-mutilation has only recently become the object of focused psychiatric scrutiny.”

Associated diagnoses in the DSM-IV-TR
There is no description of self-injury as a distinct psychological disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) (American Psychiatric Association [APA], 2000). The only mention of SI in this manual is found in the section that describes the diagnostic criteria for Borderline Personality Disorder (BPD), where it is mentioned as part of the 5th criterion: “ (5) recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.” (APA, 2000, p. 710). This paucity of information has left some medical and psychiatric professionals feeling frustrated, angry, fearful, helpless, and non-empathetic to patients presenting with SI (McAllister, et. al., 2002)
Other diagnoses have been linked with self-injury as well. There is evidence to suggest that depressive and anxiety disorders (Andover, Pepper, Ryabchenko, Orrico, & Gibb, 2005; Klonsky, Oltmanns, & Turkheimer, 2003), eating disorders such as bulimia and anorexia (Jeppson, Richards, Hardman, & Granley, 2003; Mizes & Arbitell, 1991), and substance abuse disorders (Joiner, 2005; Langbehn & Pfohl, 1993; Matsumoto & Imamura, 2008) all carry a higher percentage of those who self-injure than the general population.

The nature of self-injury necessarily occludes its true prevalence. It is unknown whether the apparent rise in prevalence is due to a greater amount of individuals who practice SI, or whether it is due to more people being willing to identify themselves as self-injurers.  In the general population, about 4% of adults report a history of SI, with 1% indicating the presence of severe SI (Briere & Gil, 1998; Klonsky, et. al., 2003).
Higher rates are reported among younger age groups such as middle school, high school, and college age individuals. Prevalence rates of 14-15% are common when students are asked whether they have engaged in self-injury at least one time (Laye-Gindhu & Schonert-Reichl, 2005; Muehlenkamp & Gutierrez, 2004; Ross & Heath, 2002). Ross, Heath, and Toste (2009) state that recent estimates of SI among adolescents have ranged from 4% to 38% among nonclinical samples of adolescents and young adults. They found a prevalence rate of 13.9% among their sample of four hundred and forty students (Ross, et. al., 2009).

Age of Onset
Though much of the research regarding self-injury has been done in clinical settings, the nonclinical studies are revealing similar information regarding the age of onset. Self-injuring students report first practicing SI behaviors at around the seventh or eighth grade, or about age thirteen (Favazza & Conterio, 1989; Nock, Joiner, Gordon, Lloyd-Richardson, & Prinstein, 2006; Kumar, Pepe, & Steer, 2004; Muehlenkamp & Gutierrez, 2004, 2007; Ross & Heath, 2002). Ross and Heath (2002) found that 24.9% of the students in their study had begun to self-injure in sixth grade or earlier (Ross & Heath, 2002).

Contagion has been defined as “the infliction of self-injury by one individual and imitation by others in the immediate environment” (Rosen & Walsh, 1989, p. 656). Research has indicated the need for concern regarding contagion when dealing with SI. Students have become involved with electronic websites serving as social forums for those wishing to share about their SI with others (Whitlock, Powers, and Eckenrode, 2006). Nock and Prinstein (2005) found that social modeling may be a factor in the etiology of SI and their study indicated that many youth who engage in SI also have a friend who engages in the behavior. Hodgson (2004) states, “As popular culture begins to recognize and publicize self-injury, and the internet becomes a widely used source of information, the chances and likelihood of other-learning increase as information on self-injury is becoming more widely available” (Hodgson, 2004; p. 177). It has been suggested that because of the contagion factor, group counseling with self-injurers should be avoided (Walsh, 2006). It may, however, be effective to include those who self-injure in a heterogeneous group focused on a meaningfully related skill such as help seeking, coping skills, and emotional regulation (Lieberman, 2004; Ross, et. al., 2009).

Personal Examples
Much of the literature regarding self-injury is phenomenological in nature. The following examples are included to personalize SI for the reader:
This passage was written by a 21 year old college student who has engaged in SI for the past twelve years:
I grew up in an invalidating environment. Communication with my parents was not substantial and emotions were disregarded and never nurtured. Despite the fact that my parents showed little emotions, I grew up being very emotional and sensitive. By the time I reached fourth grade and started to deal with stresses, I needed to find an outlet for what I was feeling. Since I couldn’t express emotions outwardly through words, my mechanism for channeling pain began to come out in the form of self-injury. I don’t remember how I discovered that hurting my body would make whatever feelings I had inside go away. All I know is that it worked, and it worked well. (Austin & Kortum, 2004, p. 520)

From a paper written by an anonymous student under the pseudonym “Josephine” at the John Dewey Academy in Great Barrington, Massachusetts:
In a chillingly detached journal entry, I described the way I felt shortly before I was hospitalized:  I close my eyes and I can’t stop thinking about cutting and dying. I feel so empty inside. If something doesn’t change during this week, I’m going to kill myself. I don’t know of any other way. I have no idea what’s become of my life or myself. Everything is basically numb. The physical pain is really all that remains, but that pain is immense. It hurts to shower. It hurts to walk. It hurts to tie my shoes. Hurts to move, hurts to breathe, hurts to sleep. (Josephine, 2008, p.47)

Alexander and Clare (2004) share the following personal remarks from one participant in their research with women who self-injure in the context of a lesbian or bisexual identity:
I felt practically a wreck. I couldn’t do things that other people did. I felt incapable of having relationships with people; just felt incredibly isolated, and so I became suicidal, and I tried to tell people and they didn’t listen, and that’s when I started self-harming, because I got angry at being told to pull myself together. (Alexander and Clare, 2004, p. 79)

Life Events associated with Self-Injury (Etiology)

The literature review revealed that several researchers have conducted studies with the goal of understanding life events that may contribute to the probability of an individual manifesting SI at some point in their lives. There appear to be several factors that are found to occur in a portion of the SI population, however, none seem to be truly predictive.

Sexual and Physical Abuse
The literature is not in agreement on the link between childhood sexual abuse and self-injury.  Favazza and Conterio (1989) found that 62% of ongoing self-injurers reported sexual or physical abuse in their histories. Strong (1998) stated “There are many roots to cutting, but the single, most common casual factor is childhood sexual abuse. In fact, sexual abuse is now recognized by experts as the primary diagnoses of self-mutilators.” (Strong, 1998) Klonsky and Moyer (2008) conducted a review aggregating the results from 43 studies and found that the connection between childhood sexual abuse and SI is not as strong as earlier conclusions have suggested (mean weighted aggregate phi = .23). It may be that other mitigating factors play a role in the lives of those who have experienced childhood abuse and choose to self-injure. One suggestion is that sexual abuse combined with an invalidating environment may be the confounding factors that more accurately predict future SI (Alexander & Clare, 2004; Saxe, Chawla, & van der Kolk, 2002).  One research participant stated: “I definitely think that if I hadn’t been abused it’s very unlikely that I would be a self-harmer.” (Alexander & Clare, 2004).

Invalidating Environments
An invalidating environment is one theme that emerges as researches explore the life histories of those who self-injure. Linehan (1993) found that SI is connected to invalidating environments where children’s thoughts and behavior are met by erratic, insensitive, or inappropriate responses from their parents.  Yates, Tracy, and Luthar (2008) looked at this question in further detail and conducted research among a large sample of youth within a high socioeconomic area. The results of their study indicated that perceived parental criticism and a sense of alienation were significantly related to the presence of SI. Phenomenological research also uncovers recurring themes of childhood invalidation and alienation (Alexander & Clare, 2004; Josephine, 2008; Wagner & Rehfuss, 2008).

Sexuality/Sexual Identity
Two recent studies have highlighted the connection between sexual identity development and emerging SI. Wagner and Rehfuss (2008) conducted a small phenomenological study with three Caucasian Christian women, aged 18 to 25.  Respondent’s themes included the following: 1) A conservative Christian upbringing connected to past feelings of unworthiness, 2) Negative and limited sexual education, and 3) SI related to relational stress with opposite sex. One participant commented, “They never taught you the one important thing, which is take care of yourself first! That’s where the whole self-injury thing came in- I gave myself the attention I wanted, those were the dreams that got me to sleep, either sex or self-injury and sometimes both in the same instance.” (Wagner and Rehfuss, 2008, p. 179).
Alexander and Clare (2004) conducted a similar study including 16 interviewees who identified as lesbian or bisexual. Themes of common experience emerging from the analysis of the interviews included: 1) Bad experiences, 2) Invisibility and Invalidation, and 3) Feeling different. One research participant commented, “I grew up taking it for granted that there was something wrong with me.” (Alexander and Clare, 2004, p. 76).
These studies are confirmed by research indicating that the lesbian, gay, and bisexual community has a much higher rate of attempted suicide than the general population. Bell and Weinberg (1978) found that 38% of gay males and 42% of lesbian women had attempted suicide compared to 5% of heterosexual males and 26% of heterosexual females.  The correlation between the general invalidation of an individual’s thoughts and feelings and the invalidation of one’s sexuality is apparent when considering the results presented here.

The Functions of Self-Injury
Klonsky and Muehlenkamp (2007) conducted a review of the extant SI literature and found that there were seven recurring themes when exploring the functions of SI. He cautioned, “It is important to note that different functions are not mutually exclusive; they can and often do co-occur in individuals who self-injure” (Klonsky & Muehlenkamp, 2007, p. 1029)

Affect Regulation
Affect regulation appears to be the most commonly recurring theme in individuals describing their SI behaviors. Many accounts include the description of intense feelings that seem unable to be ameliorated in any other way (Klonsky & Muehlenkamp, 2007).  Hodgson (2004) conducted an online study including 16 participants. Results of the study suggested that, “an ultimate goal of self-injury for my participants was a means to respond to emotions evoked through interpersonal relationships they did not or could not handle normatively” (Hodgson, 2004, p. 177).  Klonsky and Muehlenkamp (2007) state that though there are some biological and psychological explanations seeking to explain the relief that SI brings about, the process is not fully understood.

Inflicting punishment on oneself was the second most common reason cited by self-injurers as motivation for their behavior (Klonsky & Muehlenkamp, 2007). A participant in Alexander and Clare’s (2004) study stated, “I kind of wanted to punish myself… I thought that the burning would hurt a lot more and be a bit more disfiguring…” (Alexander and Clare, 2004, p. 79). These findings are commensurate with other research findings that indicate that low self-esteem and self-derogation are common among those who self-injure (Klonsky, et. al, 2003; Lundh, Karim, & Quilisch 2007). One participant in Hodgson’s (2004) study stated that “self-loathing” led him to learn to cut himself (Hodgson, 2004, p. 171).

Interpersonal Influence
In their literature review, Klonsky and Muehlenkamp (2007) also found that some self-injurers have a desire to influence others and communicate through their acts of harm to their body. This motivation occurs far less frequently than affect regulation and self-punishment. Woldorf (2005) states “SI may also serve a communication function” (Woldorf, 2005). Klonsky (2007) states “A minority of self-injurers endorse reasons for self-injury such as, ‘to seek caring and support from others,’ ‘to control the behavior of others,’ ‘to get help from others.’ and ‘to bond with friends’” (Klonsky & Muehlenkamp, 2007, p.1050).

“I didn’t feel anything most of the time, it was trying to feel something because I never felt pain. I wanted to know I was alive” (Alexander and Clare, 2004, p. 79). Some self-injurers state that they feel like they are not real or not in their bodies. In these cases, the self-injurer practices SI in order to feel alive or to feel like they are back inside their bodies. The sight of their own blood seems to help them regain their sense of self (Klonsky & Muehlenkamp, 2007).

Many self-injurers are not only not attempting suicide, they are actively using their SI in order to cope with their lives and continue living. One self-injurer stated, “I would never have committed suicide, I thought it was my duty to stay alive no matter how impossible staying alive was” (Alexander and Clare, 2004, p. 79). Klonsky and Muehlenkamp (2007) noted that this function of SI is closely related to affect regulation in that the SI serves to ameliorate the negative feelings that are causing the self-injurer to desire death.

Sensation Seeking
In Teen People, Booth (2004) discusses the existence of “cutting clubs” among middle and high school students who self-injure in groups and may even cooperatively injure one another during the process. Tucson psychologist Bernard Engelhard was quoted by Kimberly Matas in the Arizona Daily Star (2006), “It’s become almost a substitute for smoking among teens. It’s become almost chic.” Klonsky and Muehlenkamp’s review of SI literature (2007) revealed that some self-injurers engage in the activity as a method of generating feelings of “excitement or exhilaration in a manner similar to skydiving or bungee jumping” (Klonsky and Muehlenkamp, 2007, p. 1050).

Interpersonal Boundaries
A sense of control and a desire to define personal boundaries has also been reported by individuals practicing SI. “I cherished the pain, because I was the one causing it, and I could stop it. I was in control, and I had the power” (Austin & Kortum, 2004, p. 521). Klonsky and Muehlenkamp (2007) state that research has found that some self-injurers may find that marking the skin may help them to feel more independent, autonomous, or separate and distinct from others.

Intervention for Self-Injury
The literature review reveals that there is not one established way for therapists to intervene in the lives of self-injurers. Woldorf (2005) states, “No single therapy or medication has proven itself the treatment of choice for individuals who self-injure” (Woldorf, 2005, p. 198). Two areas of relative agreement emerge in the literature when considering intervention for self-injurers: 1) It is no longer recommended for practitioners to work with groups of self-injurers. The limited research on clinical groups combined with the information available on the contagion phenomenon suggests that self-injurers show better response when worked with individually. The exception would be working with a heterogeneous group of individuals on a related skill such as help seeking and coping skills. (Lieberman, R., 2004) 2) The motivation for an individual’s SI may be used to inform the chosen therapy. For instance, a client who uses SI as a self-punishment may benefit from Cognitive Behavioral Therapy where he learns new thinking patterns to replace his faulty ones (Klonsky and Muehlenkamp, 2007).

Dialectical Behavior Therapy
Dialectical Behavior Therapy (DBT; Linehan, 1993a, 1993b) is the only researched method proven to be effective in working with individuals with Borderline Personality Disorder (Linehan, Armstrong, Suarez, Allmen, & Heard, 1991). Further trials have demonstrated that DBT also appears to produce positive results in regards to reducing self-injury behaviors in general (Linehan, Comtois, Murray, Brown, Gallop, Heard, et. al., 2006). Most recently, DBT has been adapted and researched in adolescent self-injuring populations (both suicidal and non-suicidal). Results indicate DBT reduces occurrence of SI in these populations (Katz, Cox, Gunasekara, & Miller, 2004; Rathus & Miller, 2002). DBT combines cognitive-behavioral techniques for emotional regulation and reality testing with Buddhist-inspired mindfulness practices, distress tolerance, and acceptance. Nock, Teper, and Hollander (2007) state that “DBT has consistently shown significant reductions in self-injury for both adults and adolescents; however, these reductions generally have not been significantly better than those observed in credible alternative conditions, such as treatment by experts in the community” (Nock, Teper, & Hollander, 2007, p. 1083).

Cognitive Behavioral Therapy
In 1999, manual-assisted cognitive behavior therapy was studied by Evans, Tyrer, Catalan, Schmidt, Davidson, Dent, et. al., and this preliminary study suggested that this technique was effective for clinical practice. This study was duplicated in 2004 by Tyrer, Byford, Schmidt, Jones, Davidson, Knapp, et. al., with a much larger study sample. The conclusions of this study suggested that manual-assisted cognitive behavior therapy demonstrated more success with self-harmers who did not also have a diagnosis of Borderline Personality Disorder (Tyrer, et. al., 2004). Cognitive Behavioral Therapy (CBT) proposes that emotions and behavior are driven by an individual’s thoughts and beliefs.  CBT is a short-term intervention with the goal of changing the client’s dysfunctional behavior and thinking (Tillotson, 2008). Tillotson (2008) stated “There would appear to be a sufficient evidence base to demonstrate efficacy of this intervention… although more research is necessary to continue to develop the use of CBT with those who self-harm” (Tillotson, 2008, p. 31).

Anxiety management/Emotional Regulation
In their study of nonsuicidal self-injury (NSSI) and eating pathology in the schools, Ross, Heath, and Toste (2009) concluded that “The centrality of emotion regulation difficulties in both NSSI and eating pathologies in adolescence highlights the need to work to develop programs for effective emotion regulation in the early grade school years as a possible preventative measure” (Ross, et. al., 2009, p. 90). Wester and Trepal (2005) propose alternatives for anger and aggression, restlessness, and emotion regulation as interventions for those engaging in SI. Examples include focusing on another task such as ripping up paper for anger and aggression, household cleaning for restlessness, and repetitive counting or the writing of sentences or words for emotional regulation (Wester & Trepal, 2005).  Gratz and Roemer (2008) completed a study among female undergraduate students that also indicated that teaching more adaptive ways of responding to emotions would be beneficial due to the relationship found between dysregulation of emotions and SI.

Other Approaches
Other methods referred to in the literature include Problem Solving Therapy along with DBT(Muehlenkamp, 2006), Rational Emotive Behavior Therapy (Beck, 1975; Ellis, 1975), Eye Movement Desensitization and Reprocessing with psychotropic medications (Lader & Conterio, 1998), narrative techniques (White & Epston, 1990), and family interventions (Yates, et. al., 2008). The emphasis throughout the literature is on matching the approach to the presenting diagnoses, motivations, and etiology of the individual self-injurer.

Educators and Self-Injury
The literature review revealed several studies conducted in England, Canada, and the United States among educators regarding self-injury. The results of these research projects suggest that educators in each of these countries feel the need for more information about self-injury and how they should respond to it. Bloom (2009) wrote about the need for more SI training for educators in the Times Educational Supplement, “…teachers often have little understanding of the motivation behind the two behaviour patterns [SI and eating disorders] and are unaware that both can be methods of coping with overwhelming emotions” (Bloom, 2009, p. 22).
Another repeated theme throughout the literature was the need for educators to respond appropriately when encountering self-injury in students:
First and foremost, a broader understanding of the symbolic value of such human acts helps to destigmatize a seemingly horrific and senseless behavior. Most commonly, parents, teachers, and even clinicians recoil from the apparent perversity and violence of an adolescent’s self-injurious behavior. If frightened, disgusted or overly condemning, such reactions render the adult unable to effectively reach out to the teen and provide assistance. (Plante & Hayward, 2007, p.6)

This common theme suggesting the need for an empathetic response to students presenting with self-injury (Best, 2005; Heath, Toste, Beettam, 2008; Malikow, 2006; Toste, Wagner, Heath, & Schaub, 2006) is among the most important principles to include in teacher training. “Hopefully, a teacher’s style of relating will encourage cutters to resort to people, rather than self-injury in managing anxiety” (Malikow, 2006, p 49).

Ron Best’s 2005 Research in England
Ron Best, a professor of Education at Roehampton University in London, interviewed 32 British educators regarding their knowledge and experience with self-injury in the school environment  (Best, 2005). The staff members interviewed included teachers, counselors, and nurses among others. Best compiled the results of the interviews into the following categories: descriptions of incidents of self-harming; the prevalence of self-harm; teachers’ awareness of self-harm; teachers’ reactions to self-harm; links between schools and other care/support agencies; and, training and support for teachers dealing with self-harm (Best, 2005).
The result of these interviews indicated that educators are sometimes frightened and upset when encountering self-harm, especially for the first time. It was also discovered that very little training on the topic of self-injury had taken place. The exception was at one school site where there had been a completed student suicide. Best suggests that further training is essential for these teachers. He states that educators can be taught to recognize that for some students self-harm is an adaptive behavior and should not be stigmatized and condemned. Active listening skills and training in empathetic, supportive responses to students in need were also recommended for all educators. While many of the teachers mentioned referring students to other resources, the referral methods and places varied greatly. Best recommended that a more organized system of referral should be instituted as well. Finally, Best asserts that the stress brought about by dealing with students in distress cannot be overlooked. Supervision for teachers and other educators should enhance the quality of educators’ responses to children in need and also provide the educator with emotional support.  (Best, 2005)

Toste, Wagner, Heath, and Schaub’s 2006 Study
Twenty-four high school teachers working in schools in and around a large urban area were included in this study. Conclusions of the study included the fact that only 29% of the teachers reported confidence in their knowledge regarding self-injury. About 50% of the teachers found the idea of SI horrifying, but most did not find it manipulative or merely for the purpose of gaining attention. Another important finding of this study indicated that teacher attitudes to SI appear to be largely informed by the level of knowledge about SI (Toste, et. al., 2006).
Teachers overwhelmingly identified a need for continued education in this area, confirming the potential receptiveness of school personnel to dissemination of such information. Although findings suggest that awareness about this behavior and its occurrence may have grown, inaccuracies in teachers’ knowledge in the current study and their desire for further information suggest that misconceptions persist in the general public regarding the correlates and function of SI.
An accurate understanding of current factual information about SI is crucial to informing referral, intervention, and treatment efforts within the school. (Toste, et. al., 2006, pp. 3-4).

Heath, Toste, and Beettam’s 2006 Research in Canada
Heath, Toste, and Beettam (2006) conducted research with fifty teachers utilizing a survey to investigate knowledge, self-perceived knowledge, and attitudes regarding self-injury (Heath, et. al., 2006). Results of the study revealed 78% underestimated prevalence and only 20% of the teachers felt they were knowledgeable about SI. “Overwhelmingly, teachers felt that they needed more information on this topic, and that they were not well-equipped or prepared to manage SI in the schools. Responses clearly emphasized that SI is a growing issue within the school context” (Heath, et. al., 2006, p. 82).

Roberts-Dobie and Donatelle’s 2007 Research in the United States
Roberts-Dobie and Donatelle’s (2007) research was conducted among 357 school counselors. Eight-one percent of these respondents reported that they had worked with a student manifesting self-injury at some point during their career.  When completing the questionnaire used for the study, the counselors did not report high self-knowledge about SI. The most commonly identified need was building their own knowledge and skills.
They requested general information, in-service training, and published research. In training, they were looking for specific strategies for prevention, identification, intervention, and referral.
In addition to more information, counselors wanted policies and procedures to follow when working with self-injurers (Roberts-Dobie & Donatelle, 2007, p. 261).

Kibler’s 2009 Research in the United States
Kibler states, “Educators are being forced to deal with self-injurious behaviors in the schools and many are unprepared to deal with such behaviors” (Kibler, 2009, p. 311). Kibler (2009) conducted research among one hundred and twenty-two school counselors attending a Midwestern state conference for school counselors. These professionals were asked to complete a brief survey about their knowledge and experiences regarding self-injury. Results of the study indicate that school counselors are encountering and intervening with students who self-injure. Kibler’s research also indicates a need for educators, especially school counselors, to receive more training about self-injury in the schools (Kibler, 2009).
The literature review suggests that self-injury is a pervasive problem in our society. Prevalence studies indicate that while 4% of the population report SI over their lifetime, approximately 15% of middle and high school students report at least one instance of SI. Further, studies indicate that educators in England, Canada, and the U.S. all report insufficient knowledge regarding self-injury. Counselors, teachers, and other educators have stated the need for further information regarding how to understand, recognize, and respond to this ever-increasing phenomenon. The purpose of the current study is to create a handbook for educators addressing this need.

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