How Do Young Women Perceive Adult Responses to the Disclosure of Their Self-Harm and What Is the Impact of That Perception?

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

How do young women perceive adult responses to the disclosure of their self-harm and what is the impact of that perception?

 

The study focuses on the increase in rates of self-harming behavior among young women. Only half of them disclose their self-harm, and when they do, some receive harmful responses from adults and others receive responses that are helpful to their recovery.

 

The Objective of the study is to understand how these girls perceive the responses of adults (parents, health professionals) to their disclosures of self-harm, and the impact these responses have on them.

 

The introduction and review of the theoretical framework is accurate and up to date. It focuses on the analysis of self-harming behavior, which occurs when a person intentionally causes harm or pain to their own body. This behavior can serve various purposes, including controlling and regulating emotions, connecting with others, punishing oneself, or controlling suicidal thoughts.

Self-harm is associated with an increased risk of suicide, and one study shows that almost all participating adolescents who had attempted suicide had previously self-harmed. Self-harm is also associated with an increase in other risky behaviors, poorer educational and employment outcomes, a higher likelihood of substance use, and greater mental health problems.

Studies show that more than half of college students who have self-harmed have not told anyone about their self-harm

There is extensive literature identifying reasons why someone might choose not to disclose their self-harm, including perceived stigma, shame, judgment, and misunderstanding, as well as concern about how disclosure might affect the other person and reluctance to feel like a burden to others.

The impact of responses to disclosure of self-harm depends on the response itself and how it is perceived by the person disclosing the self-harm. Negative experiences when disclosing self-harm can negatively affect a person's decision to disclose again, delay future disclosures due to increased hesitation and caution, or potentially trigger subsequent episodes of self-harm. Conversely, if the trusted person responds with acceptance, understanding, and empathy, this can reduce the shame associated with self-harm and encourage future disclosures and help-seeking, which may ultimately reduce future suicide risk. In addition, emotionally supportive responses are associated with decreased levels of depression.

Understanding the impact of different types of confidants is critical to encouraging help-seeking and developing interventions that support recovery from self-harm. Friends can provide frontline support to adolescents who self-harm, and they may be available both physically and emotionally to help the adolescent stop self-harming and disclose it to adults. Adults, such as parents and health professionals, may play a different role than peers in a young person's recovery. Parents can provide ongoing support and may be more involved in the young person's daily recovery, while other adults, such as health professionals, may play a more formal role in the person's treatment. Understanding the specific impact of adult responses (e.g., parents, teachers, health professionals) to disclosures of self-harm by young women is critical to supporting help-seeking behaviors, providing ongoing emotional support, and developing appropriate interventions.

It is important to note that several studies highlight the need for additional training and support for parents and professionals in relation to responding to and managing self-harm.

 

The sample is formed by 27 semi-structured interviews were conducted with women with a mean age of 20.9 years who reported a history of self-harm. Participants were recruited through advertisements on the Black Dog Institute (BDI) website and social media accounts (Facebook, Instagram, LinkedIn) between October and November 2023. The advertisements directed potential participants to a website with information about the study. Participants were considered eligible if they (i) confirmed a history or current behavior of deliberate self-harm (with or without suicidal intent), (ii) were between 16 and 24 years of age, (iii) identified as female, (iv) could speak and understand English clearly, and (v) lived in Australia. The most common mental health diagnoses reported across participants were anxiety and depressive disorders.

 

The working methodology. The data was collected through semi-structured one-on-one interviews. Interviews lasted 137 between 41-106 minutes. The methodology was based on the use of flexible thematic analysis

 

Results: Thematic analysis generated three themes exploring young women’s perception of responses to disclosures of self-harm; 1) the young woman’s needs were diminished 2) the confidante’s response was not attuned to the needs of the young woman, and 3) the confidante’s response was attuned to the needs of the young woman

• The first theme reflects responses that were perceived as dismissive or that caused feelings of discomfort or shame.
• The second theme captures responses that did not resonate with the participant's needs or that were unhelpful or invalidating.
• The third theme represents responses that elicited feelings of being cared for or validated.

 

Conclusions:

1.- This study provides essential information on how young women perceive responses to self-harm disclosure and the potential impacts of these responses. The findings suggest that dismissive responses (such as minimizing or ignoring the self-harm) or unhelpful responses (i.e., a response that does not support meaningful change) can contribute to increased self-harm behaviors or, in the case of dismissive responses, to suicide attempts.

2.- If an adult's response evokes feelings of discomfort, shame, or invalidation, this can contribute to a young woman's hesitancy to disclose her experience again or to engage in future help-seeking behaviors.

3.- Adult responses that are responsive to the young woman's needs and demonstrate care or emotional validation—such as a parent taking their daughter to the hospital, an adult acknowledging the young woman's distress, or providing a space to listen—can be beneficial for recovery.

 

 

 

 

 

Applicability. Future interventions could focus on educating parents and health professionals about the best approaches to responding to disclosures of self-harm that promote future disclosures and recovery.

 

 

This study identifies the following important problems that need to be addressed.

 

Important Problems:

 

1.- The authors themselves indicate that the study has some limitations, since, as part of a broader investigation, the interview questions covered a wide range of experiences related to self-harm, rather than exploring only the disclosure of self-harm. This calls into question the validity of the methodology, as the questions and answers do not adhere exclusively to the objectives set out in the text. For this reason, it is also not possible to explore specific contextual factors, such as socioeconomic status, access to mental health services, and cultural norms, which may have influenced disclosure and confidants' responses. With this limitation, the reliability of the conclusions is called into question.

2.- It has been shown that the age of onset of self-harm peaks in adolescence; however, although participants aged 16 and 17 were recruited, none participated in the present study.

3.- The authors report that some of the informants in the sample did not exactly meet the inclusion criteria for the sample (they described cases in which disclosure was involuntary or not self-directed).

4.- There is no control group, for obvious reasons, but a control group could be sought, for example, among young Aboriginal women with self-destructive behaviors.

5.- The bibliography should be updated. Only 19 of the 45 references shown are from the last 5 years. One of the references (number 42) is incorrectly cited, as it doesn't even include the year of publication.

 

 

Author Response

Please see the attachment

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

1. Although prevalence trends are mentioned in the introduction, could you elaborate on why young women in particular were chosen instead of a more general youth sample? Theoretical grounding would be improved by including a few lines connecting gender differences in disclosure experiences or service responses.
2. Parents, educators, and various health care providers are all considered "adults." These are separate groups. Think about briefly outlining the ways in which these various adult roles might specifically influence expectations, reactions, and interpersonal dynamics.
3. Although the reflexive thematic analysis section is excellent, it would be more transparent to briefly discuss how the clinical backgrounds of the researchers may have influenced coding choices or interpretation.
4. Dismissive reactions occasionally preceded escalated self-harm or suicide attempts, according to the Results and Discussion. This argument might be strengthened by including some references or a theoretical explanation of how invalidation might encourage self-harm.
5. Some of the Discussion's topics (such as shame-inducing negative reactions and reluctance to ask for assistance) are repeated from the Results. These sections could be made more readable and focused by simplifying them.
6. A number of participants mentioned unintentional or coerced self-harm discovery. It would be helpful to talk about whether intentional versus inadvertent disclosure affects how responses are perceived.
7. Interviews were done "until saturation was reached," according to the manuscript. It would be beneficial to include a sentence that explains how saturation was determined (e.g., no new codes emerging).

Comments on the Quality of English Language

Although the English is generally clear and intelligible, there are a few sentences that could use some improvement in terms of consistency, flow, and grammar. A few sections have formatting inconsistencies, placeholder text (such as "mean/median?"), and small typographical errors. To guarantee better readability and a polished appearance throughout the manuscript, I suggest a light to moderate language edit.

Author Response

Please see the attachment

Author Response File: Author Response.pdf