An Exploratory Study of Non-Suicidal Self-Injury and Suicidal Behaviors in Adolescent Latinas

Abstract

To date, there is little research to validate empirically differences between non-suicidal self-injurious behavior (NSSI) and attempted suicide among Latina adolescents. Understanding the characteristics and contextual features of self-harmful behaviors among Latina teens is a critical public health and social justice matter given the disproportionate rates of attempted suicide and anticipated population growth of this vulnerable group. In this article, we draw on an ecodevelopmental model to focus attention on factors in the sociocultural environment that shape suicidal and non-suicidal self-injurious behaviors. Through analysis of qualitative interviews conducted with girls who used NSSI (n = 18), attempted suicide (n = 29), used NSSI and attempted suicide (n = 8,) and had no reported lifetime history of self-harm (n = 28), we describe the sociocultural factors that shaped psychosocial vulnerabilities and gave rise to decisions to use NSSI or attempt suicide. Our analysis revealed that adolescents who engaged in NSSI perceived their negative feelings as something that could be controlled through self-injurious acts, whereas powerlessness was a theme underlying the emotional states of girls who attempted suicide. When NSSI ceased to function as a mechanism for control, girls came to sudden decisions to attempt suicide. Most teens identified specific, and often multiple, situations that induced these intense affective states and shaped decisions to inflict self-harm. Two situational experiences emerged as particularly salient and promising for subsequent studies on self-harmful behaviors among Latina adolescents: transnational stress and bullying. We describe each of these and offer suggestions for future research and practice.

For the past 20 years, Latina adolescents have reported elevated rates of attempted suicide compared to non-Hispanic White and African-American adolescents (CDC, 2014; Romero, Edwards, Bauman, & Ritter, 2014).¹ Although suicidal behaviors among Latina teens have been well documented in the literature, non-suicidal self-injury (NSSI) has received little attention. A growing body of research focuses on variations in the psychological and social profiles that give rise to self-harming behaviors in adolescents,² but few studies have included Latina participants (Croyle, 2007; Gutierrez, Rodriguez, & Garcia, 2001; Hilt, Cha, & Nolen-Hoeksema, 2008; Lipschitz et al., 1999; Sandoval, 2006). Given the recent recommendation in the DSM-5 for increased research on NSSI and suicidal behaviors as distinct, rather than overlapping, syndromes (APA, 2013), there is a need to investigate the similarities and differences between these two behaviors across racial and ethnic groups (Kim et al., 2014). This article represents a first step toward understanding the contexts within which Latina teens use NSSI and/or attempt suicide. Our purpose is not to provide definitive conclusions that can be generalized, but rather to open the door for a critical discussion about self-harmful behaviors within adolescent Latina populations.

Given the lack of information on similarities and differences between suicidal and non-suicidal self-injurious behaviors within diverse populations (Hamza, Stewart, & Willoughby, 2012), we begin with an examination of the challenges associated with distinguishing NSSI from attempted suicide. We then use studies of attempted suicide by Latina teens as a starting point to outline potential factors that shape decisions to engage in self-harmful behaviors. We highlight the potential for an ecodevelopmental approach to contextualize Latina teens’ decisions to use NSSI and/or attempt suicide, and we draw on this approach to frame our exploratory qualitative study of Latina teens with and without histories of NSSI and/or attempted suicide.

The Challenge in Distinguishing NSSI from Attempted Suicide

For many researchers and clinicians, the intent of NSSI is a key distinguishing factor. NSSI is often defined as self-harm without the intent to die (Nock & Prinstein, 2004; Muehlenkamp, 2005), and most evidence to date suggests that the majority of teens self-injure as a strategy to alleviate acute emotional distress (Chapman, Gratz, & Brown, 2006; Klonsky & Muehlenkamp, 2007; Nock & Prinstein, 2004; Yip, 2005). In contrast, a suicide attempt is classified as a nonfatal, self-inflicted destructive act with the explicit or implied intent to die (Goldsmith, Pellmar, Kleinman, & Bunney, 2002). Despite the seemingly clear-cut differences between NSSI and attempted suicide on the basis of intent, differentiating the two behaviors in the context of research and practice proves to be challenging. For example, the data analyzed in this article came from a larger study in which mental health practitioners originally assessed all participants as suicidal. It was only in the context of an in-depth, qualitative interview that many participants reported not having any intention to kill themselves (Zayas et al., 2010).

Distinguishing NSSI from a suicide attempt is often difficult, in part, because the two behaviors exhibit numerous similarities in terms of risk factors. Childhood trauma and abuse (Baetens, Claes, Muehlenkamp, Grietens, & Onghena, 2011; Boxer, 2010), family conflict (Wong, Stewart, Yo, & Lam, 2007), and negative peer interactions (Muehlenkamp, 2014) have all been shown to be associated with suicide attempts and NSSI, although adolescents who attempt suicide report greater exposure to stressful life events (Andover, Morris, Wren, & Bruzzese, 2012). Additionally, individuals who engage in NSSI or suicidal behavior exhibit higher levels of physiological reactivity in response to stress, a reduced ability to tolerate stress, and concurrent deficits in social problem-solving abilities compared to those without a lifetime history of suicidal or non-suicidal self-injurious behaviors (Donaldson et al. 2000; Goldston et al. 2001; Nock & Mendes, 2008).

Efforts to differentiate NSSI from attempted suicide are further challenged by extensive overlap in terms of lifetime history of the two behaviors. Studies have demonstrated that individuals often engage in both NSSI and attempted suicide over the course of their lifetimes (Muehlenkamp & Gutierrez, 2004). For example, Nock, Joiner, and Gordon et al. (2006) found that up to 55% of adolescents who reported non-suicidal self-injuries also attempted suicide, sometimes repeatedly. This research has motivated continued interest in understanding potential associations between NSSI and future suicidal behavior (Taliaferro, Muehlenkamp, Borowsky et al., 2012).

Self-Harmful Behaviors in Latina Teens

Latina teens are a growing population at heightened risk for engaging in acts of self-harm (Croyle, 2007). The Latino population has grown 43% within the past decade, accounting for more than 50% of the population growth within the U.S. between 2000 and 2010 (Passel, Cohn, & Lopez; 2011). Moreover, NSSI and suicidal behaviors often onset during adolescence (Nock, Borges, Bromet, Cha, Kessler, & Lee, 2008). Among Latina teens, the 12-month prevalence of attempted suicide is 15.6% (CDC, 2014). The prevalence rate of NSSI among Latina teens is understudied, but in general, adolescents have been shown to be at increased risk for engaging in NSSI compared with adults (Nock & Prinstein, 2005), with lifetime rates ranging up to 56% in some nonclinical community populations (Cerutti, Manca, Presaghi, & Gratz, 2011).

Despite limited research on NSSI among Latina teens, studies on suicidal behaviors can provide a foundation for identifying potential factors that shape decisions to engage in NSSI (Croyle, 2007). In the literature on Latina teens suicide attempts, research consistently demonstrates that stressed relations between attempters and their parents seem to be a common factor (Zayas et al., 2010; Duarté-Vélez & Bernal, 2007; Flouri & Buchanan, 2002; Johnson, Cohen, Gould et al., 2002). Family relationships of the attempter have been characterized as tense or weak, stemming from poor communication, mentoring, and/or support (Zayas et al., 2010, Zayas & Gulbas, 2012; Garcia, Skay, Sieving, Naughton, & Bearinger, 2008; Herrera, Dahlblom, Dalgren et al., 2006; Razin et al., 1991). Differences in perceptions of parenting style, respectful behavior, adolescent autonomy, and the allocation of household rules and responsibilities have not only been shown to contribute to conflict (Bronstein, 1994; Cardona, Nicholson, & Fox, 2000; Halgunseth, Ispa, & Rudy, 2006; Szapocznik & Williams, 2000); but to act as the triggering event that precedes a suicide attempt (Zayas et al., 2010, Zayas & Gulbas, 2012). In its most extreme form, family conflict can engender violence, and many Latina teens decide to attempt suicide in the wake of violent family trauma (Zayas et al., 2010; McFarlane, Groff, O’Brien et al., 2003).

By focusing attention on family dynamics, this literature has helped to elucidate links between culture and Latina teen suicidal behavior. Family conflict can be especially burdensome to Latina adolescents because it contradicts salient cultural values that posit the family as a cohesive, harmonious, interdependent social unit (Romero et al., 2014). Put another way, Latino families often espouse a value orientation that is “household-centered rather than child-centered” (Villenas & Dehyl, 1999, p. 424). Yet, the capacity to uphold this cultural value is context-dependent. When Latino families endure stressors, such as underemployment, discrimination, or fragmented social structures, parents and adolescents sometimes find themselves unable or unwilling to provide family support (Zayas & Gulbas, 2012; Guarnaccia, Parra, Descamps, Milstein, & Argiles, 1992). Using this cultural framework, attempted suicide by Latina teens can be understood as an act that speaks not only to the psychosocial state of the individual, but also of the family: Individual distress is a family affair, whereas family suffering is deeply felt at the individual level (Zayas & Gulbas, 2012). The question remains: Do similar individual, family, and sociocultural processes shape the use of NSSI among Latina teens? We assert that an ecodevelopmental framework presents a productive starting point to addressing this question.

An Ecodevelopmental Approach to Self-harmful Behaviors

To frame our understanding of self-harmful behaviors among Latina teens, we draw on an ecodevelopmental framework to highlight the proximal factors that give rise to self-harmful behaviors within a specific sociocultural context (Zayas et al., 2005; Bronfenbrenner, 1979; Coatsworth et al., 2002; Szapocsnik & Coatsworth, 1999). An ecodevelopmental approach focuses attention on the various ways in which adolescents—and all individuals—engage their surroundings through different levels of interaction. In the microsystem, which is the focus of this paper, adolescents have direct contact with their surrounding environment through their relationships with family members, peers, schools, and communities. The mesosystem refers to links between the different microsystems encountered by adolescents, for example, interactions between parents and teachers. The exosystem includes those aspects of the environment that indirectly shape an individual’s microsystem, such as place of residence. Finally, the macrosystem references the ideological underpinnings of a group or society that shape and are shaped by mico-, meso-, and exosystems (Coatsworth et al., 2002; Korbin, 2013).

In the study of self-harmful behaviors among Latina adolescents, an ecodevelopmental approach promotes a shift from strictly individual or psychological variables to consider the links between an adolescent and the context of her daily life. The framework focuses attention on factors in the sociocultural environment that shape an adolescent’s emotional and psychosocial vulnerabilities and give rise to harmful behaviors. To date, this conceptual model has been influential in understanding Latina teen suicide attempts, illustrating how family conflict (Zayas et al., 2010, Zayas & Gulbas, 2012; Fortuna, Perez, Canino, Sribney, & Alegría, 2007; Garcia, Skay, Sieving, Naughton, & Beringer, 2008), racial and ethnic discrimination (Romero, Wiggs, Valencia, & Bauman, 2013), and immigration-related traumas (Zayas et al., 2009; Cervantes, Goldbach, Varela, & Santisteban, 2014) play a role in decisions to attempt suicide.

Few studies have utilized an ecodevelopmental approach to distinguish NSSI and attempted suicide. It is the aim of this paper to describe and compare the conditions and experiences that precede the decision to self-harm in order to contribute to an understanding of the contexts surrounding self-harmful behaviors within Latina adolescent populations. In this exploratory study, we analyze in-depth qualitative interviews conducted with Latina teens who used NSSI and/or attempted suicide. We also include interviews with Latina teens who had no report of suicidal or non-suicidal self-injurious behaviors in order to contextualize normative social processes and ecological contexts that are shared among Latina adolescents sampled within this study. We direct specific attention to themes of emotional vulnerability, family context, and broader sociocultural environment to identify potential factors that shaped adolescents’ decisions to engage in acts of self-harm and distinguish NSSI from attempted suicide.

Method

For this report, we draw on data from a large federally-funded, mixed-method project conducted between 2005 and 2010 that examined the interplay between sociocultural processes and suicidal behavior among young Latinas living in low-income households in New York City (see Zayas et al., 2005, Kuhlberg et al., 2010). Adolescents with no lifetime history of suicidal behavior were also included to examine why some Latina adolescents attempt suicide compared to others who share similar developmental, social, and demographic characteristics, including country of origin, place of residence, socioeconomic status, family structure (single-parent or dual-parent household), and levels of acculturation. A total number of 139 adolescents were recruited for participation in the qualitative phase of the larger study, including 73 Latinas between the ages of 11 and 19 who engaged in acts of self-harm within six months preceding the interview and a comparison group of 66 Latina adolescents with no reported lifetime history of self-harm.³

Participants who self-harmed were recruited from a municipal hospital with psychiatric emergency and outpatient departments, a private psychiatric hospital, and mental health services associated with an agency that served a large Latino population. Participants with no history of self-harm were recruited from primary care medical clinics and local community agencies that provided after-school, prevention, and/or youth development programs. Exclusionary criteria for participation among all participants in the study included diagnosis of schizophrenia, psychotic disorders, bipolar disorder, or cognitive disability. Among all participants, girls and their parents gave assent and consent for participation in the study.

Procedures for recruiting and obtaining informed consent proceeded as follows. First, agency intake supervisors and community agency liaisons identified potential participants. For the purposes of recruitment, participants with a history of self-harm were identified by mental health clinicians who assessed their behavior as suicidal based on their professional and clinical judgment. The degree of lethality was not used as an exclusionary criterion because suicidal behaviors among Latina adolescents exhibit low lethality (Turner et al., 2002; Berne, 1983; Razin et al., 1991; Trautman, 1961). Then, agency staff discussed the study with both the adolescent and parents. At this stage, families with an adolescent with no lifetime history of self-harm who expressed interest were referred to the research team, who contacted the girl and parents for assent and consent. When adolescents who engaged in acts of self-harm and their parents expressed interest, a staff member informed the parents that the girl’s therapist would need to grant approval to participate. With parental agreement, the adolescent was assessed for her readiness to participate by her therapist. All agency staff and therapists emphasized the volunteer nature of participation to prevent adolescents from feeling coerced. Following approval, the therapist referred the adolescent and her parents to the research team for assent and consent.

After the completion of informed consent procedures, researchers scheduled interview appointments. Approximately 95% of adolescent interviews occurred the same day that consent was granted. Of those participants approached for participation in the study, nearly 90% agreed to participate (see Zayas et al., 2009). All respective institutions where research activities were undertaken granted IRB approval.

Participants

In this article, we present data drawn from a subsample of participants in the larger study. Among participants with a history of self-harm, we incorporate only those individuals who explicitly stated in the qualitative interview the intent of their actions. To select the sub-sample, we read each interview transcript of the 73 Latina youth who self-harmed to determine how the participant defined her behavior according to her answer to the following interview question: “At the time, what was the intent of your action?” Based on the answer, we distinguished NSSI from a suicide attempt according to the meanings given to the self-harming behavior by the participant. From the total sample of 73 participants, we coded 18 interviews as NSSI, 29 as a suicide attempt, and 8 as a combination of NSSI and attempted suicide. Eighteen interviews were excluded from analysis because the intent of self-harm was ambiguous.

To identify and contextualize normative events, experiences, and processes among Latina teens, we included participants with no lifetime history of self-harm (n = 28). To select the sub-sample, transcripts were first randomly ordered. Then, each transcript was read and coded following the procedures outlined below. Thematic saturation occurred after analyzing 28 transcripts, at which point the selection of cases for the sub-sample ended.

Across each sub-group (NSSI, attempted suicide, NSSI and attempted suicide, no self-harm), the average age of the girls was 15 years. Most were born in the U.S. (68.7%). Participants identified with several different Hispanic subgroups, but the majority identified as Puerto Rican, Dominican, and Mexican (see Table 1).

Table 1.

Characteristics of Adolescent Latinas in Sub-Sample

	Participants who used NSSI (N=18)		Participants who attempted suicide (N=29)		Participants who used NSSI and attempted suicide (N=8)		Participants with no self-harm (N=28)		Total participants (N=83)
	M ± SD	n (%)	M ± SD	n (%)	M ± SD	n (%)	M ± SD	n (%)	M ± SD	n (%)
Age in years	15 ± 1.4		15.5 ± 2.0		15 ± 2.3		15.1 ± 2.1		15.3 ± 1.9
11–13		2 (11.)		6 (20.7)		1 (12.5)		7 (25.0)		16 (19.3)
14–16		14 (77.8)		14(48.3)		4 (50.0)		13 (46.4)		45 (54.2)
17–19		2 (11.1)		9 (31.0)		3 (37.5)		8 (28.6)		22 (26.5)
US Born		16 (88.9)		14 (48.3)		6 (75.0)		21 (75.0)		57 (68.7)
Hispanic Cultural Group
Puerto Rican		7 (38.9)		9 (31.0)		0 (0.0)		12 (42.9)		28 (33.7)
Dominican		3 (16.7)		9 (31.0)		0 (0.0)		7 (25.0)		19 (22.9)
Mexican		2 (11.1)		6 (20.7)		0 (0.0)		5 (17.9)		13 (15.7)
Colombian		1 (5.6)		1 (3.5)		2 (25.0)		3 (10.7)		7 (8.4)
Ecuadoran		0 (0.0)		3 (10.3)		0 (0.0)		0 (0.0)		3 (3.6)
Other1		5 (27.7)		1 (3.5)		0 (0.0)		1 (3.5)		7 (8.4)

Notes:

¹This includes participants who identified as Venezuelan, Guatemalan, Honduran, Salvadoran, and mixed

Qualitative Interview

In-depth qualitative interviews were conducted with all participants in either English (n = 63) or Spanish (n = 20), depending upon the participant’s preference. All interviewers—masters- and doctoral-level social workers and psychologists who were bilingual Latinas—were trained to encourage participants to talk freely and in-depth about topics in the interview guide to allow for as much information to emerge as possible. Prior to beginning the qualitative interview, each participant was asked standardized questions regarding self-harmful behaviors to ensure that participants who were identified as non-attempters did not have a history of self-harm at the time of the interview.

All teens participated in an interview that explored perceptions of family life and interaction; delineation of roles, responsibilities, rules, and discipline; examples and sources of conflict that occurred among family members and methods of conflict resolution; and perspectives of life outside the home, including peer relationships, dating, and school. Among girls with histories of self-harm, interviewers also elicited an account of the self-harmful behavior, including the solicitation of a detailed, retrospective account of emotional experiences and family context before, during, and after the act. All interviews were audiotaped, transcribed, and analyzed in the language of the interview by a team of bilingual and bicultural researchers. Qualitative interviews lasted between 25 and 70 minutes.

Data Analysis

Following Teddlie and Tashakkori (2006), we used an exploratory mixed-method analytical design, which entailed qualitative analysis of interview data followed by the quantification of qualitatively-derived themes. This strategy facilitates the evaluation of patterns in the data in ways that are not always available through traditional qualitative analysis (Fakis, Hilliam, Stoneley, & Towned, 2014; Guest, MacQueen, & Namey, 2012). Although this study integrates qualitative and quantitative techniques, our approach is strongly rooted within a qualitative tradition that emphasizes the participants’ perspectives and explanations of the behaviors in question (Singer, 2006). Thus, we quantify the qualitative data in order to make systematic comparisons across groups of participants (NSSI, attempted suicide, NSSI and attempted suicide, and no self-harm).

We employed a thematic framework that combined deductive and inductive coding for qualitative analysis (Arcury & Quandt, 1998). We deductively developed four broad themes to focus our attention on the primary aims of the paper (see Table 2). These broad codes were then systematically applied to interviews with participants who used NSSI and/or attempted suicide to identify themes that were salient to their decisions to self-harm. A second inductive coding pass was performed on coded text to identify sub-themes within each broad category. For example, any event or process identified by a participant under the code “sociocultural context” constituted a sub-theme. After we developed the final list of sub-themes, all interviews (self-harm and no self-harm) were read and coded, with attention directed to the emersion of new themes and validation of previous themes.

Table 2.

Deductive Coding Framework

Theme	Definition
Modality	The method by which self-harm was inflicted
Intent/Motivation	The participant’s reason for engaging in self-harm
Emotional State	The emotions present during the moment of self-harm
Sociocultural Context	An event, process, or experience the participant identified as shaping the decision to self-harm

Interviews were then coded and converted into numerical form (yes = 1, if a theme was present; no = 0, if a theme was not present). Author 1 first carried out all deductive and inductive coding using digital spreadsheet software (Meyer & Avery, 2009), after which Author 2 independently coded and reviewed 100% of the text, including the conversion of the qualitative data. Any discrepancies or concerns about the application of codes to sections of text were highlighted and brought to the attention of research team members, discussed, and revised according to group consensus (Guest et al., 2012).

Results

Analysis of the qualitative interviews revealed subtle differences in the ecodevelopmental factors surrounding Latina teens’ decisions to use NSSI and/or attempt suicide. Below, we direct attention to the ways in which adolescents explained their acts of self-harm. In doing so, we contextualize their motivations and situate their psychosocial vulnerabilities within broader familial and sociocultural contexts to understand the events, processes, and experiences that gave rise to decisions to engage in suicidal and non-suicidal self-injurious behaviors.

Adolescents who Reported NSSI

Within the sample of 18 teens who reported NSSI, the majority harmed themselves through cutting (n = 14). Those adolescents who cut chose sharp instruments (e.g., razor blades) due to their perceived accessibility, reflecting the spur-of-the-moment decision to self-injure. As one adolescent explained, she chose to cut with a piece of broken glass because it was “the sharpest thing I could find.”

In every case of cutting behavior, the decision was motivated by a need to interrupt the intensity of emotions experienced in the moment. Girls did not view their cutting as a suicidal act, but rather as a way to process thoughts, feelings, and emotions. As one 15 year-old, explained, “It was in my hand [the nail file], and I was thinking, ‘What I’m going to do with this? I’m not going to kill myself because I don’t want to die. I want to just stop feeling angry.’ Inside me was screaming. I was feeling really, really angry.” This sentiment—the need for emotional regulation—was echoed across participants who cut. NSSI was perceived as way to release overwhelming emotional states, which included experiences of sadness, depression, tiredness, stress, frustration, and uselessness. Of these emotional reactions, anger figured prominently (n = 12). Although emotional regulation was the most frequently reported reason for cutting, three participants described an additional need to feel physical pain through cutting. One girl explained, “I just wanted to feel physical pain. I feel like part of me already felt pain, so I need the other part to feel more pain.” In these cases, the desire to experience pain was a strong motivator for using NSSI.

Conversely, participants who overdosed on pills (n = 3) described different motivations for engaging in NSSI. In these cases, the primary aim was interpersonal: to punish or enact influence over parents. For example, one Latina described a time when her mother had broken the household rules, breaching a written contract they had that no one would enter her room without her permission: “I was like, you know what? I should drink [the pills] ‘cause she broke the rules three times, not twice, but three times.” In this case, the teen perceived NSSI as a way to punish her mother for breaking their written contract. Thus, NSSI could be utilized to communicate the intensity of anger towards parents with the aim of punishing them for their perceived acts of transgression.

Although the intent of NSSI differed across participants, an underlying theme in each case was control. For example, cutting provided girls with the ability to be in control of their emotions or the kind of pain inflicted. Although emotional suffering was intense, overwhelming, and chaotic, NSSI could be used directly to manage that suffering and the ways in which it was experienced. Similarly, girls who cited interpersonal motivations for NSSI expressed the salience of feeling in control. As one participant clarified, “I hate the feeling that other people can make me cry so it’s a relief that they are not controlling me crying this time. I can do it myself.” Thus, NSSI could be used to reframe emotional encounters wherein the adolescent was an active agent of her emotions and the emotions of others.

Adolescents who Attempted Suicide

Among the 29 girls who attempted suicide, 13 ingested pills, 8 cut, and 3 engaged in other methods of attempting suicide that included suffocation or ingesting household cleaners. The remaining five adolescents combined multiple methods, most frequently ingesting pills and cutting. In each case, the intent of self-harm was to cause death, and participants described coming to a sudden decision to end their lives.

Powerlessness was a key theme underlying the emotional states of girls who attempted suicide, and participants described the inability to identify alternative mechanisms to escape their emotional suffering. In this void, the decision to attempt suicide emerged as a possibility. As one girl explained, “I just didn’t know what else to do.” The primary motivation underlying attempted suicide was a desire to end overpowering feelings, and participants cited sadness and worthlessness most frequently. Unable to endure the intensity of the emotional pain, adolescents perceived suicide as the only option. As one attempter recounted, “I felt depressed. It’s like a black hole that you can’t see the light. So everything is dark. I just wanted to do something about it, so I tried killing myself.” She ultimately ingested more than 50 pills and lost consciousness.

Many attempters described feeling unloved and unsupported within their families, and a suicide attempt symbolized the depths of their loneliness. Yet, three girls thought their attempted suicide could improve their relationships with their parents. For example, one participant believed that her suicide attempt “would make everything better. So I figured that if they knew the way I was feeling, that I didn’t want to be there, that I felt like I didn’t belong, that maybe they would change.” Despite the semblance of hope in this narrative, the emotional tenor of her interpersonal relationships was still predicated on the agency of others, and in this case, her parents. In the end, she still perceived herself as powerless to change the situation, echoing a theme expressed by each girl who attempted suicide.

Adolescents with NSSI and suicide attempts

Eight participants disclosed histories of both NSSI and attempted suicide. Five participants used multiple methods, which included cutting and ingesting pills. The three remaining participants in this sub-group caused harm to their bodies through cutting. All teens in this group distinguished acts they identified as “relieving pain” from those that were intended to cause self-inflicted death. As one participant noted, “I don’t have any suicidal thoughts when I’m cutting, like, ‘cause I feel I don’t have control over anything, but at least, I can control that.” In contrast, she attempted suicide by ingesting pills:

“The reason I took the [acetaminophen] was ‘cause I just couldn’t take it anymore. It’s like, everything got out of control. I kept thinking, ‘This is not my life. This is not my life. I don’t want this to be my life.’ Then I saw the bottle of [acetominephen] lying on my bookshelf, and I just, I just, I took out all the pills. I started counting them. I counted 14 pills. And I took the whole bunch.”

Despite seemingly clear-cut differences between suicidal and non-suicidal self-injurious behaviors in terms of intent, several participants noted that different acts of self-harm could easily blur together. NSSI did little to alleviate patterns of interpersonal dynamics that contributed to emotional pain, and over time, the embodied relief initially achieved through self-injury dissipated. For example, one participant turned to cutting soon after the death of her mother. Yet, one night, after a protracted argument with her father, she went to her room and saw the knife that she used to cut:

“I thought about when I had cut myself. When I did it, it gave me a feeling of relief. It kind of like took my head away from all the problems and all the pain that I was feeling emotionally. But honestly, I did it [cut] again, and I still felt the same. I still felt sad and horrible, so I came to realize it was pointless … I just couldn’t stand living anymore”

Similarly, another participant cut for several years to alleviate emotional distress, yet that same behavior soon became a way to attempt suicide when cutting no longer provided the sought-after relief. As she explained, “At first, it was like, I guess, to relieve pain. And then after, it just became a way to kill myself.” Other participants, upon their realization that cutting was no longer providing relief, switched methods and ingested pills to attempt suicide.

Comparing the Sociocultural Context: Self-Harm and No Self-Harm

As noted above, Latina teens expressed a range of overwhelming emotions, which motivated their decisions to use NSSI and/or attempt suicide. Their narratives revealed the ways in which emotional states were ultimately rooted within broader sociocultural contexts, and participants identified several different circumstances that contributed to their decisions to engage in acts of self-harm. All participants, including those with and without histories of self-harm, reported on how they dealt with a broad range of issues, such as parental divorce, the migration of a close family member, or experiences of physical assault. Analyzing the ways in which participants reflected upon and recounted those events reveals how they differentially reacted to, interpreted, and ascribed meaning to stressors occurring in daily life. Table 3 describes the number of participants who experienced stressful life events and compares the frequency with which such circumstances were reported among those who used NSSI, attempted suicide, or had no lifetime reported history of self-harm.⁴

Table 3.

Comparing the Sociocultural Context of Self-Harmful Behaviors

	Participants who used NSSI (N=18)	Participants who attempted suicide (N=29)	Participants who used NSSI and attempted suicide (N=8)	Participants with no history of self-harm (N=28)	Total participants (N=83)	Example of theme in interview
	n (%)	n (%)	n (%)	n (%)	n (%)
Fragmented family	11 (61.1)	22 (75.9)	7 (87.5)	19 (67.9)	59 (71.1)	“When I was little, I was close to my father, like a little daddy’s girl. Then when I was like six, like around there, he had left.”
Family conflict	14 (77.8)	24 (82.8)	7 (87.5)	11 (39.3)	56 (67.5)	“Sometimes I try to talk to them about, like, my day. But they get, like, you know, they’ll always have something to say and we’ll get into a fight.”
Parental criticism	7 (38.9)	18 (62.1)	4 (50.0)	5 (17.9)	34 (41.0)	“I don’t really like talking to my mom about it because she’s—like she puts it down and she makes me feel worse about the problem.”
Transnational stress	3 (16.7)	14 (48.3)	3 (37.5)	2 (7.1)	22 (26.5)	“I didn’t want to be here, but only to go to [country of origin]. I thought, ‘Better to die than be here in the U.S.’”
Bullying	7 (38.9)	2 (6.9)	3 (37.5)	10 (35.7)	22 (26.5)	“This girl at school, she decided that she doesn’t like me cause she doesn’t like my attitude, something like that. So she was getting this group of girls together to jump me or whatever.”
Physical abuse	3 (16.7)	11 (37.9)	2 (25.0)	5 (17.9)	21 (25.3)	“Like since I was little, if I broke a page out of my notebook, or if I didn’t pick up my toys after I played, he would just like come up and beat me.”
Academic challenges	2 (11.1)	7 (24.1)	1(12.5)	4 (14.3)	14 (16.9)	“There was a lot of projects due in school, all the pressure in school. And I didn’t want to go to school ever. So I started thinking why should I live, live anymore?”
Sexual abuse	3 (16.7)	5 (17.2)	0 (0.0)	1 (3.6)	9 (10.8)	“There’s still times that I do think about what happened, and I ask myself, like was that my fault?”
Domestic violence	0 (0.0)	5 (17.9)	2 (25.0)	3 (10.7)	10 (12.0)	“My mom and dad had a fistfight. He punched her, like eight times in a row. And I got so scared.”

Notes: Participants could have expressed more than one sub-theme.

Fragmented family structure

Fragmented family structure emerged as the most frequent theme across all participant groups, and girls reflected on the various family losses incurred by parental divorce or separation, death, or migration. Those girls who experienced NSSI and/or attempted suicide perceived a family member’s absence as salient to their decisions to engage in acts of self-harm. For example, one Latina explained,

“I felt real alone, like there’s no reason of me being here… I lost my mother. I thought at that point [of my suicide attempt] that I had lost my father because me and him were at the point where we would not even talk to each other. We would walk right by each other like if either didn’t exist. So I was like, wow, my whole life came down on me. I just, I couldn’t stand living anymore.”

In contrast, adolescents with no history of self-harm responded to family fragmentation in more pragmatic ways by focusing on the strength of ties with others. For example, one girl explained, “I just think you have to… like, find people who are gonna help you. They are gonna help you get out of what you are going through, or at least help you through it.” Thus, supportive interpersonal ties fostered individual resilience, which could help soothe emotional suffering that resulted from many of the challenging life circumstances discussed below.

Family conflict

The expression of family conflict as a theme was most frequent among girls with histories of both NSSI and an attempted suicide (87.5%), followed by girls who attempted suicide (82.8%), used NSSI (77.8%), and had no history of self-harm (39.3%). One teen explained that just prior to using NSSI, she argued with her mother about her “freedom.” As she explained, “[My mom] gives me freedom, but not the freedom that I want, like, to go hang out with my friends, and like do what every other kid does as a teenager—have fun.” When these arguments became particularly “intense,” she would go to her room and cut her arm with a knife. This case illustrates a common pattern that was found among participants who engaged in acts with self-harm. Conflicts with parents frequently centered on different perspectives regarding autonomy, and these conflicts were interpreted by many teens as symbolizing a cultural or generational divide that could make it difficult for parents and children to connect.

Among girls with no history of self-harm, participants were either less likely to describe their relationships in terms of conflict, or they expressed an empathetic awareness of factors that contributed to less-than-optimal dynamics. As one teen noted, “I actually understand why my mother gets angry, you know, ’cause…if I’m not supposed to be doing something and I disobey her, she’s gonna get angry.” Ultimately, adolescents without self-harm were particularly cognizant of and empathetic toward social and economic stressors facing their parents.

Parental Criticism

The presence of parental criticism as a theme in interviews was highest among girls who attempted suicide. As one participant who attempted suicide reflected, “It’s about, like how I dress. No, not how I dress, like how I do things. I’m sloppy. Like how I do my hair. I’m not accepted. Like she doesn’t accept me for who I am. And that she’s very negative towards me.” Expressions of criticism ranged from negative parental judgment about appearance or behavior to verbal assaults, and participants explained that parental criticism often led to feelings of worthlessness and alienation. For example, one girl who attempted suicide noted that her father would frequently curse at her without provocation. As she recounted, “My father would say, ‘You are going to turn out to be a bitch just like your mother. You won’t have any shame.’ I would be like, ‘How can you say these things to me if I am your daughter?’” In response to such verbal onslaughts, the teen went to the bathroom, grabbed a bottle of pills, and overdosed.

Parental criticism, although less frequent among girls with no history of self-harm, held the potential to induce emotional suffering. As one teen explained, “It’s like I don’t fit in. I think [my mom] doesn’t really love me.” Parental criticism, in all its forms, destabilized bonds of kinship and left teens feeling like outsiders in their own families.

Transnational stress

Girls who attempted suicide were more likely to report transnational stress than participants in other sub-groups. Transnational stress referenced the explicit and communicated desire by participants to return to their country of origin as a result of the stress produced by their daily life in the U.S. Participants described emotional trauma experienced by leaving behind those family members who were charged with raising the girls during their parents’ migration. Upon family reunification with birth parents, girls felt that they were strangers in their home. As one participant noted, “I didn’t know my family and they didn’t know me.” The perception that one was living among strangers, both in the home and community, could further exacerbate the emotional strain incurred by coming to the U.S. One teen who attempted suicide noted:

“When you are in your country, you feel at home. You feel good. You feel that you are independent. When you come to a country where there are different people, you feel strange. You feel like you can’t move. Because of this, I, I think it is better to stay in one place.”

As this participant references, any social encounter held the potential to trigger feelings of difference, alienation, and marginalization. Girls who articulated transnational stress echoed this sentiment, and participants directly attributed transnational stress as a factor that shaped decisions to attempt suicide. As the quote in Table 3 highlights, participants perceived death to be a “better” alternative to a lonely existence in the U.S.

Bullying

Approximately 25% of participants in our sample described experiences of bullying and victimization by peers, but it was least common among girls who attempted suicide. Bullying took many forms, ranging from verbal teasing to ethnic and racial discrimination or threats of violence. Girls who used NSSI reported feeling extreme and immediate anger after being teased or threatened by classmates. For example, one teen remarked, “My whole class and some seventh-graders kept making fun of me cause of my age and my weight, and I told them to stop it and they wouldn’t. I got mad so I went to the bathroom, started crying, and I cut myself.” Sometimes, victimization by peers would escalate to threats or experiences of violence. As noted by one teen who cut, “The last time I cut myself was Friday, cause for no apparent reason, this girl at school, she decided that she doesn’t like me cause she doesn’t like my attitude, something like that. So she was getting this group of girls together to jump me or whatever.”

In contrast, girls with no history of self-harm were less likely to narrate their emotional responses to bullying as immediate and overwhelming. Instead, they emphasized the advice or support they received from parents. As one participant explained, “They always make fun of me because of the sneakers I wear. They have real uptowns, I have a fake. They hate a lot on me. But every time, I tell my mom, and my mom goes up to the school.”

Experiences of Violence

Some adolescents reported experiences of violence in the home, including episodes of physical abuse, sexual abuse, and witnessing domestic violence. Teens who reported a suicide attempt, with or without NSSI, were most likely to recount these experiences and attribute such experiences to feelings of loneliness. The enormity of experiences of violence led the girls to conclude that they were alone for two reasons: (a) no one would be able to understand what they were undergoing, or (b) they did not want to burden someone by discussing their problems because that person was also a victim of violence. For example, one 16 year-old described the everyday terror of witnessing the domestic violence between her mother and stepfather. She dreaded coming home from school every day:

“My body could be in school but my, my mind is in my house thinking, ‘what if one day I come from school, go to my house, and see my mother on the floor?’ I can’t really tell my mother. So, for me, I just get crazy [with] all this stuff that is going on. I keep it to myself. So they build up until I can’t take anymore.”

In contrast, girls who used NSSI or had no lifetime history of self-harm were more likely to turn to those family members they identified as supportive to help soothe distress brought on by experiences of violence. For example, one teen explained that although she often cut following arguments with her mother about curfew, she turned to her mother for emotional support after her father molested her sexually. As she remembers the event, “My mom was shocked at first. And she, she told me that she was glad I told her.” Her mother ultimately filed charges, and the girl explained that together, “we’ve been getting over it.”

Similarly, one participant with no history of self-harm described being raped by a stranger while she was walking home one evening. She recalled that as soon as she walked in the door after the assault, her mother knew something was wrong. Afterwards, she described going through a period of aggression and engaging in physical acts against peers at school, but with the help of her mother, she was able to heal and move forward:

“My mom taught me, you know, “you gotta sit down, you gotta really speak no matter how angry or how bad it is. You always come to us and tell us.’ You know, your best friends in the world is your parents. ‘Cause they will never turn their back on you, never.”

Academic challenges

Experiences of academic challenges, although discussed with less frequency among participants, were described as taking a significant toll on their emotional well-being. School and parental pressures to augment scholastic performance shaped intense feelings of stress. For example, one adolescent recounted, “School was getting on my nerves. I was really stressed and I decided I would do a cut every day.” As this participant’s account illustrates, decisions to use NSSI stemmed from a need to control stressed affective states produced by school difficulties.

Latinas who attempted suicide were more likely to interpret academic shortcomings as evidence of their perceived worthlessness. As one teen recounted at the time right before her attempt, “I remember that I was thinking to try to kill myself so I wouldn’t have to go to school. I wouldn’t have to explain to people why, why my grades were bad. I wouldn’t have to be perfect.” Negative evaluations of self-worth and perceived comparison to and by others were central to this participant’s decision to attempt suicide. For this reason, young adolescents sometimes reported academic challenges as the most distressful event incurred in their daily lives.

Discussion

In this paper, we used an ecodevelopmental approach to compare and situate decisions to engage or not engage in different acts of self-harm (NSSI and/or attempted suicide) within the micro-contexts of everyday life, revealing how Latina teens coped with multifaceted emotions and experiences. Most teens identified specific, and often multiple, situations that induced powerful affective states and shaped decisions to inflict self-harm. In our analysis, a primary theme distinguishing NSSI and a suicide attempt was the emotional response to difficult life circumstances, and girls who used NSSI were more likely to identify anger as a predominant emotion.⁵ Adolescents who engaged in NSSI perceived their negative feelings as something that could be controlled through injurious acts upon their bodies, and they employed NSSI as a mechanism for emotional regulation. In contrast, adolescents who attempted suicide perceived isolation as a symbol of their everyday life – this loneliness could not be mitigated, only ended. However, such distinctions could easily become blurred, as evidenced in our analysis of interviews with girls who used NSSI and attempted suicide. When NSSI ceased to function as a mechanism for controlling intense emotions, girls came to sudden decisions to attempt suicide.

The American Psychiatric Association (2013) has encouraged research that examines NSSI and attempted suicide as discrete behaviors, and to some extent, our results support the extant literature that distinguishes NSSI and suicidal behavior in terms of intent. Yet, our study also points to ways in which intent occupies an uncertain position in the narratives of Latina teens who self-harm, suggesting a greater potential for ambiguity.⁶ Several participants (n = 18) were excluded from analysis because they were unclear about their intentions at the time the act of self-harm took place. Moreover, there was a distinct theme of chaos in the narratives of girls who self-harmed compared to their peers with no history of self-harm despite that the interview guide explored topics of conflict, stress, and trauma across all participants. Although girls who used NSSI tried to gain some semblance of control over the chaos, teens who attempted suicide felt entirely unable to enact control. Yet, the boundaries between the controllable and incontrollable were not clear-cut, suggesting a more complicated relationship between the two behaviors. This is of particular concern given the potential for NSSI to shape decisions to attempt suicide (Klonsky, May, & Glenn, 2013).

Given the diverse, and sometimes, conflicting meanings surrounding the notion of “intent” (Chandler, 2014); broadening clinical definitions of intent to include an analysis of the communicative aspects of self-harm could be a productive arena for research and practice. Situating an adolescent within a broader context provides for an analysis of those events and experiences that preclude easy classification, and there are important sociocultural elements to consider when contextualizing Latinas’ acts of self-harm—and all acts of self-harm—that go beyond a focus on intent to die or emotional regulation. For example, Latina adolescents living in the U.S. must continually navigate multiple, and often competing, ecodevelopmental contexts that position them between childhood and adulthood, country of origin and country of destination, family and peer, and Latino and “American.” Many Latina teens, regardless of their lifetime history of suicidal or non-suicidal self-injurious behaviors, discuss the salience of these multiple contexts as contributing to a sense of cultural fragmentation in their lives (Zayas, 2011).

In this paper, the decision to engage (or not to engage) in self-harmful behaviors reflects the psychosocial processing of cultural fragmentation. Our analysis suggests that Latina teens with no history of self-harm are able to normalize, and thus stabilize, this fragmentation, often with the help of those in their social networks. For those girls who used NSSI, cutting provided an avenue to control the chaotic emotions produced by fragmentation. When NSSI no longer enabled control, some participants turned to suicide. Among suicide attempters with and without histories of NSSI, their perceived inability to bridge their chaotic and fragmented world led to desires for self-destruction. It might be that intent is ambiguous because adolescents feel uncertain about their place in the world due to the competing and contradictory messages they receive about who they are and who they should be. We offer this interpretation as a potential avenue for future investigation, particularly among minority populations.

In our study, there was considerable heterogeneity in the events, process, and experiences that lead to various kinds of emotional suffering described by participants. Across groups, themes related to family relational problems figured prominently, although suicide attempters with and without histories of NSSI reported a greater frequency of exposure to stressful family and life events. These findings are consistent with research on self-harmful behaviors in other racial and ethnic groups (Andover et al., 2012). For example, family relational problems have been shown to be directly related to the onset of both NSSI and attempted suicide (Adrian, Zeman, Erdley, Lisa, & Sim, 2011; Brent & Mann, 2003; Bridge, Goldstein, & Brent, 2006). Moreover, several studies have found that adolescents with a history of attempted suicide report more stressful life events that adolescents who use NSSI (Andover et al., 2012; Baetens et al., 2011; Muehlenkamp & Gutierrez, 2004; Wong et al., 2007).

However, two themes, transnational stress and bullying, emerged as particularly salient and promising for subsequent studies on self-harmful behaviors because they point to the distinct concerns and struggles faced by adolescent Latinas. Transnational stress was a prominent theme among teens who attempted suicide, but it is important to note that the frequency with which this theme surfaced in interviews reflects differences in the overall sample population. Only 48.3% of the participants who attempted suicide were U.S. born, compared to 89% of girls who used NSSI, 75% of the girls who used NSSI and attempted suicide, and 75% of girls with no history of self-harmful behaviors.⁷ Some research has suggested that the risk for attempted suicide among immigrant groups is due to the experience of a combination of stressors, such as dislocated systems of social support, socioeconomic strain, and discrimination (Hovey, 2000). In this sense, an attempted suicide among immigrant groups might represent an extreme form of “culture shock” (Cho & Haslam, 2010). Future research should consider the ways in which experiences of immigration produce different stressful events and give rise to different psychosocial responses that might shape decisions to attempt suicide.

Although girls who attempted suicide, both with and without histories of NSSI, reported adverse factors in their sociocultural context with greater frequency than other participants, the theme “bullying” did not follow this overall pattern. Girls who used NSSI were more likely to recount experiences of bullying than participants who attempted suicide. But unlike their peers with no history of self-harm, they rarely reported such events to their parents. To date, the extant scholarship on the relationship between peer victimization and suicidal and non-suicidal self-injurious behaviors reports mixed findings (Heilbron & Prinstein, 2010). Our study indicates the continued need to explore this relationship and investigate the various factors that contribute to and protect youth from engaging in NSSI following experiences of bullying, especially as related to perceived systems of social support.

Limitations

Caution should be utilized when generalizing our results for several reasons. This study was designed to be exploratory, but the use of a deductive coding framework that emphasized the sociocultural context precluded the identification of other factors that might distinguish reasons for engaging in self-harmful behaviors among Latina adolescents. Moreover, the qualitative interview was not designed to explore lifetime history of suicidal and non-suicidal self-injurious behaviors even though several participants noted that they had engaged in acts of self-harm more than once. Furthermore, we did not analyze interviews with adolescents who were unsure of their intent. Continued and confirmatory research is needed to examine similarities, differences, and links between NSSI and attempted suicide, especially in ways that take into account the heterogeneity of Latina populations (e.g., place of birth; Hispanic sub-group) and the ambiguity of intent.

There is also the potential for self-selection bias because this study used a purposive sampling design. Participants were aware of the purpose of the study, and they might have been more likely to volunteer for participation because they were eager to discuss their own experiences. Despite these limitations, this exploratory study provides important insights that can be applied toward the development of strategies to improve prevention and treatment efforts.

Implications for Assessment, Intervention, and Practice

Our study points to several implications for assessment, intervention, and practice. It is important to note that all participants in the study who engaged in self-harm were originally referred by mental health practitioners who assessed their behavior as suicidal. Considering the difficulties in assessing and differentiating NSSI and suicidal behaviors, we would like to highlight potential arenas for consideration among clinicians and researchers.

If we consider that self-harmful behaviors might reflect an adolescent’s relationship to her ecological environment, assessment and intervention could begin by prioritizing the meaning of the self-harmful act from her perspective. As part of an assessment, practitioners could engage patients in a kind of mini-qualitative interview to elicit the adolescent’s own explanation and viewpoint (see Groleau, Young, & Kirmayer, 2006). For example, our study indicates that it is imperative to ask adolescents what circumstances led to the production of their intense affective states. Given that control emerged as a salient theme among girls who used NSSI, eliciting teens’ perspectives on their behavior could enable a sense of empowerment in the clinical encounter. Such a discussion could indicate keys domains to explore during additional intervention protocols (i.e., dealing with parental conflict and/or peer victimization). Moreover, given that some participants attempted suicide when they perceived NSSI to no longer function, enabling participants to develop awareness of their need for control might pave the way for a dialogue around sources of personal strength and resilience.

Among Latina suicide attempters, powerlessness, loneliness, and perceptions of negative self-worth played a pivotal role in decisions to attempt suicide. Attention could be directed toward helping girls shift their personal evaluations of their self-efficacy, alongside interventions that would help them to build meaningful, relational bonds with other individuals. This is especially important among girls who have recently immigrated to the U.S. Acts of self-harm reveal how Latina adolescents differentially ascribe meanings to their experiences and struggles, uncovering the perceptions and beliefs that comprise their understanding of their social reality. It is here that we might find a productive starting ground for practice.