On the Risks of Medicalization of Adolescents Self-Injuring Acts

Although common among community adolescents, self-injuring acts are mainly studied by psychiatrists and psychologists and rarely by social work researchers. The preponderance of medical research in the field has come to associate self-injuring acts with mental issues. This view has to a large extent been adopted among professionals as well as among laypeople. When examining adolescents’ unsolicited internet published narratives, this medicalization of self-injuring acts was found to have negative consequences for disclosure and help-seeking, and hence limit the adolescents’ possibilities to get adequate help and support. The main objective of this work is to study adolescents’ views on hampering factors for help-seeking for self-injuring acts and the role of med-icalisation for their willingness for disclosure and help-seeking. Disclosure of self-injuring acts within the social network was described as met with demands to seek professional mental help. Seeking professional help was accompanied with fear of being perceived as crazy or diagnosed as mentally ill. Internet web-sites were described as value free and safe arenas giving opportunity to disclose self-injuring acts without fear of being stigmatized and labelled as mentally ill. An extended involvement of social work researchers and professionals, approaching self-injuring acts not primarily as a sign of mental problems, but as an adolescent way of trying to manage a complicated social context, could enhance finding adequate support systems. It is also necessary that the medical profession contributes to a demedicalization of self-injuring acts.


Introduction
Self-injuring acts, the intentional destruction of one's own body tissue without

Background for the Study
In a literature overview, following trends in research from the 1960's until now [13], it was shown how early clinical research on psychiatric patients came to associate self-injuring acts with intrapersonal characteristics, establishing a medical view.Numerous studies of assumed links to deviant emotionality [14] and psychopathology [15] have further reinforced this view.This preponderance of medical research on self-injury has formed a view on self-injuring acts as a medical issue [13].
The tendency in modern society to medicalize socially originated phenomena has been thoroughly studied and discussed by sociologist Peter Conrad [16] [17] [18].In his view, the key to medicalization is definition.Medicalization is a phenomenon that occurs when a problem that originates in a social context is defined in medical terms, is described by a medical vocabulary and understood through the adoption of a medical framework or treated with medical interventions [18].This must not be a problem in itself; rather it is the social response that decides whether or not medicalization is positive or negative [19].
The focus on self-injuring acts as an individual health problem and an issue for medical care and treatment has lately been problematized in The Lancet Psychiatry by Smith et al. [20].They strongly question both the need for healthcare and the ability of health service assessment to be of help for those who seek Forster, et al. 2020 [5] 39,682 33,966 14 17 16 15 USA USA Baetens, et al. 2020 [6]   651 13 14.9 Belgium Open Journal of Psychiatry clinical contact for self-injuring acts.A further reason to question the view on self-injuring acts as a health care issue is the fact that the vast majority of those who self-injure do not present in clinical contexts [21].
The medical focus in research on self-injury, and the adoption of this view among health care professionals, has come to form a view among laypeople on self-injuring acts as an issue for medical or psychological treatment.This view is reinforced by popular literature, books and films displaying those who self-injure as carrying a psychiatric disease or being emotionally deviant [22].Examining news narratives on self-injuring, Bareiss [23] shows that the dominant perspective in such narratives are that of the health professionals.Bareiss argue that this skews the perspective towards pathology of the individual and neglects problems in the adolescent's social context, such as catastrophic losses, bullying or growing up in dysfunctional families.Thus, the medical view on self-injuring as an individual problem of those who self-injure is spread among laypeople and puts the burden on the self-injurer to deal with the symptom, regardless of the social context that has caused the adolescent to turn to self-injuring [23].
As previous research has shown, support systems are often directed to treatment of emotions or psychological problems [24], but the high figures of adolescents who self-injure indicate that the majority do not suffer from individual psychological problems.Rather, the reasons for adolescents' self-injuring have been found to be closely related to a problematic social context.
The aim of the present study is twofold.Firstly, it aims to study adolescents' subjective views on what they regard as hampering factors for disclosure and help-seeking for self-injuring acts, as described in unsolicited Internet published narratives.Secondly, the aim of the discussion is to offer a critical appraisal of how the medicalization of self-injuring acts has come to influence adolescents' willingness for disclosure and help-seeking.

Material
This study forms part of a larger project where adolescents' Internet published narratives about experiences of self-injuring acts are studied.Variations of the search term I cut myself resulted in a plethora of Internet websites on self-injuring acts.Besides blogs, chat fora, information and help sites, a few websites with unsolicited first person narratives on experiences of self-injuring acts were found.These websites are publicly available with no requirement for membership or password.Moreover, these websites are not intended for interaction and holds no possibility to contact the narrators.Three of these sites, together containing approximately 3000 narratives, were chosen for the project.
In an earlier study, the narratives were studied in order to find descriptions of the social context surrounding the start of self-injuring acts.After thoroughly examining more than a quarter of the narratives, 500 narratives describing the start of self-injuring acts were found.The remaining narratives were read, and Open Journal of Psychiatry no further explicitly new or contradictive information was found.The vast majority of the narrators described a problematic social context characterized by instability, transitions and disruptions at the start of their self-injuring acts, indicating adolescents' self-injuring acts to be substantially related to interpersonal issues in their social context [25] in Table 2.
In reading the narratives, it was noted that a large amount of the narrators expressed thoughts on disclosure and help-seeking.For the present study, the 500 narratives were once again examined, with the aim to find such descriptions.

Analysis
The analysis of the narratives is inspired by interpretative phenomenological analysis (IPA), following guidelines formulated by Smith, Flowers and Larkin et al. [26].IPA focuses on thorough investigation of human lived experience and aims to conduct the investigation so that those experiences are articulated in Total Open Journal of Psychiatry their own terms, rather than according to pre-set categories or themes [26].
Given the flexibility and variation of available routes, it may be more appropriate to understand IPA as a perspective from which to approach the analysis than as a distinct method [27].
Besides trying to get as close as possible to the participants' descriptions and views, a second aim of IPA is to situate these descriptions in a social context.
The analysis was carried out on a narrative-by-narrative basis, following the guidelines outlined by Smith et al. [26].The first step was to familiarize with the material through reading and re-reading the narratives several times.Secondly, all passages expressing thoughts on disclosure and help-seeking were noted.To make the large material more manageable and transparent, those passages were assembled in a separate file and clustered according to the themes disclosure and help-seeking respectively.This process made it possible to identify recurrent accounts and capture common patterns in the narratives.
The narratives were further examined in order to relate the descriptions to the wider social context.At this point, given that fear of stigmatization has been found to act as a barrier to disclosure and help-seeking [10] [11], the concept of stigma was brought into the analysis, and the narratives were re-organized according to self-stigma and social stigma respectively.In the analysis of these two categories, a special form of social stigma, courtesy stigma, was found.The discussion deals with these forms of stigma and demonstrates how fear of stigmatization is related to the medicalization of self-injuring acts among laypeople as well as among professionals.

Ethics
As digital communication is part of many adolescents' everyday life, an Internet based study was considered to be the best available alternative to reach the otherwise mainly invisible group of adolescents who self-injure.Researching digital material raises somewhat other ethical issues than research based on physical encounters.A first concern is whether Internet published material should be assessed as public or private.This is thoroughly discussed among internet researchers.
The accessed web-sites do not demand membership or password.The narratives in this study, even though publicly available, consist of sensitive information that could be characterized as very private.However, one can assume that the narrators expect others to read their stories and want to share the content, thus being aware of their stories as publicly available and not expecting privacy.
Similar arguments concerning public and private has been put forward by leading Internet researchers (e.g., [28] [29] [30]).In the present study, it was assessed that the importance of making the voices of those who self-injure heard justifies the usage of their narratives for research.
Internet research without interaction does not need approval by a Resesarch ethics committee according to the Swedish law on research ethics.The Swedish Open Journal of Psychiatry Research Council has emphasized the responsibility of the researcher to thoroughly reflect on the relation between risks and benefits for the researched group.According to the Council it would be almost unethical to exclude research on factors that may come to improve peoples' health and living conditions and eliminate existing prejudices.

Results
How could the reluctance to disclose self-injuring acts and seek help be understood?In order to shed light on this question, typical quotes from the researched narratives are displayed.An overall view is that the narrators' reluctance to disclose and seek help is strongly influenced by the perception that they would run the risk to be interpreted and defined as deviant or mentally ill, if they did.
The findings are structured around disclosure and help-seeking respectively.The narrators most often describe thoughts of disclosure in relation to their close social network, friends and family, while thoughts on help-seeking most often are associated with a professional contact.There is however no clear demarcation between those two themes.As the narrators in this study are young, between 12 and 18 years of age, the findings must be viewed in relation to an adolescent context in which dependency on adults for provision of care, support and guidance is essential.

Thoughts on Disclosure
The narratives in this study often follow a similar pattern; some personal information, a description of the social context at the start of self-injuring, motives for continuation and thoughts on disclosure and help-seeking.A considerable part of the narrators describes the non-disclosure of their self-injuring acts as related to fear of negative consequences, demonstrating knowledge of the common association of self-injuring acts with deviance and psychiatric disorders.Thoughts on disclosure of self-injuring acts are accordingly found to be accompanied with fear of being defined as carrying a mental illness, which the narrators perceive as incorrect.
Everyone labels self-injurers as crazy freaks and borderline.I am not a freak and I am not crazy.I do everything I can to hide it so that no one will pay attention to the scars or to me.I am certainly no borderline and I don't want to go to a mental hospital.This quote displays the dominance of the medical interpretation of self-injuring acts in society; that those who self-injure are in need of psychiatric care, and that this view is established among laypeople in society.The narrator displays resistance towards being categorized and defined as deviant or mentally ill.Hiding the self-injuring acts is therefore perceived as important.There are also expressions of fear that disclosing self-injuring acts could lead to getting an attached label, difficult to eradicate, that conceals or overshadows other aspects of the person.Open Journal of Psychiatry Self-injuring is just a small part of me.It doesn't define me.It shouldn't define anyone.I don't want to forever be defined as a mental cutter.
A central and recurring theme in the narratives is not only assumptions of negative consequences of disclosure for oneself, but also reflections of assumed negative consequences for others, especially family members.A decision not to disclose is often framed in care and respect for the feelings of family members.
The notion of self-injuring acts as related to mental illness is described as having a hampering effect for disclosure.
I would like to tell my mom, but I couldn't.Telling her would ruin her picture of our perfect family life and it would totally destroy her.She would hate having raised a freak, it would make her so ashamed in front of her perfect friends.
I have been thinking of telling my dad, because we are really close.But I think it would frighten him and make him very upset.I think he would feel as he has failed to do a proper job if he knew one of his kids were that mental.
Narratives like these show the narrators are aware of the dominant societal perspective on those who self-injure.The assumption that others would associate self-injuring acts with psychopathology is visible and clearly articulated.
The narrators seem to wish to spare their families from the shame of having a child that is seen as mentally disturbed.

Experiences of Disclosure
There are also narratives of reactions on disclosure, both voluntary and non-voluntary disclosure.Being discovered appears to be more common than voluntary disclosure.Being discovered or voluntarily disclosing self-injuring acts is most often described as a negative experience, causing reactions that the narrators find inadequate and unhelpful.I thought telling my parents would help, that they would talk to me and help me.But all that happened was that my mother said I must stop and I was grounded, and then we never talked about it again.
The discovery is repeatedly described as causing a turbulent situation, which the adolescent sometimes handles by convincing the adults that self-injuring has been terminated.It is notable that very few of the narrators describe being understood.Instead, they describe how the disclosure of self-injuring acts is received as unwanted information, or perceived as a problem too complicated to be handled within the family, thus requiring professional care and treatment.
A teacher noticed my scars and told my mum.I don't really know how it happened, but suddenly I found myself in an institution with other crazy people.I was there for a week, had some therapy and then was free.This was the worst thing that ever happened to me because when I came back to Open Journal of Psychiatry school everyone knew that I had been in a mental hospital.So they started to tease me, calling me freak, crazy, lunatic, insane and all things like that.This is an example of how not only adults, but also adolescents are affected by the medical view associating self-injury with mental illness or a form of deviance.Narratives like this show that the dominant explanation of self-injuring as related to psychopathology is adopted even among the young.

Thoughts on Seeking Help
Thoughts on help-seeking are often accompanied with expectations that self-injuring acts are too complicated to be understood by those who lack own experience.Some of the narrators express that websites containing personal stories on experiences of self-injuring should be valuable for educating therapists and others who want to be of help.
I know that I need help but I also know that people need to understand more and that's why I'm posting this, because in my opinion not even the best therapist in the world can completely understand what we who self-injure think or feel.I know no therapist will ever read my story, but I wish therapists would read all stories on this site.It would help them to understand, and it would help us to get help.This perception of lack of knowledge and understanding is reflected in numerous narratives.The narratives of the few who describe experience of ending self-injuring often offer advice on possible ways to stop self-injuring.Some narrators tell they read the stories of others with a hope of finding some kind of help or relief, but seeking support and comfort in other's narratives is not always directed towards getting help to stop.The purpose can also be to feel less alone, and a confirmation of not being crazy or weird.
Seeking professional help is often surrounded by an assumption of having to reveal private and innermost thoughts and emotions.This is often perceived as awkward and several narrators express that they feel uncomfortable speaking about personal issues with an unknown person.
I don't want to reveal my innermost thoughts to someone that expects me to hand my emotions on a silver platter.I am sure they will force me to speak about emotions as they see me as one of those emotional teens.Maybe I am emotional, but all of you who have read my story know why I feel so sad.I don't think therapists would care about my problems at home, they will probably only dig into my emotions.
Narratives like this reflect the narrators' awareness of the common view on self-injuring acts as an emotional issue, and fear that emotions, not the situation that has led to the self-injury, would be in focus in professional help.Emotions are certainly involved in self-injuring acts, but in the narrators' stories it is notable that those emotions are described as directly related to the adolescent's social situation.To be understandable, emotions must be related to the situation that has evoked those emotions.

Experiences of Seeking Help
Assumed insufficient knowledge on the part of the professionals is described as a hindrance to seek professional help.In the material for this study, only a few of the narrators describe having or having had clinical or other professional contact.In several narratives though, there are descriptions of experiences of professional care among friends, as exemplified below.
I have a friend who self-harm, she was sent to a nuthouse.I don't want to be locked into a nuthouse, I mean I am not crazy or schizophrenic or borderline or something like that-I just cut myself to be able to live.And my friend started to cut again when she was released.
Narratives like these point to an assumed inadequateness in professional care that is perceived as verified by friends who have experienced professional care without getting help.This quote also reflects fear of being referred to mental care, which is expected to put more burdens on the one who self-injures, as clinical contact is associated with receiving a psychiatric diagnosis.The narrator's statement "I just cut myself to be able to live" reflects the often described experience of those who self-injure that self-injuring acts have been proven to be the best available remedy to endure an otherwise unbearable situation.
However, even if a regular professional contact is seldom described in the narratives, experiences of attempts to seek professional care are present.Being very young of age, typical sources for expected available help are school nurses, school counsellors and Internet helplines.I want to stop cutting myself but I need help do that, and when I tried to get help from the counsellor at school she almost panicked.She said I must stop immediately and I must tell my parents and I must talk to a psychologist and I must go to the hospital-my God she really flipped out!This quote is an example of descriptions of how disclosure of self-injury often evokes strong feelings.The reaction of the counsellor seems to reflect a feeling of being both responsible and powerless, related to the common view on self-injuring as too difficult to be handled by non-medical professionals, and an issue for medical interventions.
The few who refer to a regular mental health contact often describe that these encounters are characterized by conflicts on the interpretation of the self-injuring acts.Being subjected to mental health care has sometimes had negative consequences as the help has not been directed to the main reasons for the self-injuring acts.
My therapist said my cutting was all about dealing with emotions.I know it is something else.Even if I tried the best I could to explain and make her understand that cutting is something I do to put up with the chaos in my family life, she refused to understand and continued to talk about my emotions.
This quote, like several others, demonstrates a resistance on the part of the therapist to focus on what the adolescent found needed to be addressed; the social situation that is handled by self-injury.In this case, the therapist acts within the borders of the dominant paradigm, defining self-injuring acts as an individual problem primarily related to emotions, disregarding the narrator's own descriptions and efforts to explain the reasons for the self-injuring.As the narrator emphasizes the social context as the main problem, it might have been more fruitful for the therapist to follow the narrator and respect her point of view.

Discussion
The notion of adolescents' self-injury as a hidden phenomenon and the repeated observation that only a minority of those who self-injure have clinical contact is confirmed by the narratives in this study.Medical professionals only meet with a minority of those who self-injure, and medical research on self-injury is predominantly focused on intrapersonal characteristics, emotional deviation and psychopathology.Therefore, there is a risk of skewing the knowledge towards an individual pathology when relying on medical professionals as the primary source of information on self-injuring.Furthermore, even the relevance of medical and psychological assessment and treatment for those who present clinically has been challenged [20].
The main goal of this study is to increase the knowledge of the many adolescents who secretly self-injure, neither disclosing nor seeking help.In the narratives, the main obstacle hindering disclosure and help-seeking is described as a fear of being perceived as deviant, weird, crazy, mentally ill or as one of those "emotional teens", thus implying a fear of stigmatization which is clearly related to the medicalization of self-injuring acts.
Even though medical research has been shown to be formative in the medicalization of self-injuring [13], medicalization can be understood as a collective action with the medical profession and laypeople as active collaborators in the medicalization of a social phenomenon [18].When a certain view on a phenomenon or a group of people is established, it runs the risk to create an oversimplified and stereotyped view.Once a stereotype is in place, it might be resistant to changes or alternative views [31].Developing Goffman's theory of stigma, Link and Phelan conceptualize stigma as present when a number of different components co-occur [31].The first component is about labelling human differences, while the second component links labelled persons to undesirable characteristics and to negative stereotypes.A third component is about "us and them", as those labelled are placed in a category that separates them from others.Fourthly, the labelling process has consequences with respect to numerous situations in life and holds aspects of status Open Journal of Psychiatry loss and discrimination.Finally, what matters is whose view prevails, who has the power to uphold a definition and form people's conceptions of a group who has been labelled as different [31].In other words; there can be no stigmatisation without the fifth component of stigma, the exercise of power [32].Thus, stigma and stigmatization is related to power situations that allow components of stigma to unfold.In this case the power and authority of the medical profession to describe and define self-injuring acts within a medical framework, using a medical vocabulary, appears central for the medicalization process and has formed a view among laypeople of self-injuring acts as a mental health issue that requires mental health services.

Medicalization as a Stigmatizing Attack on Identity
Only 19 of the narrators mentioned that their self-injuring acts had caused less self-esteem or less self-respect.This indicates that for the majority, as long as they keep their self-injuring acts private and concealed, the acts seldom influence their self-image nor create self-stigma.According to Corrigan et al. [33], self-stigma begins with stereotype agreement; endorsing the same stereotypes perceived to be common in the public.To be associated with a mental illness could constitute an attack on the identity [34], which could be devastating for an adolescent who is in a process of identity seeking and autonomy development.
The notion of mental illness as a stigmatized condition appears well-known among the narrators.The vast majority of the narrators make it very clear that they do not agree with the common view of self-injuring as related to mental health issues and refuse to internalize the stereotyped picture of a person who self-injures.This holds elements of resistance to permit self-injuring acts to become an identity mark, as expressed in the quote "self-injuring is just a small part of me.It doesn't define me.It shouldn't define anyone".

Medicalization as a Basis for Social Stigmatization
The narratives in this study demonstrate that a stereotyped medicalized view on self-injuring acts has been established in society.In a qualitative study on how adolescents talk about self-injuring acts, Klineberg et al. [35] found that very few of the study participants had experience of professional care; rather they expressed ideas of assumed consequences of seeking help.In this study, although very few of the narrators have experienced clinical contact, there are expectations that disclosure and help-seeking would result in social stigma.
Mental health services continue to be perceived by many as uncomfortable, risky and unhelpful [36].Seeking help carries with it a negative perception, which may be perceived as worse than the problem [37].In the narratives, a definite barrier for disclosure and help-seeking is the fear of receiving a psychiatric diagnosis, as this would reinforce the social stigma, risking status loss and discrimination.This is a verified fear, exemplified by the narrator who faced being labelled as a freak and a lunatic by schoolmates when returning back to school Open Journal of Psychiatry after treatment at a mental health institution.
In the narrators' expressed fear of social stigma there are also signs of courtesy stigma.Goffman [38] defines courtesy stigma as the negative impact that results from association with a person that is marked by a stigma.The quote "she would hate having raised a freak" exemplifies how protecting the family can be an important aspect connected to thoughts on disclosure and help-seeking.Similarly, "I think he would feel as he has failed to do a proper job if he knew one of his kids were that mental" reflects concern and care for the well-being of the family.
Narratives about protecting the family show the social stigmatizing character of self-injuring acts, and fear of causing courtesy stigma appears to be an important aspect in keeping self-injuring acts a secret.The only place the narrators describe as a value free and safe arena is Internet web-sites where it is possible to describe and disclose self-injuring acts without risking social stigma.

Towards a Demedicalized View
Medicalization directs the gaze on the individual, and reinforces individualized approaches to social problems [18].Searching for individual characteristics, using a medical vocabulary and recommending treatment by mental health professionals threatens to conceal the context surrounding self-injuring acts, as it tends to downplay aspects of interpersonal and structural features [39].However, medicalization is a bi-directional process, and as such a social phenomenon can be both medicalized and demedicalized.
Demedicalization occurs when a phenomenon is no longer defined in medical terms and medical treatment is no longer considered as the primary solution [16].For demedicalization to occur, it most often demands that people directly involved in the problem takes action [18].However, adolescent self-injurers do not have the power to alter the medical view.This is clearly demonstrated in the quote at the end of the findings section, where the narrator tries to explain the basis for her self-injuring to the therapist, while the therapist continues to talk about emotions.The interaction between the therapist and the narrator seems to be characterized by a contest on the preferential right on interpretation-a conflict that has also been documented in other research [40].
Emotions involved in self-injuring acts most often originate in a problematic social context [25].Focusing primarily on emotions tends to conceal a problematic social situation [20].In an interview study on how adolescents recruited from a mental health service organization talk about their self-injuring, Hill and Dallos [41] found that the adolescents seemed to be repeating explanations they had heard from health professionals, which might explain why they were more able to talk about their self-injury than the difficulties behind it.This indicates a need for extended research on unsolicited narratives where young people are free to articulate their motives without being restricted to pre-set questions in interviews or surveys.It also stresses the need to reach adolescents outside of clinical settings, in order to gain knowledge about how to support those who Open Journal of Psychiatry self-injure as a reaction to a problematic life situation, thus stimulating the development of other perspectives.
A demedicalized approach to self-injuring acts has been outlined by social science researchers, arguing that the medicalized view formed by research on clinical populations bears limited relevance for the wider community population (e.g., [13] [42] [43] [44]).In order to gain an understanding of adolescents' own view on self-injuring acts, without predetermined assumptions, the first step in approaching adolescents who self-injure should be asking "what has happened to you?" [20].Questions like this can unfold the situation that has led to the acts and direct the gaze towards the social context.Smith et al. [20] argue that health systems that support people presenting with self-injuring acts are particularly at risk of providing maladaptive responses, if the focus is primarily on identifying signs of psychopathology instead of asking for social factors and other problematic situations.Framing adolescents' self-injuring acts as a response to pressure and stressful events, rather than as related to individual psychopathology or deviance, should increase the understanding of self-injury and promote a demedicalized view, consequently opening for other supporting systems.This in turn may promote the willingness for disclosure and help-seeking among adolescents trapped in situations they find unbearable, which they at present handle by self-injury.
We have a new school social worker and I can tell her everything.About problems at home, having no real friends, no one wanting to work with me in group works at school and always being the last one to be chosen for teams at sports lessons.We don't talk about me self-injuring, even though she knows about it.That feels good and I always feel a little bit better after talking to her.I think she has spoken to the sports teacher because now it is always he who divides into teams in the sports lessons.We are also going to meet with my mother some time.I think it will be good, I feel there is hope for me.

Strengths and Limitations
A strength of the study is that it is based on many first person account by those who have experience of self-juring acts.Some of the narratives might have been inspired and affected by other narratives on the web-sites, so the narators could have been influenced by other stories on the web-sites.This study probably also illustrates the youth culture in the western culture.So the selection procedure might screw the narratives.A dilemma is also the lack of a possibility to ask follow-up questions to get clarifications or confirmations on re-issue?

Conclusions and Implications for Practice and Research
The very magnitude of community adolescents who self-injure, with a prevalence of up to 35% [1] [4] contradicts the notion of self-injuring acts as related to character traits that should qualify for mental health services.The findings in this study indicate that the present medicalization of self-injuring acts has negative consequences for disclosure and help-seeking among adolescents.Likewise, medicalization was found to have negative consequences for parents' confidence in their own ability to be of help and support, shown by their described readiness to suggest psychological and psychiatric treatment.
The medicalization also has implications for social work professionals encountering adolescents in their everyday work.As shown in the quote describing the reaction of a school counsellor, the association of self-injuring acts with mental issues may hamper non-medical professionals to identify or recognize the social context of self-injuring acts.
To alter the medical view on self-injuring acts, initiating a demedicalization process, social work professionals and researchers are important actors.Social work professionals are well educated in handling an abundance of adolescent issues and concerns.Referring adolescents who self-injure to psychological or psychiatric instances could therefore be regarded as a devaluation of the competence of the social work profession.Confidence in being listened to, trusted and nonjudgmentally encountered by, for example, a school social worker, might enhance adolescents' willingness for disclosure and help-seeking.Similarly, focusing on what is happening in the adolescents' social context could increase the possibility to be of support.Such a demedicalized approach by social work professionals might encourage adolescents' openness on self-injuring acts, mitigate their fear of stigmatization and facilitate getting help and support.
Using the Internet as a source of information was found to be valuable, as it provided access to adolescents' unsolicited voices on disclosure and help-seeking.Social work research has the possibility to affect and alter the medical view by endorsing self-injuring acts as socially originated.Respecting and describing adolescents' own views on disclosure and help-seeking can provide new aspects on what is needed to end self-injuring acts.Even though self-injury has been found to decrease adolescents mature, and spontaneously resolve for most adolescents [45], the adolescents' narratives calls for a response from the adult community.A demedicalized perspective should increase the willingness for disclosure, and likewise the possibility to find adequate support.Social work, with its unique focus on the interaction between the individual, the social context and societal structures, should be apt to do positive interventions and contributions in the field of self-injuring acts.
As all adolescents spend many years at school intervention programs aimed at preventing and reducing self-injuring acts targeting pupils have been developed and evaluated.Two programs have been shown to reduce self-injuring acts, the Youth Aware of Mental Health Program (YAM) and Happyles [6] [46].There are also programs targeting teachers and other school personel [6].
It is also important that the medical and psychological professions contribute to a demedicalization of self-injuring acts.Psychiatrista should be careful classifying selfinjuring acts as signs of mental illness, personality disturbance or emotional instability and also be careful not to prescribe medications without care-

Table 1 .
Selected studies on the prevalence of self-injuring in adolescents.
To ensure capturing adolescents' views on disclosure and help-seeking, only narratives in which the narrator reported age at the time of posting were included.187 narratives fulfilled that criterion, and of those, 162 narrators were defined as adolescents and included in the study.These narrators were between 12 and 18 years of age.No other specified criteria were required for inclusion in the study.As the narrators are anonymous it was not possible to get more in-

Table 3 .
Reported age at the start of self-injuring acts.