Volume 11, Issue 2 (Spring 2023)                   PCP 2023, 11(2): 151-166 | Back to browse issues page

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Yekta M, Farahani M N, Khanipour H, Shahgholian M. Investigating the Effective Factors in the Formation of Deliberate Self-harm in Adolescence: Mental Health Professionals’ Viewpoints. PCP 2023; 11 (2) :151-166
URL: http://jpcp.uswr.ac.ir/article-1-833-en.html
1- Department of Psychology and Education, Faculty of Psychology and Educational Sciences, Kharazmi University, Tehran, Iran.
2- Department of Psychology and Education, Faculty of Psychology and Educational Sciences, Kharazmi University, Tehran, Iran. , mn.farahani@khu.ac.ir
3- Psychological Studies Institute of Educational, Psychological and Social Research, Kharazmi University, Tehran, Iran.
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1. Introduction
Deliberate self-harm refers to deliberate self-harm by hitting, cutting, pounding, or intentionally poisoning oneself without the intention or motive of suicide (Houghton et al., 2012). Deliberate self-harm in adolescents usually begins between the ages of 12 and 13 years (Nock, 2014). Despite the diversity in the definition of self-harming behavior, the prevalence of this behavior has been reported to range from 13% to 17% in the normal adolescent community and 50% to 60% in the clinical adolescent community in different countries (Gillies et al., 2018). Research in this area shows an increase in the frequency of self-harming behavior among adolescents in different countries (Morgan et al., 2017). Findings from research indicate that deliberate self-harm behavior is associated with mental disorders, suicide risk factors, social characteristics, negative events and life trauma, and genetic, and psychological factors (Miller et al., 2019). In a study by Solanineja et al. (2013), the prevalence of self-harming behavior in soldiers was reported in the range of 5.7% to 8.4%. In addition, Khanipour et al. (2013) stated that the risk of suicide in adolescents with a history of self-harm is higher than in normal adolescents and adolescents with depression. In another study conducted by Fakhari et al. (2007) on 1772 adolescent male students in Tabriz City, Iran, 4.3% of the subjects had self-harming behavior. Findings of studies in Iran indicate that the experience of alcohol consumption, having friends who smoke, low self-esteem, a history of trauma, and emotional dysregulation play important roles in the prevalence and occurrence of self-harming behavior (Fakhari et al., 2016; Nobakht & Negvar, 2017; Gholamzadeh et al., 2017). What is abundant in the literature is that self-harming behavior is related to pain or anger resulting from interpersonal relationships. In addition, the origin of this behavior is an interpersonal cause and stress (McAndrew & Warren, 2014) by the role of emotion-regulation defects, including defects in recognizing, changing, and modifying emotions has been mentioned as one of the main causes of deliberate self-harm (Gratz, 2003). On the other hand, family problems as well as problems with peers have been suggested as the cause of self-harming behavior; however, family and peers have been suggested as factors that can reduce behavior and support in stopping such behavior (Wadman et al., 2018). In most studies on self-harming behavior, researchers have emphasized the function of self-harming behavior as a way to control and overcome trauma and regulate individual emotions, as well as express psychopathic content (Yakeley & Barbridge, 2018). For example, McLean (1996) referred to self-harming behavior as “skin tone.” Elsewhere, Matz (2010) used “a sign of hope” and Brady (2014) used “breaking the silence” to describe their harmful behavior. In a qualitative meta-analysis conducted by reviewing 20 qualitative studies of self-harming behavior from the perspective of adolescents, this behavior was discussed as follows: 1) a way out, 2) controlling problematic emotions, 3) expressing unaccepted emotions, and 4) communication with another individual (Stänicke et al., 2018). Various theoretical models, such as evolutionary approaches, interpersonal, object relationships, functional models, emotion regulation models, self-discipline, and analytical models have been proposed to explain deliberate self-harm (Klonsky, 2007; Nock, 2014; Penn et al., 2003; Nixon et al., 2002; Hoyoc et al., 2019). Findings from the study on deliberate self-harm are mostly obtained through a questionnaire or the researcher’s default qualitative concepts. However, in Iran, few studies have been conducted on explaining deliberate self-harm in the form of self-injury without suicide (Ezakian et al., 2018; Khanipour et al., 2013; Rashidi Asl et al., 2021; Hasanvand et al, 2016; Khedmati, 2020); however, most of these studies have often evaluated the same common models of this behavior in Iranian samples and obtained findings about the status, characteristics, and role of textural, social, and cultural factors in this behavior.
The results of case studies along with qualitative and quantitative research on deliberate self-harming behavior as well as existing theoretical concepts show the phenomenon of deliberate self-harm among adolescents from the perspective of experts. Adolescence and the relationship between deliberate self-harming behavior in this period are important among adolescents with sociocultural issues and interpersonal relationships (Duarte et al., 2018; Byrne et al., 2008). For instance, some scholars in Western societies consider the spread of individualism, the compulsion to choose, freedom, a culture that constantly emphasizes growth and self-actualization, and the acquisition of borderless originality factors that are more likely to lead to self-loathing and shame. They argue that to adapt to these cultural conditions, these individuals may resort to self-controlling behaviors that can be reflected in the forms of burnout, addiction, eating disorders, and self-harm (Monell, 2021). Study findings indicate the relationship between socio-cultural factors and self-harming behavior in a way that social deprivation can affect the occurrence and persistence of self-harming behavior (Avevor, 2007; Pooling et al., 2020; Cairns et al, 2017). The new findings also support the effect of conditions caused by the outbreak of COVID-19 on increasing the prevalence of deliberate harmers behavior (Henry et al., 2021). Self-harm behavior has also been suggested and research results indicate that people with self-harming behavior are unstable and uncontrollable and need to be cared for, in addition to being encompassed by the outside world and others as they are powerless and helpless in a psychological situation. Other evidence suggests that Pakistani mental health professionals maintain that people with self-harming behavior do not have access to the healthcare system because of illegality and community labeling. Factors that cause or aggravate their behaviors include intrapersonal skills, a threat to the outside world, mental disorders, attention seeking and need for approval and acceptance, poverty and economic problems, family turmoil, emotional communication problems, and humiliation and blame by adults (Kiran et al., 2021). Findings from another qualitative study include psychological factors such as early unpleasant experiences of sexual abuse, loss of meaning and emptiness, helplessness and grief; Physical factors such as chronic pain; Social factors such as interpersonal conflicts, economic problems, insufficient external support and care, loneliness and avoidance have been cited as motivating factors for self-harm behavior (Wand et al., 2019). 
In recent years, the prevalence of self-harming behaviors has increased (Fournier & Malcher, 2017). This imposes heavy consequences on society and public health; on the other hand, these behaviors have high negative consequences for familial relationships (Fu et al., 2020). These behaviors occur in all societies, cultures, and social classes (De Olvira Costa et al., 2020) and are not limited to a specific group; however, teenagers have been particularly noticed by researchers as adolescence is a period of conflict and fluctuations between dependence and independence as well as a search for discovering and experiencing predetermined desires. Adolescence is a dream-like period in which anything can happen. In this period, anxieties, fears, nightmares, fears, crushing values, and mixing thoughts or fantasies are considered normal (Kansra et al., 2021). This is another reason for paying more attention to this age group as the prevalence of self-harming behaviors among teenagers is higher compared to other age groups (Klonsky, 2009). These behaviors are also noticeable in Iranian teenagers. For example, Marin et al (2020) showed in research that 17.9% of female students studied in the year before the research at least once and 11.1% of them had engaged in harmful behavior more than once. In this regard, Ezakian et al (2017) demonstrated in a review study entitled “investigation of the prevalence of self-injury without suicide in iranian adolescents” showed that the prevalence of self-injury without suicide among adolescents in Iran varies from 3.4% to 40.5%.
Another related national study was conducted by Mozafari et al. (2021). They showed that the prevalence of self-injurious behaviors among girls and boys was 9.6% and 7.1%, respectively. The pattern of self-injurious behaviors of girls was more invisible and irregular compared to boys. Among self-injurious behaviors, intentional wounding, intentional cutting of one’s body, performing self-destructive behaviors, and annoying self-talk had the highest frequency. Also, girls’ self-injurious behaviors were more intrapersonal compared to boys.
This evidence shows the seriousness of these problems in the Iranian adolescent population. Also, this recent study shows that examining self-injurious behaviors under the title of a uniform and general structure is not correct, and without considering the type of self-injurious behavior, the function of self-injurious behavior, and the demographic characteristics of adolescents, a comprehensive picture cannot be drawn from such behaviors.
The findings of studies on deliberate self-harm have mostly been obtained through questionnaires or presupposed qualitative concepts of the researcher (not from systematic qualitative research). Although many quantitative studies have been conducted in Iran on deliberate self-harm in the form of explaining deliberate self-harm without suicide (Ezakian et al., 2018; Khanipour et al., 2013; Rashidi Asl et al., 2019; Hassanvand et al., 2015; Khedmati, 2018); however, most of these studies have evaluated the same common models of this behavior in the Iranian sample. Meanwhile, these studies have not found any findings about the situation, characteristics, and role of contextual, social, and cultural factors of this behavior in Iranian teenagers. Most of the studies in this field have dealt with partial and scattered components, and few studies could comprehensively examine different layers and aspects related to self-injurious behaviors. Also, most of the studies are dependent on the available data that came from teenagers’ or parents’ reports and few studies have a simultaneous combination of opinions. Finally, most of the studies in this field are quantitative and in the background of paradigmatic qualitative studies and have received the least amount of attention.
The importance of causal, intervening, contextual, and strategic factors is a more accurate explanation of the formation process of deliberate self-harming behavior as well as the dynamics between the influencing factors. Also, national studies have mostly dealt with the prevalence of such behaviors and they are less related to structural factors. The few studies conducted in the country are mostly limited to quantitative methods. Therefore, the necessity of conducting this research is to provide a theoretical model, including factors that have not been mentioned in previous studies, and to examine this theoretical model.
Societal and cultural values ​​of Iran are different from other social and cultural structures and it is possible that social and cultural processes and lived experiences of deliberate self-harm in our society have differences or similarities with other societies (Khanipour et al, 1392). According to the literature, environmental factors play a role in the formation of intentional self-injurious behavior, examining the point of view of experts who deal with adolescents with this behavior to form a theoretical model and investigate the factors involved in the formation of this behavior more deeply. One of the sources that help in better understanding these differences and similarities is mental health professionals. Are their views and experiences of this phenomenon similar to those experienced in the literature and theoretical models? Accordingly, this qualitative study focuses on examining the behavior of deliberate self-harmers in adolescence through qualitative interviews from the perspective of mental health professionals who have experience working with these individuals along with adding knowledge about the important features involved in the behavior of these adolescents. The research questions were as follows: What factors are involved in the prevalence of this behavior in Iranian adolescents? According to Iranian mental health experts, what factors play a role in the formation and continuation of this behavior?

2. Materials and Methods 
Study design

This was a qualitative approach to content analysis to gain an in-depth understanding of the mindset of mental health professionals about the effective factors in forming deliberate self-harm behavior in adolescence. 
In this qualitative study, the main focus of the study was on the structures and perspectives of mental health professionals on the behavior of deliberate self-harmers among adolescents. The sample consisted of 9 mental health professionals, including 6 men and 3 women with a Mean±SD age of 42.88±5.28 years. They had experiences in the field of adolescents’ deliberate self-harm behaviors. The subjects were selected by the purposive sampling method. Sampling was done in the winter of 2020 and spring of 2021. Sampling was done via Skype. They had expertise in clinical psychology (n=3), child and adolescent psychology (n=2), and psychiatry (n=4). Their work experiences varied from 9 years to 23 years (Mean±SD 17.22±5.74 years). They worked in the cities of Isfahan, Mashhad, Tabriz, Tehran, and Yazd in Iran.
Sampling was continued until saturation was reached. The semi-structured and in-depth telephone interviews were conducted by an interviewer with a background in psychological and social work practice, along with familiarity with qualitative research interviews. All interviews were conducted online at different times because of the outbreak of COVID-19. The average time of the interviews was 75 min. The interviews began with a brief introduction of the interviewer and the purpose of the interview. The interviews continued until obtaining a rich description of the topics related to the research. In all interviews (after obtaining permission), a recording device was used to conduct the interviews. To create a friendly relationship before starting the interview, the conversations started with informal topics. In addition to the research title, the researcher, the purpose of the study, and the content of the consent form were explained. The questions were mostly the same for all participants. Nonetheless, an attempt was made to discuss and investigate some questions in case a person may have a better expertise. In the beginning, the experts who were in contact with teenagers with self-injurious behavior asked about various dimensions and main components of the formation process of intentional self-injurious behavior, causal conditions and antecedents of this process, as well as background factors and intervening factors (promoting and inhibiting) along with strategies to prevent this behavior. Then, a semi-structured interview was provided. The 4-axis guideline (Spradley, 2016) was used to compile this interview.

Data analysis
After completing each interview, the researchers implemented the recorded interviews and after reviewing and performing the desired coding, they began to determine the main categories and secondary concepts in the data. In the meantime, if necessary, the interview questions were constantly checked and modified. After conducting and coding 9 interviews, all categories of the underlying theory were formed until the codes became repetitive, i.e. theoretical saturation was created. The participants’ responses were analyzed through the content analysis method. This method emphasizes the individual and personal experience of the participant, thus creating unpredictable and predetermined ideas and opinions. Data analysis was performed in several stages according to the instructions of Sterling-Atride (2001). In the first step, the content of the interviews was read repetitively by the researcher, and the open-source code was prepared. In the second step, the resulting code became the subject. This step required rereading all the quotes, codes, and sections of the interview to get a common pattern that underlies the codes. Thematic analysis is a method for analyzing qualitative data and entails searching across a data set to identify, analyze, and report repeated patterns (Braun & Clarke 2006). It is a method for describing data and involves interpretation in the processes of selecting codes and constructing themes. Thematic synthesis has 3 stages: Line-by-line coding of the text, developing descriptive themes, and generation of analytical themes. There are various approaches to conducting thematic analysis; however, the most common form follows a 6-step process: Familiarization, coding, generating themes, reviewing themes, defining and naming themes, and writing.
In the network of themes method, there are 3 categories of code and concept, namely basic, organized, and comprehensive. By studying the full text, the most detailed codes were identified and coded as basic themes. The third step involved reviewing and combining similar basic themes and achieving organized themes. Finally, the comprehensive themes included high-level themes that cover the entire text. The themes network method is a powerful and sensitive tool for organizing and presenting qualitative analyses (Sterling-Atrid, 2001).

To ensure the study’s trustworthiness, we considered 4 criteria throughout the research: Credibility, dependability, confirmability, and transformability (Nguyen et al., 2021). To increase trustworthiness, the researchers shared the findings with participants during the data collection and analysis process to ensure that the findings were consistent with their experiences. In addition, to support the trustworthiness of the findings, we used the techniques of reviewing the findings by colleagues and long-term and continuous interaction with the data. To evaluate the validity and reliability of the data from the interviews, the obtained codes were shared with two interviewees to determine the extent to which the findings and the obtained codes are comprehensive and a complete reflection of the phenomenon of deliberate self-harm in adolescents. The external observers’ review method was also used to determine the reliability of the findings. Thus, the relevant notes were examined by two coders (Tobin & Begley, 2004).

Inclusion and exclusion criteria
The inclusion criteria were as follows: 1) Psychologist and psychiatrist with experience in working with teenagers, 2) having work experience in the field of self-injurious behavior, and 3) having at least 10 years of work experience.

Study instruments
Semi-structured interview

This interview was based on the research literature and several other qualitative studies. The outline was based on the research literature and changes were made during the interview. The interviews included the following questions:
1) What is your definition of deliberate harmful behaviors?
2) How have you seen the history of adolescents with deliberate self-harming behavior?
3) What do you know about the reason for the decrease in the age of onset of this behavior and the increase in the prevalence of this behavior among adolescents?
4) How do you see the role of family and peers?
5) Have socio-cultural factors played a role in the occurrence of this behavior?
6) What factors in today’s culture play a role in reducing or increasing this behavior?
7) What has changed the position of adolescents in the family and society compared to the past?
8) What is the difference between adolescents with deliberate self-harming behavior and other adolescents?
9) What strategies are available to prevent this behavior?
10) What factors in the family contribute to this behavior that did not exist before?
11) What is the purpose of adolescents with deliberate self-harming behavior?
3. Results
The data analysis resulted in the extraction of 86 concepts from the text of the interviews, which were classified into 32 basic, 7 organizing, and 3 global themes (Table 1).

In Figure 1 the results related to the main and organizing themes are presented. Figure 2 shows an image of basic, organizing and global themes.

Theme 1: Cultural and social themes
The first main theme and related sub-themes address the socio-cultural issues involved in adolescents’ deliberate harmful behaviors. According to experts, data analysis of harmful elements of society includes the rejection of a new identity, materialism, repression, and disintegration of social identity. According to most mental health professionals, factors related to the traumatic community play a role in the occurrence and exacerbation of self-harming behavior in adolescents. One of the factors that play a significant role in today’s society in the occurrence and prevalence of adolescent self-harm behavior is the rejection of new identities because of turmoil in society. For example, participant 2 stated, “at present, our culture is multipolar and fragmented. It is anti-dialogue and anti-tolerant; therefore, new and emerging identities are not accepted and are labeled. The special situation of our society has reached a boiling point and this issue has been exacerbated, thus it cannot be a safe space for regulating emotions. Hence, this behavior will intensify.”
Another factor that plays a role in the development of adolescents’ self-harm is materialism. For example, participant 4 stated, “the materialization of culture is another factor. In recent years, the public culture, especially adolescents, has moved toward materialism in such a way that individual defines their identity with objects and objective issues as if the identity of each person is branded as objects and based on the type of brand, its price, and the respect for it.”

Repression is another factor. Most of the interviewees believed that the repressive and discourse-free atmosphere in society and family has increased and intensified the behavior of deliberate self-harm in today’s society. Participant 2 stated that “it is a kind of socio-political action against the system of repression and self-promotion. Adolescents in this period see themselves as strangers who seek destruction more than they care about themselves and the future.”
The disintegration of social identity refers to the lack of social role of adolescents in today’s society. Participant 6 stated that “in today’s society, teenagers are somehow not seen and do not have a role. In the past decades, teenage boys had a role by working alongside their elders in their workplace, and girls by being with their mothers in daily interactions; therefore, they had an identity.”
According to experts and the experts’ analysis of data, the elements of the vulnerable family were identified as economic poverty, border duality and freedom, a lack of power, and unresolved parental conflicts. In most interviews, economic problems resulting from inflation and the economic turmoil in society, along with the materialism of adolescents’ lifestyles play a role in the occurrence of deliberate self-harm in adolescents. Also, the lack of homogeneity of adolescents and families on issues related to adolescents’ independence, such as the time of going out, number of interactions per week, style of clothing, type of friends, and so on has caused ambivalence between dichotomy and freedom, which is effective in the occurrence and severity of deliberate self-harm. On the other hand, most of the interviewees believed that, currently, most Iranian families have unresolved conflicts that lead to competing with the teenager or not understanding their feelings and inner world, as well as projecting their needs onto them. Thus, parents have lost their position of power and adolescent cannot imitate their parents as their role models and shape their identity. As a result, deliberate self-harm behavior is used as a way to express anger toward this issue. For example, participant 4 stated, “Iranian families face several new challenges, one of which is the same cultural contradictions that I mentioned, and the other is that our culture in the past had a cohesion, and the family was stable. But in individuals who were born in the 70s and 80s, these behaviors have increased significantly. For example, the age of smoking, drinking, and so on. has decreased considerably, and this is a sign that the family no longer has its function and the reference position of power is lost along with its cohesion. The child cannot follow the parents as examples.” Participant 7 stated in this regard, “in today’s society, we are faced with families where the role of parents has been lost as the position of a source of power to be a role model for their child and a guidance source for them in their path toward identification. Other parents have the same problem. They are not respected and valued because they cannot understand the needs and feelings of their teenagers and there is a big gap between them.”

Themes 2: Interpersonal effectiveness and influence
The third theme was interpersonal effectiveness. According to experts, the data analysis of interpersonal influences included border demarcation, acceptance and communication with others, and emotional feedback from others, such as shame and guilt, blame, anger, neglect, fear of harm, liberation, and loneliness.
Most experts report that one of the factors that have a significant impact on the occurrence and exacerbation of self-harm behavior in adolescents is the use of this behavior to create a border between themselves and the outside world, especially in adolescents who are in broken families without structure and borders. Accordingly, their body is a symbol of the border between themselves and the other. Participant 6 stated in this regard that “a person who has a borderline structure or border vulnerability can show that aspect in different stages of life, and also attribute self-hatred and body hatred that can be seen in adolescents. In a way, I see this as social hatred. People who are not acceptable in the family can internalize this disapproval from their parents and society in the form of self-hatred; however, at the same time, this can be a kind of protest behavior and demarcation with the society that wants a one-handed and dominant narrative of the body. As a result, injuring the body and creating a scar on the body can be the basis of this issue.”
Another factor that influences the aggravation of deliberate self-harm behavior in adolescents was peer acceptance. Adolescents need external approval to identify themselves and one of the sources of this approval is their peers. Behavioral self-harm is deliberate through sharing. For example, participant 8 stated that “usually, adolescents use different ways to gain identity and position among their peers, and since this behavior has become fashionable among adolescents, it is a way to be accepted among groups to join them.”
Experts also report the effect of other people’s emotional feedback when understanding and experiencing this behavior in adolescents and aggravating their deliberate harmful behavior. Many families as well as school principals do not have enough knowledge about how to deal with adolescents with self-harming behavior and are unable to cope with their role and contribution to this phenomenon, and subsequently, with their emotional reactions. They cause more adolescent identity breakage, thereby intensifying this behavior. Participant 5 stated that “those who know usually respond by blaming and questioning the teen and are less likely to ask why they did so or question their feelings or moods. Meanwhile, those who know and refer are usually desperate, helpless, and afraid.”

Themes 3: Developmental injuries
The third theme was related to developmental injuries. Based on the analyzed statements and findings obtained from interviews with mental health professionals, the constituent elements were considered individual self-rupture, self-communication rupture, and intra-psychological functions. According to the participants, most adolescents with deliberate self-harm behavior have experienced abuse (sexual, physical, or emotional) and this is one of the effective factors in the mental structure of this group. Interviewees reported that adolescents with deliberate self-harm behavior have low self-esteem because of their life history and the type of relationship they have with their parents as they do not have a coherent and appropriate self-image; therefore, one of the ways to create identity and cohesion and self-structured behavior is deliberate self-harm. For example, participant 9 stated that “deliberate self-harm is a manifestation of identity disorder and a manifestation of anomalous identification. Adolescents in this period see themselves as strangers who seek destruction more than they care about themselves and the future.” Participant 4 stated in this regard that “sexual abuse is very common. Adolescents do not acquire the necessary skills and are added to daily tensions, and as there is no space for acceptance, self-confidence, and self-esteem are not formed in them. The image they have of themselves is fragmented and incoherent, and if something is made, it has no depth.”
In addition to individual self-rupture, most participants considered self-communication rupture to be a factor in initiating or exacerbating their deliberate harmful behavior. Most interviewees stated that adolescents with deliberate self-harm behavior have conflict and communication problems in their relationships with both adults and peers and do not have sufficient skills to improve their relationships; therefore, one of the ways to repair this rupture in relationships is by deliberate self-harm behavior. For example, participant 8 stated in this regard that “most adolescents today do not have sufficient skills to communicate and maintain their relationships, and we see broken and borderless relationships as well as stressful ones. Failure to start or maintain a relationship repeatedly leads to excessive failure, unbearable anxiety, and anger, and one of the actions they do to eliminate these conflicts is deliberate self-harm.” Participant 6 stated that “because today’s adolescents do not have sufficient skills for interpersonal relationships and enter into relationships, especially emotional relationships, immaturely and emotionally, we see frequent breakups in their relationships and the ego’s capacity for repeated failures is filled. As a result, they suffer from severe pain and despair, and the voice of blame and punishment that they have internalized forces them to punish themselves.”
Respondents also saw deliberate self-harm behavior as a way to self-care, to cope with the experience of self-disintegration, a mechanism to escape a psychiatric crisis or an alternative to invisible psychiatric wounds. For example, participant 5 stated that “deliberate self-harm behavior in adolescents is a way to show mental wounds that no one can see, or rather to be ignored by those around them. They are repairing them, but on the other hand, self-harm can be a way to escape the volume of emotions and unpleasant experiences that are unbearable for them.”

4. Discussion
This study aimed to investigate the topics related to the nature and causes of deliberate self-harm in adolescents from the perspective of Iranian mental health professionals. From the findings of the study, among the 32 basic themes which were extracted from the interviews, 3 main themes, namely traumatic cultural and social themes, interpersonal impact and effectiveness, and transformational/developmental injuries were the most fundamental and effective factors in the occurrence and aggravation of deliberate self-harm.
To provide a qualitative analysis of the available findings, 3 general areas were considered as follows: Socio-cultural issues, the family, and the self. They can play a significant role in the occurrence and aggravation of adolescents’ self-harm behavior. 
Experts participating in the present study considered the cultural turmoil and socio-cultural crisis of today’s Iranian society as one of the main causes of adolescents’ tendency to self-harm. They believe that by changing the culture of society and progressing to individualistic cultures as the necessary infrastructure to accept and its use has not been provided, a significant increase in social disruptions has occurred in the heart of society. Although individualism is emphasized in European and American countries, it cannot be considered a cause of self-harm. The mismatch between cultural characteristics, society’s unpreparedness for these changes, and the lack of resources to adopt social roles related to independent life can increase the tendency to deliberate self-harm behaviors in adolescents. This is an explanation from Durkheim (1897) stating that the difference in suicide rates in countries with collectivist and individualistic cultures, as well as explanations that one of the causes of adolescence problems is the mismatch between developmental characteristics and social and cultural context (Eccles et al., 1993). Similarly, consistent with the conceptualizations of social disintegration is that society does not have a coherent and integrated identity; therefore, one cannot internalize a coherent identity of the external society, but the same internal turmoil is internalized and causes internal psychological turmoil, which in turn causes adolescents to express themselves and their needs to be heard in other ways, including self-harm (Congdon, 1996; Hawton et al., 2001).
Experts also pointed to the reduction of the space for discourse and interaction between people in society, and as a result, the expansion of the repressive atmosphere that governs society. An oppressive environment refers to an environment in which the needs of the individual are not understood and no context exists for satisfying those needs; therefore, the individual suffers from anger, depression, and frustration when their needs are not met and their voice is not heard. Meanwhile, because they do not find a space to express these issues, they repeatedly fail. This leads to self-destructive anger and the person begins to hurt themselves. This finding is consistent with the social signaling model (Nock, 2010). According to this model, interpersonal defects in the expression of annoying emotions as well as interpersonal experiences of rejection, coercion, and harassment are among the risk factors for deliberate self-harm.
Another factor mentioned by experts is the lack of social role of adolescents. The lack of social role in society during adolescence can cause a person to fail and feel powerless in independence along with the feeling of being a burden on the family and being useless; thus, a person’s self-confidence decreases over time and the feeling of inferiority overwhelms them. On the other hand, society has expectations that the adolescent is unable to meet due to feelings of inability and finds no choice but to seek isolation. In parallel with external expectations, adolescents also have expectations from society and those around them so that they can form their identity through imitation and understanding. In a society that is chaotic and fragile, such a need is not met and the condition that adolescents experience is the unbearable pain from failure and not being accepted and not being heard, and they find no choice but to deliberately harm themselves (Parker et al., 2008; Gunnell et al., 2004). These findings may be due to the impact of the spread of mass media and social networks, which according to Bandura’s (1969) theory, observational learning may be important in the exponential increase of this behavior in adolescents.
Another factor involved in self-harm is the deliberate harm of economic poverty. There is ample evidence to suggest the role of low socioeconomic status, low family income, and living in poverty as risk factors for self-harm behavior (Kiran et al., 2021; Shekhani et al., 2018; Hawthon et al., 2007).
The results indicated the role of the family in the occurrence and persistence of deliberate self-harm behavior in adolescents. The answers to the interview questions show turmoil in the family environment as well as in the parents’ psyche. When the person’s inner conflicts are not resolved, when they are in the position of a parent, they cannot have a correct image of themselves as a parent; therefore, the necessary boundaries are broken, and since children first imitate their parents (first the mother and then the father) to find a coherent picture of themselves from birth, the assimilation with a parent who is suffering from mental disorders causes psychological limitlessness in adolescents. The child, on the other hand, is the target of the parents’ projections; therefore, they cannot form a self-image and suffer from confusion and mental turmoil. Adolescence is also a period in which, due to identity crisis and inner confusion, individuals need to rely on a source of power to be cohesive and feel free from any tension. Accordingly, poor and conflicting parenting is one of the risk factors causing deliberate self-harm behavior in Iranian adolescents. This finding also overlaps with previous studies in this field (Chen, 2021; Sim et al, 2009). Sinha et al. (2021) showed that parents have a major role in the occurrence of self-harm. They emphasized that parental abuse has a relationship with self-harm behavior. The present study showed that the lack of identity of family members and disintegration in society were the two essential factors that promote deliberate self-harm. The lack of identity of families comes from economic poverty, unresolved parental conflicts, the duality of border and freedom, absence of authority position, cultural confusion coming from repression, disruption of social identity, materialism, and not accepting the new identity.
Another factor was developmental injuries that result in self-dissociation, relational self-dissociation, and intrapersonal function. Adolescence is a period in which due to fragility and mental weakness, the identity is formed and is influenced by the behavior and reactions of others and also has a strong need for approval and acceptance by those around. The results indicate that adolescents do not receive adequate attention and support from their school principals and educators and they are often overlooked. These findings are consistent with the results of a study in the United Kingdom and China (Chen et al., 2021; Wadman et al., 2018). Some parents find their behavior shameful and the adolescent experiences feelings of humiliation and blame; therefore, emotional feedback and others’ view of self-harm behavior is another factor in shaping and intensifying this behavior. The emotional reaction of others to this behavior or labeling intensifies the adolescent’s negative feelings and thus forms a vicious circle. Hence, unexpressed negative emotions, such as shame, guilt, low self-esteem, and anger were the reason for their behavior of deliberate harm, and the reaction of others and labeling increases these feelings and this behavior is repeated. Other qualitative studies in this field confirm the evidence that in societies such as Pakistan or Asian societies, due to the colorful meaning of their image in the eyes of others, reputation with self-harming people is not treated properly and increasingly with anger, blame, and embarrassment responds that are consistent with the findings of this study (Shahid & Hyder, 2008). In other words, many parents see themselves as responsible for this behavioral disorder or mental problems of their teenager and experience feelings of guilt and shame, and because it is unbearable for them, they project their unpleasant feeling onto their teenager and hold them responsible for their shame, or they do not seek treatment or help from mental health professionals to avoid judgment and shame. Černis et al. (2019) showed in their studies that a positive correlation exists between the severity of dissociation and the severity and frequency of deliberate self-harm in adolescents, and a small number of results suggest that dissociation mediates the relationship between childhood trauma and adolescent self-harm.
Adolescence, on the other hand, is a prominent period influencing and being influenced by peers and friends, and many adolescents receive most of the support they need; therefore, peers’ attitudes and feedback on the adolescents’ deliberate self-harm behavior can reduce or increase this behavior. The results suggest that adolescents with self-harm behavior are deliberately harmed to find a place among their peers and to be approved and accepted, which gradually builds part of their identity through assimilation with them. Thus, deliberate self-harm behavior is on the one hand a way to manage the pressures of interacting with peers and demarcating between oneself and another, and on the other, because of the lack of necessary communication skills, is a way to enter into groups and communicate (McAndrew & Warren, 2014; Wadman et al., 2018. De Luca et al. (2022) showed that there is associations between peer problems (i.e. friendship stress, loneliness) and NSSI may be largely explained by shared underlying factors; yet, some evidence also suggests that NSSI engagement may increase adolescents’ risk to experience difficulties in the relationships with their peers, in part via increases in depressive symptoms. According to experts, their experience in external communication and in relation to the inner world is a prominent role in how self-harm behavior is formed and continues, and the findings show how deliberate self-harm behavior is a way and mechanism for communication with the outside world. Is inside. For some, deliberate self-harm behavior is a mechanism of escape or substitution, and coping with self-disintegration, which in early psychoanalytic studies also referred to the self-punitive function of self-harm behavior. In others, it is used as a way to take care of oneself against external injuries, which has been mentioned in other studies (Wand et al., 2019). Also, according to the findings, because of the lack of skill in expressing one’s emotions properly to the outside world, self-harming behavior is a way to express unspoken emotions, eliminate pain and anger, and relieve it. These findings support the theoretical model of deliberate self-harming behavior as an emotion-regulating function (Miller et al., 2019). Mikolajczak et al. (2009) showed in their studies that if emotional intelligence was high, the likelihood of self-harm could be decreased; therefore, self-harm is a strategy for regulating emotion in adolescence. This can create self-confidence and a sense of power in the person. Some adolescents with deliberate self-harm behavior, as many studies have noted (Hawton et al., 2012; Miller et al., 2019), have a history of sexual, physical, or emotional abuse. Wounds from deliberate self-harm behavior can tell a life story as the person is speechless (Gardner, 2021; Miller et al., 2019). According to mental health experts, the history of childhood abuse leaves a wound on the psyche of these adolescents, which is often ignored and suppressed; however, with the onset of adolescence, the experience is suppressed due to current trauma. Revival comes to life and the person deliberately damages themselves to heal the past wounds. Thus, self-harming behavior is a way of expressing oneself, creating a coherent and integrated image of the self, and creating an identity for oneself in adolescents. In addition, based on the findings, disruption in adolescents’ self-communication has prominent deliberate self-harm behavior (Corcoran et al., 2007; Hawton et al., 2001). These adolescents fail due to the lack of communication skills and the lack of a proper image of themselves and others in managing their relationships with others, and these repeated failures cause a rupture in the psyche; thus, self-harm behavior is a deliberate response to these failures to relieve the unbearable pain caused by the failures. Hence, transformational injuries play a role in the occurrence of deliberate self-harm behavior along with their persistence; therefore, improving relationships or adolescents’ skills in how to manage relationships may help reduce this behavior. As the findings of other studies show, intensive interpersonal psychotherapy can be a way to reduce deliberate self-harm behavior in this area (Tang et al., 2009).
Based on the findings, it seems that Iranian mental health professionals see the role of culture and family in the occurrence and persistence of their deliberate harm to adolescents. They believe that the cultural context of today’s society has disintegrated for economic-political reasons, and as a result, society is in a period of transition. This means that Iranian society itself does not have a coherent and unified identity. On the other hand, because of the existing turmoil and the absence of powerful authority, there is no bed for discourse and tolerance; thus, the resulting atmosphere is a space full of repression, suffocation, unheardness, and ignorance, all of which cause subdued anger in each individual and create a sea of ​​angry and conflicted people. With this description, the smaller community, which is the family, is undoubtedly influenced by the general community, and the confusion of roles and positions, as well as the pressure of economic issues, has crept into the fabric of the Iranian family. They are not mentally enough to endure their conflicts and adolescent issues. Thus, today’s adolescents do not find a place to be heard, seen, or understood, and the result is a body full of broken, fragmented, and fragmented lines that can be a symbol of the image of today’s society and family.
Findings of the present qualitative study on the views of mental health professionals about the behavior of deliberate self-harm in adolescents show that several factors play a role in the occurrence and exacerbation of this behavior, including traumatic community, vulnerable family, interpersonal impact, and developmental injuries. Although deliberate self-harm behavior by adults is harmful and destructive in nature, mental health professionals believed that deliberate self-harm behavior has an adaptive function for adolescents as it is a way to take care of oneself, deal with a mental breakdown, regulate unpleasant and negative emotions, as well as a way to express protest and suppressed anger toward the repressive atmosphere, which in contemporary models is also deliberate self-harm to some extent has been mentioned (Graz, 2003; Nock, 2010). On the other hand, it can be concluded that culture and issues related to culture and society can play a large role in the occurrence and aggravation of self-harming behavior in adolescents. Mental health professionals in different situations should pay more attention to the nature and function of this behavior in adolescents to avoid misdiagnosis and misdiagnosis; In other words, in evaluating such behaviors in adolescents, factors such as the cause of onset, the family environment in which the person lives, the socio-cultural, economic level, the antecedents and consequences of this behavior should be examined. To prevent deliberate self-harm behavior in adolescents, skills in regulating negative emotions or strategies for proper parenting and reducing family conflicts as well as solving family members’ psychological problems can be effective.
Also, experts in this research stated that to prevent deliberate self-harm behavior in adolescents, based on the factors that play a role in the formation and spread of this behavior, factors such as recognizing their new identities, tolerance, and dialogue with these people, which are not at the community level and not at the family level, there is no platform for discourse, training to better understand teenagers in the family to reduce the generation gap, eliminate labeling and create a space to express their common experiences and concerns in group therapy. Identifying vulnerable people through school officials and psychologists present in schools and creating an environment such as group therapy or individual therapy for these teenagers, while at the same time developing parenting programs for adolescence as well as cultural and social programs is another strategy to reduce these behaviors.

5. Conclusion 
Social-familial problems are the most important issue the participants discussed. They maintained that it is important that there was dissociation and confusion in society and among family members. Therefore, these adolescents experience many psychosocial consequences. Therefore, using counselors in health centers or schools can be effective. The experience of dissociation in society and families, followed by a lack of self-care, dissociative self, reduced ability to establish their identity, and too much loneliness, caused them to act to eliminate negative emotions. Also, experiencing negative emotions to remove this intra-psyche and inter-psyche suffering is one of the main features of these people which can cause pathological behavior, such as deliberate self-harm. The role of healthcare has been emphasized in preventing deliberate self-harm. 

Study limitations
This study was performed on mental health professionals who are working with adolescence. It is recommended that this study be performed on adolescence and parents, social workers, and sociologist. The limitations of the present study include the lack of social health professionals in the sample group and the lack of conditions for holding focus groups to expand and refine interviews. It is suggested that the meanings and definition of deliberate self-harm behavior be examined from the perspective of adolescents with self-harm experience as well as adolescents without self-harm experience. The experience of parents of adolescents with deliberate self-harm behavior can also be examined in a qualitative study. The needs of parents, adolescent caregivers at school, and mental health professionals in the face of deliberate self-harm behaviors can also be examined in a study. This study was performed by telephone interview due to the COVID-19 pandemic. The most important advantage is not to impose stress on participants due to attending interviews and getting COVID-19. However, if the interview were face-to-face, the study would be more prosperous, and its analysis would be easier for the researcher. Another limitation was the great difficulty of collecting samples to reach saturation. Participants are informed before the interview that their voices will be recorded. It was challenging to convince some participants to do this study.

Ethical Considerations
Compliance with ethical guidelines

From the beginning of the research, the participants were reminded that they can withdraw from the research whenever they want. An informed consent letter was obtained from the subjects and their permission was granted for recording the interviews.

The paper was extracted from the PhD thesis of Mehrnaz Yekta at Department of Psychology, Kharazmi University.

Authors' contributions
Conceptualization, Methodology and Supervision: Mohammad Naghi Farahani and Hamid Khanipour; Writing – original draft, and review & editing: Mehrnaz Yekta, Mohammad Naghi Farahani and Hamid Khanipour; Data collection and Data analysis: Mehrnaz yekta.

Conflict of interest
The authors declared no conflict of interest.

Authors of this article are indebted to all participants for the time and effort dedicated to their involvement in this research. 

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Type of Study: Research | Subject: Analytical approach
Received: 2022/05/13 | Accepted: 2023/01/16 | Published: 2023/04/1

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