Using Digital Storytelling as Voice for Adolescent

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Using Digital Storytelling as Voice for Adolescent Females Who Self-Injure Rhonda Goodman, PhD, ARNP, FNP-BC, NCSN, AHN-BC Florida Atlantic University

abstract adolescent females who self-injure may use their skin as a canvas to tell their stories. Storytelling provides adolescents an opportunity to express those stories in a different venue. this research included the use of digital storytelling. the intent of the research was to discover the efficacy of using digital storytelling to provide voice to adolescent females who self-injure. a common theme throughout the stories was their desire to continue self-injury, although most had ceased the behavior. Digital storytelling may be an effective way to provide voice and to help adolescent females who self-injure to articulate their experiences to others, providing an outlet for their emotions. Key Words: Child and adolescent health, computer applications, mental health, storytelling, self-injury Introduction Many adolescent females feel they have no voice, no vehicle with which to express difficult emotions, and some of them use their skin as a canvas upon which they record their stories (Lesniak, 2008). Each scar may represent a painful period or incident in the lives of these adolescents and, consequently, the pain is recorded on their skin. The scars then become visible and tangible representations of otherwise unexpressed feelings. Storytelling provides a means by which persons may express themselves (Pennebaker, 1990) and digital storytelling utilizes a computerized format that may appeal to this generation of adolescents (Lambert, 2009). The purpose of this pilot study was to use digital storytelling as a means to provide voice for adolescent females who self-injure. Background and Significance Approximately 7% to 12% of adolescents deliberately injure themselves (Favazza, 1996; Ross & Heath, 2002; Strong, 1998; Whitlock et al., 2006). However, due to the secret and private nature of the behavior, accurate statistics

are difficult to obtain. The person who selfinjures may feel trapped and unable to find a voice with which to be heard. It is sometimes possible to find expression in the self-inflicted injury, thereby making the voice heard. In particular, adolescents who self-injure describe their self-injury experience as a way to record their history (Lesniak, 2008). This project was an attempt to reach out to these adolescents and offer them a means by which to find their voices and record their stories on something other than their skin. literature review There are varied definitions of selfinjury: Deliberate destruction of body tissue without suicidal intent (Cerdorian, 2005), an attempt to find self-expression (Estefan, McAllister, & Rowe, 2004; Lesniak, 2008), expression of deep distress (Sharman, 2007), “the act of attempting to alter a perceived intolerable mood state by inflicting physical harm serious enough to cause tissue damage to the body” (Levander, 2005, p. 3), and a deliberate non-life threatening, self-effected bodily harm of a socially unacceptable nature (Shaw, 2002). Favazza (1996), one of the first to document self-injury behavior, defined it as selfmutilation, or “the deliberate destruction or alternation of one’s body tissue without

conscious suicidal intent” (p. xviii), although some who participate in this behavior find the term “self-mutilation” to be offensive (Hoyle, 2003; Levander, 2005; Sutton, 2005). For the purpose of this study, self-injury behavior is defined as the nonsuicidal, deliberate infliction of a wound to oneself in an attempt to seek expression (Lesniak, 2008). Self-injury behavior usually begins between ages 12 and 14, and is more common among females (Madge et al., 2011; Whitlock et al., 2006; Wilkinson & Goodyer, 2011). However, Hall and Place (2010) reported from their research that there was no specific age involvement and males are becoming just as likely to selfinjure as females. The most common method is cutting, although those who selfinjure may also use other methods, such as burning, scraping, picking at sores, hair pulling, punching self, and scratching (Cleaver, 2007). Instruments of choice may be needles, razors, broken glass, matches, knives, fingernails, or sandpaper (Murray et al., 2005). Commonalities reported by adolescent females who self-injure are history of childhood abuse, alienation, repression of emotions, feeling relief after cutting, stigmatization, abandonment, marginalization, self-loathing, and a desire to feel hopeful again (Lesniak, 2008). Storytelling provides an opportunity for persons to reflect upon their experiences and to come to terms with how the experience has shaped their own world and how that world is perceived. Holloway and Freshwater (2007) reported that storytelling allows persons to recognize their vulnerability, share their emotions and experiences, and have a voice that can be heard. Storytellers may feel empowered to take control of difficult emotions and

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Using Digital Storytelling as Voice for Adolescent Females Who Self-Injure feelings. The act of storytelling may also be utilized as a coping strategy. By telling their stories, adolescents who self-injure are able to “summarize and organize the experience in order to better understand it, to store it, and move beyond it” (Holloway & Freshwater, 2007, p. 707). The human story is “a recounting of one’s current life situation to clarify present meaning in relation to the past with an eye toward the future, all in the present moment” (Smith & Liehr, 2008, p. 207). In addition, Smith and Liehr (2005) advocated for storytelling as a means for intentional dialogue between the nurse and the person telling the story, providing a conduit for an increased level of connection and awareness of self. Lamph (2011) reported study narratives that included statements from participants referring to the need for coping strategies such as talking with another person. Digital storytelling is a method of recording stories that appeals to adolescents who have primarily learned to communicate through the use of technology. While today’s adolescents may experience frustration if asked to tell their story with paper and pen, those same adolescents may feel a much higher degree of comfort with a computer. They are already telling their daily stories on social media. Therefore, they may feel comfortable utilizing the media to record their stories with video, photographs, and sound. Sandars, Murray, and Pellow (2008) reported that “creative acts, such as writing, taking photographs or making music, engage individuals in a process of constant reflection” (p. 774). The finished product may be kept for personal reflection or shared with others to raise awareness of the complex health challenge discussed in the narrative. In addition, digital storytelling provides participants with control over their stories while allowing self-expression. The process of digital storytelling has become relatively simple with software, cameras, web cams, and media sharing web sites (Gubrium, 2009). The participant is allowed to choose the media they desire to represent their self-

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injury experience. The ability to self-reflect is enhanced by learning how to use metaphor, to express distress, to let an image represent a feeling or emotion (Adshead, 2010). The media actually tells the story; therefore, text is not used and the presentation is usually 3 to 5 minutes in length. The storyteller makes the choices of the topic and the form of media used; hence, they are encouraged to take control of their own story. theoretical framework The humanistic nursing theory of Paterson and Zderad (1976/1988) was the theoretical framework that guided this study. The theory is described as “an experience lived between human beings” (Paterson & Zderad, 1976/1988, p. 2). This theory is based upon the existential quality of the nursing situation, which is experienced by nurse and other, who come together in a simultaneous and reciprocal encounter, each being allowed the full expression of their uniqueness. The nurse attempts to be intentionally and authentically present with other during the nursing situation. It is through this presence that genuine dialogue may occur. After the experience of the nursing situation, the nurse reflects upon it, describes it, and identifies the call for nursing, which is reciprocal between nurse and other. The nurse is concerned for the adolescent’s unique qualities and for potential in growing in well-being and more-being. (Paterson & Zderad, 1976/1988). method Human Subject Protection and Procedure Approval for the study was sought from and granted by the Institutional Review Board of Florida Atlantic University. Recruitment flyers were placed in the offices of Family Nurse Practitioners and in the Student Health Services at a local university. Recruitment was for adolescent females, ages 14 to 20 years, with a history of self-injury. If they were currently selfinjuring, it was required that they be

International Journal for Human Caring

receiving therapy at the time. Seven adolescent females were ultimately included in the study. There were others who wished to be included, but did not want to disclose their self-injury to their parent(s); consequently, these potential participants, if they were minors, were not included in the study. Sample and Design This study was qualitative and phenomenological in design; the data were the stories of the participants as they expressed themselves through media, using photographs, videos, and soundtracks. The method was story gathering through the use of computers and software specifically designed for the purpose of digital storytelling. During the first session with each participant, the researcher discussed the study and ascertained that the participant felt comfortable and at ease. Then the participant was shown two or three digital stories of varying topics, excluding any stories referring to self-injury, to prevent any influence over the participant’s story. The researcher demonstrated the various media tools to be used for the digital story production. The question asked of the participant was, “What is your story of your self-injury experience?” The participant was asked to write a 250- to 350-word narrative of the story and bring it to the next session. At the second session, the participant practiced reading her story aloud into the microphone and the story was ultimately recorded. The researcher did not edit the story, nor correct grammar or spelling; this prevented external influence that could contaminate the data. Once the recording was completed, the participant was asked to bring in photos of a metaphorical nature, images that represented her feelings as she had described them in her story. To protect her confidentiality, photos of the participant were not used. In addition, the participant was asked to think about any songs or music that might represent her feelings and report that at the next session.


Using Digital Storytelling as Voice for Adolescent Females Who Self-Injure During the third session, the participant guided the researcher as to the placement of the different photos/images, layering them into the story at the appropriate moments. In other words, when the participant had a photo of something that represented loneliness, she guided the researcher to place it at the point in her story that she speaks of feeling lonely. If the participant had chosen music that also represented her feelings, the soundtrack was also layered into the story. Once final edits and transitions were complete, and the participant was satisfied with the finished product, a DVD was made for her own use. During the fourth and final session, the participant and researcher again viewed the digital story and discussed both the process and the outcome. The participant gave feedback on the effect the digital storytelling study had on her, if she had shown the story to others, and what the response was from those who had viewed the digital story. Prior to the beginning of data collection, the researcher attended two training programs at the Center for Digital Storytelling in Berkeley, California. At these programs, the researcher learned the methods of digital storytelling and became versed in the use of the specific software and digital media tools required for this process. Discussion Of the seven participants, five chose to complete their digital stories. Three stories are included here by permission of the participants. The names of the participants have been changed and some details of their stories were synthesized to protect confidentiality: Cutting was an escape. Some people would argue these actions are suicidal, but I just wanted to disappear, never wanting to take my own life. I would feel lonely, abandoned, worthless. All my self-consciousness, pessimism, selfloathing, and feelings of helplessness would crush me emotionally. When I was about 10 years old, I started burning myself. Sometimes I’d bite,

scratch, or hit myself when I felt I did something wrong. Soon, cutting became my main outlet. It felt natural, something I did almost daily, like a ritual. I wrote during this period, when family issues, painful memories, and being teased at school wore down on me. Things were spinning out of control. The only thing I could control was the length, depth, and number of cuts. Sometimes, I’d feel numb and cut just to know that I could feel. Other times, I would feel so many things that I would cut to bring my emotional pain to the surface, in hopes of cancelling out the pain or watching the emotions heal with the wound. I would end up feeling out of my body, and not like myself, which is what I wanted. The sight of my own blood created a calming feeling that I couldn’t achieve any other way. My inner forearms were covered in cuts. I wore long sleeves at all times. I never told anybody, people were harsh enough. I thought nobody, even my family, could understand that cutting actually helped me. I haven’t cut in 2 years. Looking back, I’m glad the scars are with me. They tell my story. But I can’t say I won’t cut again. (Anonymous, 2010a) This is Darcy’s story, just as she wrote it, and exactly as she spoke it into the microphone. Her voice never quavered and, although she spoke with a degree of uncertainty, she read her story just as she wanted to tell it. Darcy’s story was raw and honest, almost provoking discomfort for the listener due to its pointed honesty. She chose several metaphorical images to represent her emotions: A young girl with her head buried in her hands to represent despair, an empty swing set with eerily still swings to represent her loneliness, and a calm ocean and beach scene that represented the relief she felt after cutting herself. For her soundtrack, she chose “Cut” a song that tells a story of feeling numb and, eventually, feeling relief after cutting (Plumb, 2006). Darcy took her digital story, saved on a

DVD, home and watched it together with her father. After the story was over, Darcy looked at her father. He turned to her, placed his hand on her arm and, through his tears, said, “I get it now. I finally get it.” Darcy reported to the researcher that she felt so validated that her father finally understood all the angst she had experienced during this period of her life. She stated that making her digital story was very meaningful to her and helped her to share her story with her father in a third-person type format, instead of the intense face-to-face encounter. This is Heather’s story: When I was 16 everything was wrong. I don’t know if it was because I was quiet and not popular, or if it was because I felt like I was the only fat girl in high school and everyone thought I was gay. Maybe everyone that age feels awkward, I’m still not really sure. I was definitely a rebel in my own skin. My parents always fought and my sister, “the fuck up of the family” always taunted me. I didn’t get along with anybody. I didn’t talk to anyone. That may have been the reason for all the pent up anger and my hate toward everyone. I don’t know why I did what I did, but on the worst night of my life (or so I thought at the time) my dad and mom fought, and he told me he hated me. I felt the need to do something, punch something, anything. That started the self-mutilation, which went from cutting with knives or razors to pulling out my hair or hitting something until I bruised. It felt…nice; stress relieving. It was nice to find something to escape all the negative thoughts, which I now realize were turned into negative actions. I almost totally and completely loved how it felt. The more it hurt the better. Sometimes I got so into it, I didn’t even notice how much it hurt and almost like any type of addiction, the more I did it the more I needed to do. After everything that’s happened since the last time I cut myself, such as my mom’s death,

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Using Digital Storytelling as Voice for Adolescent Females Who Self-Injure I realize how dumb I was. I’m not sure what got me to stop, all I know it was a slow process and got less frequent. It was embarrassing when wearing dresses or even going to the beach. I didn’t realize my scars would be a conversation piece to everyone around. What I do know is that the behavior that I had before never really went away. Just because I don’t cut, pull, bruise, or hurt myself doesn’t mean anything. I went from that to smoking, to drinking, and anxiety medication. I still don’t talk to people. Sometimes I wish I was still doing all that, the cutting. Maybe I wouldn’t feel as crazy. (Anonymous, 2010b) Heather spoke of feeling marginalized at high school. She brought images of a family fighting and of a young girl pulling her hair. One image was a picture of razor cuts on a girl’s hip with the words “we all have secrets” superimposed over the cuts. The most moving image was that of a young girl’s left cheek as a tear exited her eye and moved down her face. She, too, expressed her inclination to self-injure again. Heather was estranged from her father, her mother was deceased, and her boyfriend disapproved of her previous self-injury behaviors, so she felt she had no one with whom to share her digital story. After completing her digital story, Heather emailed the researcher and stated, “Doing this project helped me to talk about things I have never talked about and helped me to come to terms with my own feelings.” About 2 months after completing her story, Heather reported that she had cut again, after a 2-year hiatus from self-injury. This is Lauren’s story: The years I suffered from depression made me physically numb and mentally fragile. I was lonely, but pushed people away – I felt misunderstood and didn’t believe anyone could possibly understand. I resorted to drugs, alcohol, and cutting to deal with the physical numbness, the loneliness, or to punish myself if I felt I did something wrong.

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And sometimes I’d think I’d see the light at the end of the tunnel, but it merely was the headlights of an oncoming train. Cutting helped the numbness because it was something I could feel and my blood reminded me that I was alive, because so often I felt dead inside. Sadly, death was often what I prayed for. I attempted suicide unsuccessfully twice and was hospitalized once. I was so desperate for everything to end – kids at school teased me and told me to kill myself. I had nowhere to go…I didn’t even belong with the misfits. I was drowning, drugs and alcohol were only a temporary fix and I was running out of places to cut. I never realized how painful my depression was to those closest to me that had to watch me go through it – those who I only pushed further and further away. If only I knew then what I know now. Cutting also wasn’t solving anything in the long run – only a temporary solution with a permanent outcome, a scar. In addition, my skin had gotten so thin from daily cutting I could literally bleed out by accident. If only I knew then what I know now, maybe I could have prevented some of these things. But, since I know now, I am passing on my knowledge. I am helping others with depression deal with their compulsions and better understand how to overcome it from a personal perspective. I still deal with depression – and although I haven’t cut in over a year, I still want to…every day of my life. (Anonymous, 2010c) Lauren chose dark, disturbing images to represent her feelings: A dead black rose, children pointing and laughing at another child, a girl hugging a tombstone, a drowning girl, and a lone, sad-looking child on a swingset. The music accompanying her story was a song by Megadeath about surviving amid suicidal ideations. She always expressed the ever-present desire to cut herself.


Conclusion The participants reported a desire to continue their self-injury practices, even though they had not cut in a while. Therefore, it is inconclusive whether talking about their feelings helps them to stop or refrain from self-injury. They did report, however, the relief experienced by finally telling their stories as it enabled them to reflect upon and process their emotions. The participant that shared her digital story with her father reported a high level of satisfaction derived from that experience. Themes emerged from the stories: Themes of feeling marginalized and lonely, desiring to continue self-injury behavior, feeling hopeless, experiencing relief after selfinjury, and confronting their story audibly and verbally. There was an overall theme of uncertainty, about their present and future lives. Future research with more participants would be beneficial in order to more thoroughly examine the use of storytelling, especially digital storytelling, as an intervention to provide voice for adolescent females who self-injure. Implications for Nursing School nurses, teachers, and counselors are many times the first healthcare professional to encounter adolescent females who are self-injuring. Many times these students need to be heard. The school health room could be a nurturing and safe place in which to share their stories. There are storytelling methods that are affordable and accessible for the students and the school faculty, such as oral storytelling. If the students desire to use a digital format, free software is readily available and user friendly. The students could record their story as a voiceover, using the computer’s internal microphone. They could use their camera or cell phones and create their own metaphorical images, creating a representation of their feelings. This is a very creative outlet that could serve as a voice for these students. However, the need for possible intervention, treatment, and medication


Using Digital Storytelling as Voice for Adolescent Females Who Self-Injure should not be ignored, nor dismissed. Some adolescents who self-injure may have an undiagnosed borderline personality disorder, depression, eating disorder, bipolar disorder, or other psychiatric issues needing attention. These adolescents should be interviewed closely to assess their potential for suicide and any necessary referrals should be pursued. Limitations The limitations of this study were in the sample size and the homogeneity of the participants. It was hoped that more participants would be available. However, usually, self-injury is not a self-reporting phenomenon within the adolescent female population. Many potential recruits who were minors did not want to reveal their self-injury to their parent; this prevented their inclusion in the study. In addition, the sample was culturally homogenous. Implications for future research would be to include adolescent females from diverse cultural backgrounds. references Adshead, G. (2010). Written on the body: Deliberate self-harm as communication. Psychoanalytic Psychotherapy, 24(2), 69-80. doi:10.1080/02668731003707501 Anonymous, (2010a). [transcription of audio recording of participant’s story]. Unpublished raw data. Anonymous, (2010b). [transcription of audio recording of participant’s story]. Unpublished raw data. Anonymous, (2010c). [transcription of audio recording of participant’s story]. Unpublished raw data. Anonymous, (2011a). [transcription of audio recording of participant’s story]. Unpublished raw data. Anonymous, (2011b). [transcription of audio recording of participant’s story]. Unpublished raw data. Cerdorian, K. (2005). The needs of adolescent girls who self-harm. Journal of Psychosocial Nursing and Mental Health Services, 43(8), 40-46.

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Levander, A. (2005). Self-injurious behavior: Assessment, treatment and the recovery process. Nashville, TN: Cross Country Education. Madge, N., Hawton, K., McMahon, E., Corcoran, P., De Leo, D., Jan de Wilde, E. et al. (2011). Psychological characteristics stressful life events and deliberate self-harm: Findings from the child & adolescent self-harm in Europe study. European Child Adolescent Psychiatry, 20, 499-508. doi:10.1007/s00787-011-0210-4 Murray, C., Warm, A., & Fox, J. (2005). An internet survey of adolescent self-injurers. Australian E-journal for the Advancement of Mental Health, 4(1), 1-9. Paterson, J., & Zderad, L. (1976/1988). Humanistic nursing. New York, NY: National League for Nursing. Pennebaker, J.W. (1990). Opening up: The healing power of expressing emotions. New York, NY: Guilford Press. Plumb. (2006). Cut. On Chaotic resolve [CD]. Nashville, TN: Curb Records, Inc. Ross, S., & Heath, N. (2002). A study of the frequency of self-mutilation in a community sample of adolescents. Journal of Youth and Adolescence, 31(1), 67-77. Sanders, J., Murray, C., & Pellow, A. (2008). Twelve tips for using digital storytelling to promote reflective learning by medical students. Medical Teacher, 30, 774-777. Sharman, J. (2007). Understanding selfharm. London, United Kingdom: Mind. Shaw, S.N. (2002). Shifting conversations on girls’ and women’s’ self-injury: An analysis of the clinical literature in historical context. Feminism & Psychology, 10, 191-219. Smith, M.J., & Liehr, P. (2005). Story theory to advance nursing practice scholarship. Holistic Nursing Practice, 19, 272-276.

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Using Digital Storytelling as Voice for Adolescent Females Who Self-Injure Strong, M. (1998). A bright red scream: Self-mutilation and the language of pain. New York, NY: Viking. Sutton, J. (2005). Healing the hurt within: Understand self-injury and self-harm, and heal the emotional wounds. Oxford, United Kingdom: How To Books. Whitlock, J., Eckenrode, J., & Silverman, D. (2006) Self-injurious behaviors in a college population. Pediatrics, 117, 1939-1948. Wilkinson, P., & Goodyer, I. (2011). Nonsuicidal self-injury. European Child Adolescent Psychiatry, 20, 103-108. doi:10.1007/s00787-010-0156-y

author note Rhonda Goodman, PhD, ARNP, FNP-BC, NCSN, AHN-BC, Assistant Professor, Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, Florida. Correspondence concerning this article should be addressed to Rhonda Goodman, 2837 Banyan Blvd. Circle NW, Boca Raton, FL 33431, USA. Electronic mail may be sent via Internet [email protected] This research was funded by a grant from the National Association of School Nurses.

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