SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS: HELPING AND HINDERING FACTORS by CARISSA NG Bachelor of Science, University of Waterloo, 2019 Thesis Submitted in Partial Fulfillment of the Requirements for the Degree of MASTER OF ARTS IN COUNSELLING PSYCHOLOGY in the FACULTY OF GRADUATE STUDIES TRINITY WESTERN UNIVERSITY May 2023 © Carissa Ng, 2023 SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS The following committee members attest to the successful completion of this thesis Deepak Mathew, PhD, Marvin McDonald, PhD, Xu Zhao, EdD, Thesis Supervisor Second Reader (or Thesis Co-Supervisor) External Examiner (or Third Reader) ii SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS iii ABSTRACT Self-harm recovery is a common clinical concern and can be influenced by various factors, including culture. This may affect second-generation Asian Canadians, who are raised within a Western host culture while also attempting to retain aspects of their Eastern culture of origin. Therefore, this study sought to explore what helped and hindered the self-harm recovery process in the lives of 15 second-generation Asian Canadians and Americans. Employing the enhanced critical incident technique (ECIT), participants identified 19 helping, hindering, and wish list categories, which included activities and alternatives; cultural and contextual factors; financial/life stability; family members; friends, peers, and other social supports; intolerance from others; intrapersonal factors; media and role models; professional supports; and romantic partners. The results can help practitioners, caregivers, other professionals, and individuals struggling with self-harm better understand and support the self-harm recovery process. Contributions to the field, practical implications, and limitations of the research are also discussed. Keywords: Asian Canadian, self-harm, non-suicidal self-injury, bicultural SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS iv TABLE OF CONTENTS ABSTRACT................................................................................................................................... iii TABLE OF CONTENTS............................................................................................................... iv LIST OF TABLES .......................................................................................................................... x ACKNOWLEDGEMENTS ........................................................................................................... xi DEDICATION .............................................................................................................................. xii CHAPTER 1: INTRODUCTION ................................................................................................... 1 CHAPTER 2: LITERATURE REVIEW ........................................................................................ 5 Non-Suicidal Self-Injury..................................................................................................... 5 Intrapersonal Factors and NSSI .............................................................................. 6 Treatment for NSSI ................................................................................................. 9 Social Supports and NSSI ..................................................................................... 11 NSSI in the Media................................................................................................. 14 NSSI and Culture .................................................................................................. 16 Ethnic Identity................................................................................................................... 17 Ethnic Identity Formation ..................................................................................... 18 Acculturation......................................................................................................... 20 Bicultural Conflict ................................................................................................ 22 Asian Canadians and NSSI ............................................................................................... 23 Cultural Factors Impacting Asian Canadian Mental Health ................................. 24 Other Factors Impacting Asian Canadian Mental Health ..................................... 27 Rationale ........................................................................................................................... 28 CHAPTER 3: METHODOLOGY ................................................................................................ 31 SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS v Position of the Researcher ................................................................................................ 31 Enhanced Critical Incident Technique .............................................................................. 32 Participants........................................................................................................................ 35 Inclusion Criteria .................................................................................................. 35 Exclusion Criteria ................................................................................................. 36 Recruitment Procedures ........................................................................................ 37 Description of Sample........................................................................................... 37 Data Collection ................................................................................................................. 38 Screening Interview .............................................................................................. 39 First Interview ....................................................................................................... 39 Follow-Up Interview............................................................................................. 42 Data Analysis .................................................................................................................... 43 Transcription Procedure ........................................................................................ 43 Extraction of Incidents .......................................................................................... 43 Formation of Categories ....................................................................................... 44 Thematic Analysis ................................................................................................ 44 Rigour and Validity........................................................................................................... 44 Audiotaping Interviews ......................................................................................... 45 Interview Fidelity .................................................................................................. 45 Independent Extraction of Critical Incidents ........................................................ 45 Exhaustiveness ...................................................................................................... 46 Participation Rates ................................................................................................ 46 Placing Incidents into Categories by an Independent Judge ................................. 46 SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS vi Cross-Checking by Participants ............................................................................ 46 Expert Opinions .................................................................................................... 47 Theoretical Agreement.......................................................................................... 47 CHAPTER 4: RESULTS .............................................................................................................. 49 Overview of Results.......................................................................................................... 49 Contextual Results ............................................................................................................ 49 Biculturalism ......................................................................................................... 49 Sense of Belonging. .................................................................................. 50 Tension and Balance. ................................................................................ 50 Connection to Self..................................................................................... 51 Growth and Learning. ............................................................................... 52 Recovery ............................................................................................................... 52 Elusive and Process-Oriented. .................................................................. 53 Cognitive. .................................................................................................. 53 Behavioural. .............................................................................................. 54 Emotional/Somatic.................................................................................... 54 Critical Incident and Wish List Categories ....................................................................... 55 Categories that Help with Self-Harm Recovery ................................................... 55 Category 1: Activities and Alternatives (17 incidents, 9 participants). .... 56 Category 2: Friends, Peers, and Other Social Supports (15 incidents, 10 participants)............................................................................................... 57 Category 3: Intrapersonal Factors (14 incidents, 10 participants). ........... 59 Category 4: Professional Supports (12 incidents, 9 participants). ............ 60 SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS vii Category 5: Family Members (5 incidents, 5 participants)....................... 61 Category 6: Romantic Partner (5 incidents, 5 participants). ..................... 62 Category 7: Financial/Life Stability (5 incidents, 4 participants). ............ 63 Categories that Hinder Self-Harm Recovery ........................................................ 63 Category 1: Intolerance from Others (16 incidents, 9 participants).......... 64 Category 2: Family Members (10 incidents, 8 participants)..................... 65 Category 3: Professional Supports (10 incidents, 7 participants). ............ 67 Category 4: Cultural and Contextual Factors (9 incidents, 7 participants). ................................................................................................................... 68 Category 5: Intrapersonal Factors (9 incidents, 8 participants). ............... 69 Category 6: Media and Role Models (8 incidents, 7 participants). .......... 70 Category 7: Activities and Alternatives (5 incidents, 4 participants). ...... 71 Wish List Categories for Self-Harm Recovery ..................................................... 72 Category 1: Professional Supports. ........................................................... 73 Category 2: Family Members. .................................................................. 74 Category 3: Friends, Peers, and Other Social Supports. ........................... 76 Category 4: Intrapersonal Factors. ............................................................ 77 Category 5: Activities and Alternatives. ................................................... 78 Scaling Results .................................................................................................................. 79 Conclusion ........................................................................................................................ 81 CHAPTER 5: DISCUSSION........................................................................................................ 83 Contextual Results ............................................................................................................ 83 What Does It Mean to Be Bicultural? ................................................................... 83 SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS viii What Does Recovery Mean? ................................................................................ 87 Critical Incident and Wish List Categories ....................................................................... 89 Intra and Interpersonal Support ............................................................................ 89 Friends, Peers, and Other Social Supports. ............................................... 90 Family Members. ...................................................................................... 92 Intolerance from Others. ........................................................................... 95 Intrapersonal Factors. ................................................................................ 96 Romantic Partners. .................................................................................... 99 Experiential and External Support and Resources .............................................. 101 Activities and Alternatives. ..................................................................... 101 Media and Role Models. ......................................................................... 103 Professional Supports.............................................................................. 105 Cultural and Contextual Influences .................................................................... 107 Financial/Life Stability. .......................................................................... 107 Cultural and Contextual Factors. ............................................................ 108 New Findings .................................................................................................................. 110 Implications for Practice and Policy ............................................................................... 113 Implications for Future Research .................................................................................... 115 Limitations of the Study.................................................................................................. 116 Benefits of the Study....................................................................................................... 118 Conclusion ...................................................................................................................... 119 REFERENCES ........................................................................................................................... 121 APPENDIX A: Recruitment Poster ............................................................................................ 144 SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS ix APPENDIX B: Phone Screening Interview ................................................................................ 145 APPENDIX C: Informed Consent and Confidentiality .............................................................. 146 APPENDIX D: Interview Guide................................................................................................. 149 APPENDIX E: Demographics Questionnaire ............................................................................ 153 APPENDIX F: Coding Steps in Atlas.ti ..................................................................................... 154 APPENDIX G: Table for Tracking the Emergence of New Categories ..................................... 157 SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS x LIST OF TABLES Table 1: Summary of Basic Demographic Data .......................................................................... 38 Table 2: Categories that Help with Self-Harm Recovery ............................................................ 56 Table 3: Categories that Hinder Self-Harm Recovery ................................................................. 64 Table 4: Wish List Categories for Self-Harm Recovery .............................................................. 73 Table 5: Summary of Participant Ratings and Changes on the Scaling Question ....................... 81 SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS xi ACKNOWLEDGEMENTS First and foremost, I would like to express my deepest gratitude to my participants. This thesis would not be possible without your vulnerability, honesty, and kindness. I am forever impacted by each of your stories and am honoured you have trusted me with them. I would also like to extend my sincere thanks to the wonderful team of individuals who assisted me throughout my research process. I am extremely grateful for my supervisor, Dr. Deepak Mathew, who has provided me with unwavering support and confidence in my ability to complete this work and develop as a researcher. Dr. Mathew’s feedback and leadership was invaluable in helping this study reach the finish line. I also wish to express my thanks to my other professors at Trinity Western University, for believing in me, motivating me, and inspiring me to continue in this profession. I would also like to thank my peers, Allison, Ashley, Esther, and Mark, for coming alongside me in this journey. Your support and presence at each stage of the research process no doubt contributed to my ability to complete this thesis. This endeavor would also not have been possible without my partner, Jason, who has always enthusiastically supported my goals and ideas for as long as we have been companions. Thank you for being my rock and a pillar of support throughout the creation of this document. Finally, thank you to my mom, dad, and sister for being my family. The three of you are intertwined in everything I do, including this work. Thank you for cheering me on and supporting all of my endeavors, both personally and academically. Together, you have created the backbone of my life, instilled in me the values that have shaped my character, and provided me with the tools to succeed. Your sacrifices, hard work, and dedication have made it possible for me to pursue my dreams and achieve my goals, and I will always be grateful for that. SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS DEDICATION To my 13-year-old self – you did it!!! xii HELP-SEEKING BEHAVIOURS FOR SELF-HARM RECOVERY 1 CHAPTER 1: INTRODUCTION NSSI can be defined as self-injury with no suicidal intent (Torres, 2016), and, according to the Diagnostic and Statistical Manual of Mental Disorders (5th ed; DSM-5, American Psychological Association, 2013), the premeditated, self-directed damage to oneself is often a result of a desire to relieve negative experiences. Although distinct from suicidal behaviour, NSSI frequently occurs in adolescents who have previously contemplated or attempted suicide (Klonsky et al., 2014). As such, it remains a common clinical concern and is the most significant risk factor for future self-harm and suicide (Al-Sharifi et al., 2015). This behaviour has also been defined in the literature as self-wounding (Tantam & Whittaker, 1992), self-mutilation (Favazza & Rosenthal, 1993), parasuicide (Ogundipe, 1999), and deliberate self-harm (Pattison & Kahan, 1983). Thus far, data on racial-ethnic minority samples have been scarce, which may be due to an ethnocentric bias that tends to underestimate the impact of culture on NSSI (Cipriano et al., 2017). Therefore, further research is required to understand how culture influences NSSI behaviour. Asian Canadians are considered Canada’s fastest growing minority group, with Chinese immigrants being projected to reach over 2 million by 2036 (Statistics Canada, 2017). Additionally, births of people belonging to a visible minority group are also projected to increase, totalling between 36% and 43% of all births in Canada by 2036. This contributes to Canada’s growing second-generation population, which is projected to increase from 6 million in 2011 to upwards of 8 million by 2036. While the population of Canada’s Chinese immigrants has been well-researched, research on Canada’s second-generation Asian Canadian population is relatively scarce although growing rapidly (Cheng, B. et al., 2018). Unfortunately, despite the common perception that Asian Canadians are a model minority, this population continues to face SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 2 high rates of mental health challenges, such as anxiety, depression, self-harm, and suicidal thoughts and behaviours (Hahm et al., 2020). In fact, the help-seeking attitudes and intentions of Asian Canadians have long been investigated by many in the mental health field (Christensen, 1987; Chung, I., 2009; Lin & Cheung, 1999; Tieu & Konnert, 2013; Yee et al., 2020), with researchers consistently observing lower rates of help-seeking behaviours and underutilization of mental health services in comparison to European Canadians (Chen et al., 2009; Li & Browne, 2000; Lin & Cheung, 1999). This help-seeking behaviour, for the purposes of this study, refers to “any action or activity carried out by an adolescent who perceives herself/himself as needing personal, psychological, affective assistance or health or social services, with the purpose of meeting this need in a positive way” (Barker, 2007, p. 2). This may include seeking help from formal sources (i.e., clinic services, counsellors, psychologists, medical staff, traditional healers) as well as informal services (i.e., peers, friends, family members, community members; Rickwood & Thomas, 2012). This difference in help-seeking may be partially due to cultural aspects, in which the influence of Confucian, collectivist tradition discourages open displays of emotion to maintain social and familial harmony or to avoid exposure of personal weakness (Kramer et al., 2002). This desire to preserve public appearance of the family for the sake of the community is also known as saving face; an extremely important concept in most Asian households (Kim, J. Y., & Nam, 1998). As the current literature on general mental health demonstrates that Asian Canadians seek help at lower rates than any other racial or ethnic demographic, it is possible that this trend will extend to Asian Canadians who engage in self-harm, or non-suicidal self-injury (NSSI). SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 3 The impact of culture may also be affected by generational differences. An early study by Phinney (1990) observed a consistent decline in ethnic group identification in later generations descended from immigrants, with later research on integration demonstrating that an acculturation gap is a major issue that often emerges between the first- and second-generation. This has been linked to family conflict and adjustment (Birman & Poff, 2011). As a result, it is reasonable to predict that second-generation Asian Canadians would feel less influenced by traditional Chinese beliefs and customs. Even more so, a bicultural identity can enable this population to be increasingly flexible in cognitive style and adaptability (Gardner, 1985; Nguyen & Benet-Martínez, 2013); therefore, how do second-generation Asian Canadians navigate recovery from NSSI? How do they reconcile Eastern and Western influences prior to seeking mental health support? What would be most beneficial in supporting them throughout this process? Since self-harm most often occurs during the period of adolescence (Gillies et al., 2018; Nixon et al., 2007), second-generation Asian Canadians engaging in self-harm must also navigate the psychosocial milestones associated with this developmental period. Particularly, individuals may begin to shift in their priorities and understandings surrounding relationships, goals, values, and beliefs as they embark on a journey of self-discovery and separation from their families of origin (Berger et al., 2017; Copeland et al., 2019). Emotional and cognitive challenges and growths also occur throughout this period (Arnett, 2007), with second-generation Asian Canadians having to navigate these changes while also attempting to understand their sense of self and bicultural identity. As a result, how does ethnic identity development and biological development intersect with one another with respect to self-harm recovery? How might this added layer of biculturalism impact the way second-generation Asian Canadians SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 4 recover from self-harm when they are also attempting to navigate adolescence and young adulthood? The aim of this research is to explore the experiences of second-generation Asian Canadians and, more specifically, those of East Asian ancestry. There will be a particular focus on understanding the experiences of this population with respect to self-harm; what helped and hindered their recovery process? This study will expand the current literature surrounding the second-generation Asian Canadian population and, in particular, the socio-cultural influences that affect this group’s desire and intention to seek help for NSSI. Additionally, the findings from this study will inform practitioners on how to best support and develop inclusive tools and counselling interventions for second-generation Asian Canadians. Given the intersection of culture and mental health along with the implications of NSSI for individuals, it is important to develop more appropriate services and interventions that are mindful of this bicultural background. Lastly, this study may assist second-generation Asian Canadians and their friends and families in being able to seek help for NSSI in the face of economic, social, cultural, and personal challenges and obstacles. SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 5 CHAPTER 2: LITERATURE REVIEW This chapter aims to provide a theoretical and clinical conceptualization on NSSI and ethnic identity. I will begin by reviewing the literature on NSSI to situate the context of this research. The following section will then review the literature on ethnic identity and biculturalism, exploring the self-harm literature in relation to the second-generation Asian Canadian population. Non-Suicidal Self-Injury Non-suicidal self-injury (NSSI) can be defined as “self-injury with no suicidal intent” (Torres, 2016, p. 746) and according to the DSM-5, the premeditated, self-directed damage to oneself is often a result of a desire to relieve emotional experiences (American Psychological Association, 2013). NSSI is direct in that the outcome of injury occurs without having to proceed through mediating steps. For example, cutting one’s own skin with a razor is considered direct self-harm, whereas overdosing on medication is not. This is because the negative health outcome is facilitated by subsequent chemical processes in the body. Furthermore, socially and culturally sanctioned behaviours are not considered NSSI, although they may result in the destruction or damage to one’s body or bodily tissues. For example, tattoos and piercings in Western cultures are not classified or studied as harmful or deviant behaviours requiring clinical intervention (Nock & Favazza, 2009). Although distinct from suicidal behaviour, NSSI frequently occurs in adolescents who may also have contemplated or attempted suicide. As such, it remains a common clinical concern and is the most significant risk factor for future self-harm and suicide (Klonsky et al., 2014). This behaviour has also been described in the literature as self-wounding (Tantam & Whittaker, 1992), self-mutilation (Favazza & Rosenthal, 1993), parasuicide SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 6 (Ogundipe, 1999), and deliberate self-harm (Pattison & Kahan, 1983). For the purposes of this research, the terms NSSI and self-harm will be used interchangeably. Prevalence estimates for NSSI are quite varied, with one meta-analysis conducted across more than 40 countries demonstrating an overall lifetime prevalence of 17% (Gillies et al., 2018). Furthermore, rates of self-harm have been increasing in recent years, with the same metaanalysis observing an increase from 1990 to 2015 (Gillies et al., 2018). Adolescence is commonly considered as the period of onset, with Nixon et al. (2007) observing a mean age of 15 years and Gillies et al. (2018) observing a mean age of 13 years. There are also several risk factors that can increase an individual’s vulnerability to self-harm, including lower socioeconomic status, gender, trauma, and other environmental and psychological stressors. More specifically, the female gender, a previous diagnosis of depression, as well as issues within one’s family or school environment, were determined to be among the most significant contributors (de Kloet et al., 2011), with studies observing females to be more likely to disclose instances of NSSI (Nixon et al., 2007) and more likely to report higher levels of internal NSSI functions, such as affect regulation (Victor et al., 2018). To date, much of the research has revolved around developing treatments for related conditions, such as borderline personality disorder (Klonsky et al., 2014). Considering the number of individuals who engage in NSSI, it is perhaps surprising to find that little research has been conducted around the specific treatment of NSSI in adolescents, especially research that gives a voice to those with lived experience. Intrapersonal Factors and NSSI Dell et al. (2021) identified intrapersonal factors as an integral component of mental health recovery, to help move from “a negative psychological state marked by loneliness, SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 7 despair, helplessness, and self-loathing to a positive state of well-being marked by meaning and purpose, belonging, autonomy, safety, and acceptance of and insight into one’s illness” (p. 248). For self-harm specifically, various intrapersonal factors have been investigated with respect to their effect on the maintenance and cessation of self-harm, including being able to regulate one’s emotions as well as self-compassion. Emotion regulation can be referred to as “the extrinsic and intrinsic processes responsible for monitoring, evaluating, and modifying emotional reactions, especially their intensive and temporal features, to accomplish one's goals” (Thompson, R. A., 1994, pp. 27-28). Indeed, emotion regulation skills are seen as a necessary part of human life; a requirement for daily functioning in situations ranging from work and school to intimate relationships (Gross & Muñoz, 1995). While there are numerous reasons behind why an individual may choose to self-harm, emotion regulation is often cited as a common underlying reason (Klonsky et al., 2014). In fact, one study observed an increase in physiological arousal during a stressful task for adolescents with NSSI in comparison to adolescents without, supporting the idea that self-harm is routinely used as a coping strategy to decrease arousal (Nock & Mendes, 2008). Other empirical support for NSSI as a means of emotion regulation has seen study participants often reporting decreases in negative emotions, such as tension, fear, and sadness following engagement in the behaviour (Andover & Morris, 2014). Another intrapersonal factor that has been explored with respect to self-harm is selfcompassion. Self-compassion is typically defined as engaging in “self-kindness rather than selfcriticism, a sense of one’s common humanity rather than isolation, and mindfulness rather than rumination” (Gregory et al., 2017, p. 3). Self-compassion has been associated with emotion regulation (Diedrich et al., 2014), which for individuals engaging in self-harm, can be difficult to extend to oneself. Indeed, individuals engaging in self-harm can experience high levels of self- SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 8 criticism and shame, with Gregory et al. (2017) observing that participants who reported previous experience with self-harm were also more likely to report lower levels of selfcompassion in comparison to participants who did not report a history of self-harm. This result is also observed in a review by Khan & Ungar (2021), who found that self-compassion served as a protective factor against self-harm. Intrapersonal factors tend to develop over time and are particularly sensitive to the biological, psychological, and social changes that occur throughout the period of adolescence (Gross & Muñoz, 1995). As such, researchers have also observed that those who engage in selfharm may also recover naturally over time (Gelinas & Wright, 2013). For instance, in a study by Gelinas & Wright (2013), participants self-reported a sudden desire for wellness and realization over the futility of self-harm, which then prompted their recovery process. Additional studies by Gelinas (2015) and Hambleton et al. (2020) observed similar results, with participants continuing to self-report an internal change that led them to be able to embrace new perspectives and realizations, desire wellness, and accept support. Indeed, the integration of one’s personality, cognition, and emotion takes place over the course of adolescence into adulthood, providing individuals with more perspective and understanding of themselves and their experiences (Arnett, 2007). Therefore, intrapersonal factors have been observed to play an important role in selfharm recovery. However, much of the literature continues to be dominated by White samples, with only few studies exploring the effect of intrapersonal factors on self-harm recovery for those of ethnic minority backgrounds (Khan & Ungar, 2021), let alone the second-generation Asian Canadian population. Future research is needed to further understand how culture may impact an individual’s development of various intrapersonal factors and whether the SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 9 intrapersonal factors that are perceived as helpful or hindering for self-harm recovery are influenced by culture. Treatment for NSSI Several treatment interventions for NSSI currently exist at both the individual and group level that promote more adaptive emotion regulation skills and coping strategies. Turner et al. (2014) reviewed several psychotherapeutic and pharmacological interventions and found that, various interventions showed potential at effectively treating self-harm, including “dialectical behaviour therapy, emotion regulation group therapy, manual-assisted cognitive therapy, dynamic deconstructive psychotherapy, atypical antipsychotics (aripiprazole), naltrexone, and selective serotonin reuptake inhibitors” (p. 576). Another review by Glenn et al. (2015) examined 29 studies regarding evidence-based psychosocial treatments for self-injurious thoughts and behaviours in youth, which included cognitive-behavioural therapy, dialectical behavioural therapy, family therapy, and individual skills training. Unfortunately, it should be noted that while many treatments showed promise of reducing self-injurious thoughts and behaviours, there continues to be a lack of understanding around the factors that mediate and moderate treatment effects and that many of these studies were limited by using exclusively borderline personality disorder samples. Indeed, treatment interventions for NSSI have historically focused on the similarities between self-harm and borderline personality disorder; however, for those who self-harm but who do not have a personality disorder, undergoing treatment for borderline personality disorder may not be effective or acceptable (Wilkinson & Goodyer, 2011). Moreover, researchers and practitioners continue to identify selfharm recovery as the complete cessation of any self-harm behaviour, largely ignoring emotional, somatic, and cognitive aspects of recovery (Gelinas & Wright, 2013; Tofthagen et al., 2017; SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 10 Wadman et al., 2016). Self-harm recovery is often viewed as an outcome rather than a journey, which has contributed to why behavioural therapies and modalities have dominated self-harm treatment. It is only in recent years that research has begun to acknowledge and discuss the emotional and somatic aspects of recovery (Gelinas, 2015; Gray et al., 2022; Tofthagen et al., 2017; Wadman et al., 2016), with a study by Gray et al. (2022) observing that cognitive and emotional factors, such as psychological distress, self-efficacy, emotion regulation, interpersonal functions, and expectations, differentiated individuals who had and had not ceased self-harm. This indicates that focusing solely on behavioural factors may not be entirely effective and that self-harm recovery is more nuanced than how it has been historically perceived. Nonetheless, many of these psychosocial treatments for self-harm have revolved around helping the individual cope through alternative methods and strategies such as harm minimization (Hambleton et al., 2020), or encouraging the individual to incorporate more activities into their daily lives, such as exercise and hobbies (Berger et al., 2017; Fortune et al., 2008; Gelinas, 2015). Although studies have shown that being engaged with activities and one’s community can have a positive effect on one’s psychological well-being (Froh et al., 2010; Lyubomirsky & Layous, 2013), this individualistic form of treatment exemplifies how self-harm recovery continues to prioritize behavioural markers and outcomes, eclipsing more emotional, somatic, and cognitive methods and strategies. Aside from encouraging behavioural changes, other forms of self-harm treatment are often accompanied by more formal inpatient or outpatient care. Along this journey, individuals engaging in self-harm may encounter physical health professionals, mental health professionals, academic supports, and other formal online resources and supports. To date, there is extensive literature examining how these different professionals are perceived by those seeking mental SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 11 health support, with many studies having examined both the positive and negative aspects of seeking professional supports (Gibson et al., 2019; McHale & Felton, 2010; Sass et al., 2022; Wadman et al., 2018). A review by Sass et al. (2022) focused on the positive aspects of professional support, citing trust, empathy, understanding, and being nonjudgmental as serving an integral role in helping individuals stop or reduce self-harm. Another review by McHale and Felton (2010) stated that the negative attitudes and treatment by healthcare workers towards individuals engaging in self-harm was a result of a lack of education, personal confidence, and clinical support, as well as negative perceptions surrounding a client’s self-control. This demonstrates how professional supports and services can be viewed as both helpful and unhelpful, and that despite the wide variety of results and perspectives, professional supports continue to be identified as playing a key role throughout an individual’s self-harm recovery process (Berger et al., 2017; Gelinas, 2015; Hambleton et al., 2020). Social Supports and NSSI Given that human beings are a naturally social species, it is no surprise that social supports have been extensively researched with respect to their effects on mental health. In fact, research has observed that when experiencing serious mental health concerns, the informal social support network is often the “first contacted and preferred source of help” (Mackenzie et al., 2006, p. 580). The relational impact of the informal network has been extensively reviewed in the counselling psychology literature, and often includes friends, peers, and family members. Particularly in adolescence, individuals may begin to prioritize their relationships with friends and peers as they embark on a journey of self-discovery and separation from their families of origin (Berger et al., 2017; Copeland et al., 2019). Given that adolescence is also the age of onset for self-harm (Hall-Lande et al., 2007), several studies have attempted to investigate the effect of SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 12 social support on self-harm recovery (Gelinas & Wright, 2013; Khan & Ungar, 2021; Shepherd, 2020; Wadman et al., 2018). A systematic review and meta-analysis by Khan and Ungar (2021) found that social support was associated with reduced self-harm behaviors and improved recovery outcomes. Specifically, higher perceived levels of social support were associated with decreased frequency and severity of self-harm behaviours. Another study involving participants from Scotland identified friends as being able to provide support and distractions, as well as help individuals take responsibility, which facilitated recovery outcomes and help-seeking behaviour (Shepherd, 2020). Social supports have also been identified as a contributing factor in the maintenance of self-harm behaviours. This has been primarily discussed in the literature as a consequence of stigma, which is defined as a “cooccurrence of its components – labeling, stereotyping, separation, status loss, and discrimination” in a situation where power is exercised (Link & Phelan, 2001, p. 363). For those engaging in self-harm, this stigma can be associated with scarring, the intentional nature of self-harm, or the perception that it is a manipulative behaviour (Burke et al., 2019). Specifically, Burke et al. (2019) observed both strong negative implicit and explicit biases towards self-harm behaviours, especially in comparison to other activities that result in changes to one’s body, such as tattoos and nonintentional disfigurement. This stigma around self-harm behaviour can contribute to individuals experiencing negative reactions, responses, and treatment from others, resulting in many individuals often refraining from disclosing and seeking social support (Gelinas, 2015). Several studies have also investigated the role of family support in self-harm recovery. One study found that family support was positively associated with self-harm recovery and that having enhancing family cohesion and adaptability was associated with reduced likelihood of SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 13 future self-harm behaviors (Fortune et al., 2016). Another study found that adolescents who received greater family support after a self-harm episode were more likely to seek professional help and cited the tangible support provided by family members as beneficial (Gelinas, 2015). However, family support has also been observed to be unhelpful, with Gelinas (2015) and Wadman et al. (2018) finding that reactions and responses from family members could also be perceived as aggressive, disconnected, distant, misguided, and misinformed. Overall, these studies suggest that family support can play an important role in self-harm recovery and have the potential to be both helping and hindering. Interestingly, aside from family and friends, other sources of social support are relatively less discussed within the literature. For instance, romantic partners, religious communities, and school peers. The literature also fails to differentiate between the support received by different members of the family, such as parents, siblings, and other extended relatives. In two studies that did address the relationship between siblings and mental health, Voorpostel and Blieszner (2008) and Hank and Steinbach (2018) found that the closeness and support felt between siblings was associated with the siblings’ relationships with the parents. Specifically, when parents were inaccessible and siblings were more accessible, the emotional support between siblings increased. This highlights the dynamic nature of family relationships and how different relationships can influence one another, especially as it pertains to seeking support for mental health concerns. As for romantic partners, these supportive individuals are often grouped with friends, peers, and other social supports (Gelinas & Wright, 2013; Wang S., & Lau, 2015; Wang, S.-W. et al., 2010). This stands in contrast with other empirical research that has observed that individuals experience social support differently depending on the source of the support (Dakof & Taylor, 1990) and that the support received from romantic partners, while helpful, is SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 14 experienced as different from the support received from friends and family members (Lee, C. S., & Goldstein, 2016). Thus, further research is needed to understand the nuances behind the different types of social supports, particularly in the context of self-harm recovery. Moreover, many of the existing studies on the effects of family support for self-harm recovery also continue to be dominated by White samples, with the research surrounding Asian samples focusing on comparative studies or first-generation immigrants (Hsu, 1985; PolancoRoman et al., 2014; Wang, S.-W. et al., 2010; Wu, C., & Chao, 2017). In fact, a study by Kim et al. (2008) reported that Asian Americans experience family support as less helpful in comparison to European Americans. In a study that did investigate the effect of birth order on the relationship between Asian American siblings, researchers found that Asian American firstborns found comfort in having siblings who shared a less traditional Asian cultural perspective in comparison to their parents (Wu, K. et al., 2018). This indicates that culture may play an important role in mediating the relationship between family support and self-harm recovery. Thus, future research is also needed to further understand the effect of culture and acculturation and, in turn, how it mediates the relationship between family support and self-harm recovery. NSSI in the Media In an increasingly digital world, social media and other forms of mainstream media have become increasingly scrutinized within the research community. In particular, the effect of social media on mental health and self-harm has become a popular topic of interest. One study by Baker and Fortune (2008) sought to investigate how young adults use and perceive self-harm and suicide websites and found that participants viewed these websites as “sources of empathy and understanding, as communities, and as a way of coping with social and psychological distress” (p.118). Other reviews have also observed similar findings, reporting benefits such as social SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 15 support, emotional support, and enhanced peer connectedness, and risks such as cyberbullying, the normalization of self-harm, and increased exposure to self-image content (Biernesser et al., 2020; Dyson et al., 2016). Studies have also noted how the social media platform Tumblr has especially influenced the relationship between social media and self-harm recovery. With over 268 million users, Tumblr was developed as an extremely lenient microblogging website, that allowed users to create communities with others based on shared interests. However, in contrast with other social media platforms where users typically preferred to connect with family, friends, and peers, Tumblr users often chose to connect with strangers (Cavazos-Rehg et al., 2017). Over time, communities emerged where depression, suicidality, disordered eating, and self-harm were chosen as its focus, sparking controversy and resulting in social media platforms implementing new policies and community guidelines to control and prevent the promotion of self-harm content (Lewis & Seko, 2016). Despite these policies and guidelines, users continued to find ways to circumvent these restrictions, with an analysis by Cavazos-Rehg et al. (2017) observing themes of self-hatred, loneliness, and suicide/death in the accounts and communities that focused on self-harm. The researchers acknowledged and discussed how viewing intense self-harm content could contribute to the glorification of these behaviours, which can have a marked influence on adolescents and young adults (Cavazos-Rehg et al., 2017). In addition to social media platforms, other forms of mainstream media have been observed to impact the way self-harm is perceived within the general population. For instance, Fortune et al. (2008) explored adolescents’ views on preventing self-harm and reported that television and music had the potential to spread more awareness of self-harm and suicide hotlines, but also had the potential to expose youth to more intense and sensationalized SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 16 depictions of self-harm. Hollywood depictions of self-harm have also resulted in controversy, with recent show 13 Reasons Why being heavily criticized for its lack of censorship around certain scenes and images (Scalvini, 2020). Thus, although technology continues to be a relatively recent invention and the research surrounding the impacts of technology on mental health continue to unfold, it is important to note the potential that various forms of media have in influencing youth and adolescent’s self-harm perceptions and behaviours. NSSI and Culture Historically, research on NSSI has been dominated by studies conducted on White samples. In the small amount of research that has examined NSSI and race/ethnicity, researchers have mostly compared prevalence rates between Whites and other racial groups, often with conflicting results (Chesin et al., 2013). In fact, a review by Khan and Ungar (2021) identified that although there are a wide range of studies surrounding the prevalence and risk factors of self-harm, there are very few peer-reviewed articles that have explored the protective factors and recovery aspects of self-harm in marginalized groups. Moreover, very few studies have examined the Asian Canadian population, with the majority of studies taking place in the United States or the United Kingdom. Specifically, some studies have found a lower overall lifetime prevalence of NSSI in individuals of Asian descent (Gholamrezaei et al., 2017; Turner et al., 2014), whereas other studies have observed higher or similar rates (Chesin et al., 2013; Thompson, N., & Bhugra, 2000). Despite these inconsistencies, the rates of depression and suicidal behaviours among Asian American adolescents remain alarmingly high in comparison to other ethnic groups (Hahm et al., 2014). In fact, in light of the COVID-19 pandemic, a crosssectional study by Sapara et al. (2021) observed that Asian and Indigenous Canadians were more likely to report an increase in passive death wishes and thoughts of self-harm. As a result, it is SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 17 also important to consider how ethnic identity and biculturalism may impact this population’s experience of and recovery from self-harm. Ethnic Identity Throughout the literature, there exists many definitions for the term “ethnic identity.” Horowitz (2000) describes this construct as “based on a myth of collective ancestry which usually carries with it traits believed to be innate. Some notion of ascription, however diluted, and affinity deriving from it are inseparable from the concept of ethnicity” (p. 52). Tajfel (1978) describes it as “part of an individual’s self-concept which derives from [their] knowledge of [their] membership of a social group (or groups) together with the value and emotional significance attached to that membership” (p. 63). Ethnicity can be taken as a multidimensional construct that encompasses self-categorization, attachment to a particular group, and certain values and beliefs associated with that group. Indeed, a person’s sense of their ethnic identity can change over time, influenced by personal exploration and socio-cultural realities, underscoring the dynamic nature of this important construct (Newman & Newman, 2020). Understanding the concept of ethnic identity is central to many bodies of work, including counselling psychology. Unlike a personal identity, such as one’s occupation, ethnic identity cannot be chosen. One’s ethnic identity can then be conceptualized as a component of one’s overall identity (Umaña-Taylor, 2011), which, in its entirety, is deeply personal yet also inherently social due to humankind’s relational nature and the societal constructions surrounding ethnicity (Adams & Crafford, 2012). As such, the guiding definition for ethnic identity throughout this research will be one of openness and relationship, described by Driedger (2015) as occurring “between an individual and the group with whom the individual believes they have common ancestry” (para. 2). SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 18 Ethnic Identity Formation As individuals move through adolescence to adulthood, identity formation becomes a central issue for many. Erikson (1964) saw identity formation as being achieved during adolescence through a process of exploration and commitment after experiencing a crisis, but did not directly examine culture or ethnicity, working predominantly with White samples and without ethnicity as an identity qualifier. However, despite this lack of direct examination, it is important to note that those who identify as an ethnic minority living in North America continue to develop psychosocially in the context of the dominant, host culture. As such, Erikson’s (1964) work is still worth considering as a model of identity development. Guided by Erikson’s (1964) foundational work on adolescent identity formation, Phinney (1993) developed a model of ethnic identity formation to assist individuals in understanding the implications of their ethnicity and in making decisions around its role in their lives (Phinney, 1993). Phinney (1990), whose work established the importance of ethnicity to the identity of minority group members, found that Asian, Black, and Latino Americans were more likely than White Americans to rate ethnicity as quite or very important to their identity. This culminated in a three-stage model, in which individuals are proposed to move from unexamined ethnic identity in Stage 1, to ethnic identity search/moratorium in Stage 2, to lastly, ethnic identity achievement in Stage 3 (Phinney, 1993). For Phinney (1993), the ideal goal is to achieve a sense of ethnic identity in which one can accept membership in an identified group, identify positive and negative aspects of this identity, and accept other cultures and backgrounds (Cama & Sehgal, 2021). This model offers an understanding of ethnic identity formation and explores how different ethnic group members deal with being part of a specific group and how they may struggle to maintain cultural traditions and customs. SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 19 Researchers have also observed a decline in ethnic group identification in the generations following immigration (Isajiw et al., 1981; Phinney, 1990). When considering second-generation Asian Canadians, it is important to consider the proportion of ethnic identity retained. While certain aspects of ethnic identity, such as language, may decrease, other aspects may undergo modifications, becoming more symbolic and subjective in ways that were not present in the first generation (Isajiw et al., 1981). When parts of one’s identity become symbolic, it may enable individuals to choose between which aspects of their ethnic identity they wish to express; however, in comparison to European Canadians, who have much more freedom in being able to choose and express their ethnic identity, second-generation Asian Canadians often face simultaneous pressure to exhibit both their Asian identity as well as their North American identity. This results in feeling caught between a fear of being too “foreign” or too “whitewashed” (Kibria, 2000). This pressure to cater to both identities can impede the development of a positive sense of ethnic identity. For instance, racial microaggressions can communicate slight derogatory or negative views surrounding people of colour. In fact, a study by Park et al. (2013) observed that perceived discrimination was associated with higher levels of antisocial behaviours in Asian Americans and that participants who identified more strongly with American society remained likely to be vulnerable to the negative impact of perceived discrimination (Park et al., 2013). This may result in rejection, concealment, and/or internalized prejudice towards parts of one’s ethnic identity, which through contemplating social rejection, be it from family or peers, can result in increased identity confusion as second-generation youth attempt to “fit in.” This is problematic, as researchers have found that identity confusion can negatively affect different aspects of an individual’s life, including mental health (Cama & Sehgal, 2021; Cheung & SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 20 Swank, 2019). Therefore, the pressures faced by second-generation adolescents to exhibit both their Asian and North American identities can strongly influence their relationship with and perception of their ethnic identity and acculturation. Acculturation Acculturation can be broadly referred to as “the process by which migrants to a new culture develop relationships with the new culture and maintain their original culture” (Tanenbaum et al., 2013, p. 12). According to a framework proposed by Berry (1990), individuals deal with acculturation along two dimensions. The first dimension refers to the extent that an individual feels motivated or allowed to retain identification with their culture of origin, with the second dimension referring to the extent to which they feel motivated or allowed to identify with the mainstream, dominant culture. Through the negotiation of these two central dimensions, four distinct acculturation strategies emerge: assimilation (identification mostly with the dominant culture), integration (high identification with both cultures), separation (identification largely with the ethnic culture), or marginalization (low identification with both; Berry, 1990). Berry’s (1990) model of acculturation was one of the first to suggest a bilinear relationship, where individuals can be both orientated towards their culture of origin as well as their dominant host culture (Miller, 2007). Indeed, research shows that the integration stage is the one which has the most favourable psychological outcomes, in which bicultural self-efficacy may lead to better well-being and mental health (David, et al., 2009; Kim, B. S. K., & Omizo, 2006). On the other hand, marginalization has been shown to have the least favourable psychological outcomes, often correlated with confusion of ethnic identity and feelings of cultural alienation (Kim, B. S. K., & Omizo, 2006; Tadmor et al., 2009). For second-generation SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 21 Asian Canadians, dealing with this bicultural conflict is often a complex and context-dependent process, resulting in the adoption of different acculturation strategies and outcomes. However, both Berry’s (1990) and Phinney’s (1993) work are limited in their conceptualization of acculturation as an outcome rather than a phenomenological variable, in which an individual’s level of ethnic identification with one culture is independent of their level of identification with the other culture. To address this shortcoming, Benet-Martínez & Haritatos (2005) developed the Bicultural Identity Integration (BII) model to capture how individuals navigate their dual cultural identities. Benet-Martínez & Haritatos (2005) demonstrated that an individual’s bicultural identity is not a unitary construct, but a construct consisting of two different and psychometrically independent components: (a) cultural blendedness versus compartmentalization and (b) cultural harmony versus conflict. In fact, lower blendedness was observed to be linked to “personality and performance-related challenges (e.g., lower openness to new experiences, greater language barriers, and living in more culturally isolated surroundings)” (Huynh et al., 2011, p. 830), whereas lower harmony was observed to be linked to “personality traits and strains that are largely interpersonal in nature (e.g., higher neuroticism, greater perceived discrimination, more strained intercultural relations, and greater language barriers” (Huynh et al., 2011, p. 830). Since then, this conceptualization of bicultural identity as multidimensional and relational has continued to be supported by other work, with a review by Cheng, C.-Y. et al. (2014) noting that this construct is influenced by the climate of the host culture as well as how the culture of origin is perceived by the host culture. Particularly, individual and contextual factors were observed to influence an individual’s psychological, social, and behavioural processes, such as self-concept, cognition, and motivation (Cheng, C.-Y. et al., 2014). Other researchers (Costigan SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 22 et al., 2009) specifically reviewed the literature surrounding second-generation Chinese Canadians’ ethnic identity development, which further supported a bidimensional conceptualization of acculturation and emphasized the important role parents play in the formation of their children’s ethnic identity. The same review also highlighted the potential psychological advantages of having a strong sense of one’s ethnic identity, indicating that while some bicultural individuals may experience more blendedness and harmony with their two cultures, others may find it more difficult to navigate this dual identity. This can give rise to a bicultural conflict, impacting how an individual may relate to and perceive their bicultural identity, as well as how they function within the host culture. Bicultural Conflict In the age of globalization and large-scale immigration, populations of second-generation Asian Canadians continue to increase. These individuals are often raised within two cultural frameworks simultaneously; on one hand, Western values and ideals are being enforced through peer, educational, and media contacts, while Eastern values and ideals are being enforced through familial and community bonds (Stroink & Lalonde, 2009). This biculturalism enables them to function in different contexts by being able to switch between the different aspects of their identity, with studies observing greater cognitive flexibility and adaptability in bicultural individuals (Benet-Martínez et al., 2006; Spiegler & Leyendecker, 2017; Tadmor et al., 2009). However, this dual identity may also give rise to some internal conflict as they attempt to reconcile aspects of both their cultural identities and the sometimes-contradictory norms and values (Stoink & Lalonde, 2009). Acceptance from parental figures and feelings of obligation often contribute to this conflict, as individuals attempt to hold onto aspects of their traditional cultural heritage while adopting and integrating into the dominant host culture and society SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 23 (Tirone & Goodberry, 2011). Accordingly, this bicultural conflict has been observed to occur in several psychosocial domains, such as career decision-making (Ma & Yeh, 2005), academic achievement (Juang et al., 2012), and dating (Chung, R. H., 2001), where youth and adolescents feel forced to choose between what is being taught at home and what is commonly accepted amongst their peers (Stroink & Lalonde, 2009). For second-generation youth, gaining stability during the transitional period into adulthood is a particularly challenging and fluid process. Through simultaneously having to navigate traditional cultural practices with traditions they learn from the dominant group, these youth undergo a process of constructing, learning, and reconstructing their bicultural identity (Tirone & Goodberry, 2011). The complexities around ethnic identity and biculturalism demonstrate how racial and ethnic minorities may navigate familial, social, professional, and academic spheres differently than European Canadians, and that having to do so can impact bicultural individuals’ mental health. Indeed, a study by Tikhonov et al. (2019) observed a negative relationship between BII harmony and symptoms of depression and anxiety, whereby symptoms of depression and anxiety decreased when BII harmony increased. As such, those who experience more compartmentalization and conflict with their bicultural identity may be more likely to experience symptoms of depression and anxiety, placing them at higher risk of developing a variety of mental health disorders, including NSSI. Asian Canadians and NSSI To date, only one study has directly examined the effects of acculturation in self-harming Asian Canadians. Turner et al. (2014) compared East Asian Canadian university students with European Canadians, finding that Asian Canadian students who were less oriented toward Asian culture were more likely to engage in NSSI in comparison to Asian Canadian students who were SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 24 more oriented toward Asian culture. However, their study did not strictly focus on the secondgeneration, with 61% of their Asian Canadian participants being-foreign-born. Thus, little is known about how factors that may be unique to the second-generation minority experience contribute to NSSI. Cultural Factors Impacting Asian Canadian Mental Health While the impact of culture on self-harm has yet to be studied in depth, researchers have investigated how cultural factors may impact the general mental health experience for secondgeneration Asian Canadians. This may include traditions, norms, values, beliefs, and stigma, which can influence how second-generation children relate to themselves and others. For instance, sigma can be conceptualized as occurring on two levels: society, and the self. Social stigma is the widely held belief of a society in which an individual with the stigmatized condition is deemed as less equal. This has been repeatedly discussed throughout the literature, with Ng (1997) and Krendl and Pescosolido (2020) observing cultural differences in Eastern versus Western beliefs regarding the sources of prejudice and the etiology of mental illness. Specifically, they found that moral or biological explanations were more often emphasized in Eastern cultures in comparison to Western cultures. Over time, however, social stigma can lead to self-stigma, the internalization of this societal belief, through which feelings of guilt and inadequacy may arise (Wen & Szeto, 2018). This can perpetuate the cycle of shame, self-harm, and stigma, in which self-stigma can have profound negative effects on one’s self-esteem and self-efficacy, leading to maladaptive coping strategies such as self-harm (Burke et al., 2019). Research on the stigma towards mental health in Eastern cultures points to a desire to save face, a term used to describe the retention of one’s social reputation (Kim, J. Y., & Nam, 1998; Lee, A. M. S., 2016). This tendency to conceal personal, distressing, or negative SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 25 information is more prevalent in Asian cultures, which can impact the way seeking and receiving mental health support is perceived (Lee, A. M. S., 2016). For instance, a study by Wang, S.-W., & Lau (2015) observed that in comparison to European Americans, East Asian Americans were more likely to experience social support as beneficial if they perceived the support as mutual rather than nonmutual. Even further, the same study observed that the East Asian American participants were more willing to “seek support from discretionary (i.e., peers) than obligatory ties (i.e., parents)” (p. 916). Other empirical research around cultural differences in seeking and receiving social supports has observed that Asian Americans were more concerned about the relational implications of asking for help from their romantic partners and, therefore, more hesitant in utilizing those supports (Kim, H. S. et al., 2008). This indicates that cultural differences can influence how individuals perceive mutuality, interdependence, and harmony in relationships. Parental affect and attitudes around mental health are also commonly cited as contributing to the maintenance of this stigma and desire to save face (Augsberger et al., 2015; Kim, S. Y., & Wong, 2002). Research has observed cultural differences in terms of which emotions are valued and promoted, with Lim (2016) observing that Western culture tends to promote high arousal emotions whereas Eastern culture tends to promote low arousal emotions. This difference in the valuation and promotion of emotion may result in Asian Canadian youth suppressing emotional and cognitive distress (Hahm et al., 2020). In fact, the suppression of unwanted thoughts is associated with the presence and frequency of NSSI in adolescent and young adult samples (Andover & Morris, 2014), with a study by Najmi et al. (2007) observing a mediating effect of thought suppression on the relationship between emotional reactivity and self-harm. As a result, parenting (Hahm et al., 2014) is another area that has been investigated by SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 26 researchers to understand how cultural differences can influence parent-child relationships and the mental health of bicultural children. In examining dimensions of parenting, themes of responsibility, filial piety, family structure, parental affect, discipline, autonomy, and control have consistently emerged in the literature as concepts describing the Asian American parenting style (Kim, S. Y., & Wong, 2002; Yoo & Kim, 2010). These themes are also markers of the more collectivistic and interdependent cultural orientation, in which harmony and avoidance of conflict are stressed in parent-child relationships (Han et al., 2013). Filial piety can influence parent-child relationships well into adulthood, with a study by Yoo and Kim (2010) finding that adult second-generation Korean Americans continued to be “motivated by feelings of gratitude and a strong sense of responsibility toward their parents” (p. 165). Especially considering language and financial barriers, the participants described a need to prepare for the future in being able to support their parents’ finances, health care, and long-term care needs. Interestingly, a study by Greenberger et al. (2000) found that Asian Americans were more likely to describe their parents as less warm in comparison to their European American counterparts, whereas adolescents born and raised in China were more likely than adolescents in the United States to report more parental warmth. This discrepancy in perceived warmth demonstrates an example of the tension experienced by many Asian Americans when considering their bicultural identity in the context of a Western society and perspective. It suggests that the perceived lower quality of family relationships among Asian American adolescents in comparison to European Canadians may be the result of acculturation-related stressors, rather than the result of factors intrinsic to Chinese culture (Greenberger et al., 2000). Indeed, Ying and Han (2007) also observed that perceived intergenerational differences predicted intergenerational conflict, which in turn, predicted symptoms of depression and SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 27 psychological distress for second-generation children. It also demonstrates that interfamilial differences in acculturation may be more predictive of NSSI than intraindividual levels of acculturation (Chesin et al., 2013). Other Factors Impacting Asian Canadian Mental Health Other factors that may impact Asian Canadians’ mental health and by extension, selfharm recovery, are related to more systemic factors such as economic and financial stability, as well as how ethnic minorities are treated and perceived by the media. While the effects of social media have been previously discussed in relation to how self-harm is perceived by the general population, mainstream media (such as the news, television, and music) can also play a role in influencing public perception of ethnic minorities as well as how ethnic minorities perceive themselves (Besana et al., 2019; Cui & Kelly, 2013). Many stereotypes and prejudices about Asian Canadians persist in North American culture, and these biases can shape how journalists, editors, and producers frame stories that involve Asian Canadians. For example, Asian Canadians are often portrayed as the model minority, perpetuating the myth that all Asians are high achievers with no problems, which has influenced how this population is treated within academic spheres (Cui & Kelly, 2013). At the same time, they may also be portrayed as “perpetual foreigners,” not fully belonging to the communities where they live. Additionally, news stories, television shows, and movies may sensationalize or exaggerate tropes and stereotypes involving Asian Canadians, further stigmatizing this community (Besana et al., 2019). These biases can have harmful effects on Asian Canadians, contributing to discrimination, marginalization, and self-stigma. Moreover, the negative effect of financial and life instability on mental health and psychological wellness has been well-documented within the literature (Oskrochi et al., 2018; SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 28 Stein et al., 2013). Instability can affect various domains in life, from family, housing (Sandstrom & Huerta, 2013), and career (Rönnblad et al., 2019), resulting in individuals experiencing detrimental effects on their mental health. A lack of security and stability can increase the amount of stress felt by an individual, leaving them with lasting psychological, emotional, and physiological impacts (Sandstrom & Huerta, 2013). In fact, Oskrochi et al. (2018) observed that merely the perception and expectation of one’s future financial situation affected an individual’s self-reported level of psychological well-being. This can adversely impact ethnic minorities, including Asian Canadians, who are forced to endure the effects of systemic and institutional racism embedded within the larger culture (Williams, 2018). Thus, addressing the effects of financial and life instability on the mental health of Asian Canadians requires a comprehensive approach that takes into consideration the systemic inequalities and discrimination that contribute to social and economic disparities. Rationale Evidently, there are many factors that contribute to the prevalence of self-harm within the Asian Canadian community. However, the underutilization of mental health services by the Asian Canadian population remains an ongoing issue. Despite the model minority stereotype, research continues to demonstrate that Asian Canadians still experience high rates of psychopathology, including anxiety, depression, self-harm, and suicidal thoughts and behaviours (Hahm et al., 2020). In fact, the model minority stereotype has been discussed as being detrimental to Asian Canadian mental health due to pressures of saving face and having to uphold stereotypes related to personality traits, behaviours, and emotions (Kawai, 2005; Lo, 2010). The help-seeking attitudes and intentions of Asian Canadians have long been investigated by many in the mental health field (Christensen, 1987; Chung, I., 2009; Lin & Cheung, 1999; SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 29 Tieu & Konnert, 2013; Yee et al., 2020), with researchers consistently observing lower rates of help-seeking behaviours in comparison to European Canadians (Chen et al., 2009; Li & Browne, 2000; Lin & Cheung, 1999). Specifically, Chen et al. (2009) found that regardless of whether Canadian-born Chinese are more likely than immigrant Chinese to suffer from depression, they showed no greater inclination to seek mental health consultation. Another study by Chang & Chen (2014) observed a similar result, with Latinos and Asian Americans being less likely to seek out formal treatment in comparison to White Americans, regardless of generation status. In fact, other literature has stated that Asian Americans perceive nonmutual support to be less helpful than European Americans (Wang, S.-W., & Lau, 2015). Therefore, the difference in mental health service utilization cannot be attributed to immigration status or language barriers. Lastly, the literature surrounding Asians and Asian Canadians has largely focused on general mental health, rather than for specific concerns such as NSSI (Chen et al., 2009; Christensen, 1987; Leong & Lau, 2001; Tieu & Konnert, 2014). However, mental health concerns are not homogenous, thus, it stands to reason that there may be differences with respect to how Asian Canadians approach seeking help for different mental health concerns. Given that Asian Canadians are the fastest growing population in Canada (Statistics Canada, 2017), the dearth of research on this population is surprising. Traditional mental health research is often conducted with middle class European Americans or Canadians. As such, many theories were derived from an individualistic culture that emphasizes autonomy, equality, and freedom throughout various aspects of daily life. The application of these theories to secondgeneration Asian Canadians is yet to be explored, as this population is exposed to both Eastern and Western values. SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 30 As the literature has identified, there is an overall lack of research into the experience of second-generation Asian Canadians. Specifically, little is known about how factors that may be unique to the second-generation minority experience affect recovery from NSSI. There is also a need for research on how recovery may differ in terms of NSSI specifically, rather than general mental health. The proposed study addresses this gap by linking these fields together by giving Asian Canadians with lived experience of NSSI a voice to share and reflect on the factors that helped and hindered their help-seeking behaviour throughout their self-harm recovery. Exploring trends in Asian Canadian mental health utilization is necessary to provide appropriate mental health services to this rapidly growing minority population. Illuminating factors associated with the use of mental health services will contribute to an understanding of culture in the mental health needs of the second-generation Asian Canadian population. Accordingly, the research question proposed is as follows: What are the factors that help and hinder self-harm recovery for second-generation Asian Canadians? SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 31 CHAPTER 3: METHODOLOGY This chapter outlines the research design for this study. It will begin with an introduction of the researcher’s own position and paradigm, including paradigmatic assumptions underlying the method of inquiry. The rationale for using the enhanced critical incident technique (ECIT) will then be explained. Finally, the research design of this study will be described, including participant selection and recruitment, data collection and analysis, as well as the methodological rigour and validity. Position of the Researcher My own personal struggle with self-harm in my early adolescence was the primary inspiration behind my research question. I am a second-generation Chinese Canadian woman who was born and raised in the Greater Toronto Area in Ontario. My parents immigrated to Canada in the 1990s, working various blue-collar jobs in order to support me and my sister, settling in Brampton as our primary area of residence. Although Toronto is considered a benchmark of multiculturalism, my primary social sphere consisted of individuals of other ethnic backgrounds and I was often one of the sole Chinese Canadians present in classes and extracurricular activities. Incidents I could not yet label as microaggressions or covert racism, combined with the comparisons of cultural differences caused much internal conflict as I attempted to reconcile the two different sides of my identity. On one hand, there was a desire to fit in with my peers and conform to the norms, traditions, and values of Canadian society. On the other hand, I also desired parental acceptance and approval, facing cultural pressures of filial piety and obedience. I felt unable to cope with these competing pressures, unable to communicate this struggle to my parents and peers, and unaware of how else to seek supports, turning to self-harm as a coping strategy. Since having been self-harm free for the past six years, SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 32 I have been curious about my own recovery process, how it may be similar or dissimilar to other second-generation Asian Canadians with lived experience of self-harm, and how recovery from self-harm may be facilitated. In my personal understanding of reality and knowledge, I view the world through a constructivist lens. The constructivist approach is one of relativity; that there are multiple, yet equally valid, realities (Ponterotto, 2005). As such, reality is confined to the contexts experienced by any one individual, influenced by interpretation and interactions with others (Mertens, 2015). Thus, knowledge is not limited to directly observable phenomena, but encompasses all that may be unobservable as well. Through this constructivist lens, I understand that my participants’ worlds and experiences are equally valid to my own and that their journey in healing and growth remains their truth regardless of any similarities or differences that may emerge. Based on my constructivist paradigm and my research question, the ECIT is a methodology that fits quite well, enabling me to pull themes of commonality out of the subjective experiences of each of my participants. However, for this study, I decided to adopt a post-positivist ontological and epistemological stance. This is due to a desire to minimize and account for the subjectivity that might distort the participants’ experiences, perceptions, and beliefs. Despite the conflict between my personal and research paradigms, ECIT is a flexible methodology with both post-positivist and constructivist elements (McDaniel et al., 2020). As a result, this flexibility provides me with the ability to acknowledge the presence and influence of subjectivity and context, while also ensuring that the participants’ experiences are understood and interpreted as accurately and objectively as possible. Enhanced Critical Incident Technique SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 33 Since its inception in 1954, the critical incident technique (CIT), subsequently modified into enhanced critical incident technique (ECIT), has been utilized as a counselling psychology research method (McDaniel et al., 2020). During this time, positivist approaches were the dominant paradigm within both natural and social science research. With roots in industrial and organizational psychology, CIT was originally developed as a scientific tool to “develop ethical standards for psychologists, measure task proficiency, select and classify personnel, design job procedures and equipment, identify motivation and leadership attitudes, and to identify factors in effective counselling” (Woolsey, 1986, p. 243). The original developer, John C. Flanagan, described his creation as “essentially a procedure for gathering certain important facts concerning behavior in defined situations” (Flanagan, 1954, p. 335). In other words, it is an exploratory qualitative method that seeks to uncover the helping and hindering factors of a particular experience or activity (Butterfield et al., 2009). By providing insight into real-life experiences, ECIT helps researchers identify broader patterns and understandings (Hughes, 2007). There is currently a wide variety of qualitative research methods in existence, and it is important to consider the philosophical underpinnings of one’s chosen research method. Some are more post-positivist in nature, while others are more constructivist or transformative. ECIT exemplifies a specific and rigorous post-positivist epistemology that also exhibits a flexible ontological perspective (McDaniel et al., 2020). Ponterotto (2005) defines ontology as concerning “the nature of reality and being” (p. 127). Whereas positivist and post-positivist researchers accept a one, true reality, constructivistinterpretivists believe in multiple, constructed realities (Ponterotto, 2005). In reviewing ECIT from this framework, it is imperative to indicate the target of inquiry. Although Flanagan (1954) referred to directly observable behaviours, which fits a more positivist or post-positivist stance, SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 34 ECIT has evolved to include psychological constructs of experiences, perceptions, and beliefs (Butterfield et al., 2005), which is more subjective in nature and thus readily approached via constructivist frameworks. This shift from behavioural observations to retrospective self-reports signifies that ECIT can be applied in either post-positivist or constructivist ways, depending on the intent and beliefs of the researcher. In focusing strictly on observable behaviours, the ECIT researcher assumes an objective, independently knowable, and measurable reality; however, if focusing on the psychological constructs of experiences, perceptions, and beliefs, the researcher leaves room for participant subjectivity, influenced by context, personal factors, and the researcher-participant relationship (McDaniel et al., 2020). Ponterotto (2005) also goes on to describe epistemology as “the relationship between the knower (the research participant) and the would-be knower (the researcher)” (p. 127). In other words, determining how knowledge is acquired (McDaniel et al., 2020). Again, in comparison to constructivist-interpretivists, who believe that reality is socially constructed, post-positivists take the position of a more dualistic and objective perspective (Ponterotto, 2005). Through the data collection and analysis process, Flanagan (1954) advised that incidents be evaluated, collected, and recorded whilst fresh in the participants’ mind. Additionally, the use of the interview guide and extensive credibility checks can render ECIT more post-positivist than constructivist as an attempt to remove some of the effects the interviewer may have on the data collected (McDaniel et al., 2020). For example, the second credibility check utilizes an interview guide and has an expert in the method observe every third or fourth interview. This ensures fidelity and confidence throughout the data collection process, increasing robustness and fitting with a more post-positivist epistemology. As a result, although the relationship between the interviewer and SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 35 participant could introduce subjectivity and bias, ECIT’s rigorous collection and analysis procedures can act as a preventative against this possibility. Similarly, ECIT’s interview protocols and credibility checks renders itself to a postpositivist axiology, which refers to the role of the researcher’s personal values within the research (Ponterotto, 2005). The interview protocols and credibility checks act as an attempt to control researcher bias, while simultaneously honouring the participants’ subjective constructed reality (McDaniel et al., 2020). While ECIT may work well within both post-positivist and constructivist frameworks, the researcher has chosen to work predominantly under a predominantly post-positivist lens. As such, the research design has been adapted to fit this post-positivist framework. However, this is in direct conflict with the researcher’s own personal paradigm. The researcher acknowledges this discrepancy and remains confident that the subjective experiences of the participants will continue to be a key component of the research and its design. Participants Inclusion Criteria To qualify for the study, participants had to: (a) have previous personal experience with NSSI: (b) have not engaged in self-harm behaviour for at least 1 year, (c) identify with both their Western and Eastern cultural identities, (d) be able to communicate in English, and (e) be raised in North America. The reason for these inclusion criteria is because there is vast diversity among communities of Asian descent. Thus, the East Asian and South-East Asian population was chosen to remain more focused and associated with the researcher’s own cultural heritage. Moreover, due to the average age of onset of self-harm occurring in early to mid-adolescence, the current age range was chosen to accommodate for the retrospective component of this study. SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 36 To allow the participants some time to process and work through their self-harm behaviour, the minimum of 1 year in recovery was chosen to increase the likelihood that participants would be able to discuss their previous self-harm behaviour in a safe and manageable manner for their mental well-being. The participants also had to identify with both their Western and Eastern cultural identities, as a focus of this study is to explore how bicultural conflicts experienced by many second-generation Asian Canadians may be related to one’s mental health experience. However, there were no constraints around how strongly one must identify with either cultural identity, as one of the aims of this study is to understand how differences in ethnic identity may affect one’s mental health journey and self-harm recovery. Exclusion Criteria There were also several exclusion criteria based on the definition and conceptualization of NSSI, such as (a) those who engaged in indirect self-harm behaviour, (b) those who did not engage in frequent and repetitive self-harm behaviour, (c) behaviours that are considered socially acceptable in North American culture (i.e., piercings and tattoos), and (d) those who primarily present with a disorder involving psychosis. For the first exclusion criterion, this specifies that the self-harm behaviour must be direct, in which there was mild to moderate damage onto one’s body. For instance, those engaging in self-poison would not be considered to be engaging in NSSI, as the harm done to one’s body is mediated through secondary biological processes as a result of ingesting substances. Furthermore, socially acceptable behaviours such as piercings and tattoos would not fall under the category of NSSI, as those behaviours do not carry the same amount of stigma as other behaviours such as cutting or burning. Lastly, those primarily presenting with a disorder involving psychosis may engage in self-harm; however, their SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 37 motivations behind the behaviour, as well as the resulting treatment and interventions may look different than for individuals who have never experienced psychosis. Recruitment Procedures Participants were recruited through posts uploaded onto the following social media platforms: Facebook, Instagram, Twitter, and LinkedIn (see Appendix A). Personal connections were also utilized to find interested participants through the snowball sampling technique, in which existing connections and initial participants would recruit future participants from their own networks. Description of Sample The anticipated number of participants was 15–18 individuals; however, the final number of participants depended on when a point of saturation was reached, meaning that fresh data no longer led to new insights or revealed new themes. In an ECIT study, this is known as “the point at which participants mention no new CIs or WL items and no new categories are needed to describe the incidents” (Butterfield et al., 2009, p. 270). Saturation and comprehensiveness are further addressed in the section on rigour and validity. Participants consisted of 15 adult individuals of East Asian (11 or 73%) and South-East Asian (4 or 26%) heritage. Participants’ ages ranged from 18–35 years, with most of the participants falling within the range of 18–24 (10 or 66%). Most of the participants identified as female (13 or 86%) and East Asian (11 or 73%). Nine participants (60%) had obtained at least a bachelor’s degree, three participants (20%) had received at least a college degree, with the remaining three participants (20%) having completed at least their high school diploma. The average household income level of the participants ranged from less than $20,000 to greater than $200,000, with most of the participants (11 or 73%) reporting income levels at or below SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 38 $100,000. The participants in this study originated from the United States of America (6 or 40%) and Canada (9 or 60%) and reported residing in rural (1 or 6%), suburban (5 or 33%), and urban (9 or 60%) communities. Table 1 provides a summary of the basic demographic characteristics of the sample. Table 1 Summary of Basic Demographic Data Participant Age Gender no. Ethnic Country of Education Average Type of background residence level household community income 1 25–30 F EA USA Undergraduate 20,000–49,999 Suburb 2 18–24 F EA USA College 50,000–99,999 Suburb 3 18–24 F EA Canada High School 100,000–149,999 Urban 4 25–30 F EA Canada Undergraduate 20,000–49,999 Urban 5 18–24 F EA Canada Undergraduate < 20,000 Urban 6 18–24 F SEA USA Undergraduate 100,000–149,999 Suburb 7 31–35 M SEA USA College 50,000–99,999 Suburb 8 31–35 F EA USA Undergraduate < 20,000 Urban 9 18–24 F EA USA Undergraduate 20,000–49,999 Urban 10 18–24 F EA Canada Undergraduate > 200,000 Urban 11 18–24 M SEA Canada Graduate 20,000–49,999 Suburb 12 31–35 F SEA Canada Undergraduate 20,000–49,999 Urban 13 18–24 F EA Canada High School 150,000–199,999 Rural 14 18–24 F EA Canada High School 50,000–99,999 Urban 15 18–24 F EA Canada College 50,000–99,999 Urban Data Collection Information was collected at three different points in time: the screening interview, the first interview (during which demographic information and informed consent was also collected), and a second, follow-up interview (where the categories were confirmed with the participants). SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 39 Screening Interview Prospective participants were invited to contact the researcher directly by e-mail and to provide information about others who might be interested in participating in the study. Once contacted, prospective participants received a telephone or Zoom call explaining the nature of the study and to screen for eligibility (see Appendix B). The questions asked were: 1) Do you self-identify as an East Asian or South-East Asian Canadian? 2) Are you over the age of 18 years? 3) Do you have prior lived experience with self-harm or non-suicidal self-injury (NSSI)? 4) During the time when you were engaging in self-harm, did the behaviour(s) fall under the following definition: Directly and intentionally inflicting damage to one’s own body tissue without intention of suicide and not consistent with cultural expectations or norms? 5) Have you been recovered from self-harm for at least 1 year? 6) Were you raised in North America? 7) Have you ever experienced symptoms of psychosis (i.e., hallucinations, delusions)? Prospective participants who responded in the affirmative for the first six questions and in the negative for the seventh question met the screening criteria and are the final participants in this study. First Interview Due to the ongoing COVID-19 pandemic, the first interview was conducted over Zoom, a video teleconferencing program, and was approximately 60–90 minutes in length. The participants were provided with the informed consent and confidentiality form (see Appendix C) no less than 24 hours prior to the first interview. This form was also reviewed with the participants at the beginning of the first interview, during which the participants were briefed on SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 40 the purpose of the study, the time commitment of the study, the renumeration of the study, as well as the contact information of relevant individuals should they have any questions or concerns regarding the study. Considerable effort was made at the beginning of the interview to establish rapport with the participants to facilitate full and rich disclosure of incidents. Verbal and written consent was obtained following the review of the informed consent and confidentiality form. The participants were also provided with information on their right to withdraw their consent to participate at any point throughout the study. Subsequently, using a structured interview guide (see Appendix D), participants were invited to reflect on their self-harm recovery process, the factors that helped and hindered that process, and how they were able to eventually cease engaging in self-harm behaviour. The interview guide began with two contextual questions and one scaling question. Participants were asked: 1) Can you tell me what being bicultural means to you in the context of your own life? 2) Because you are here, I know that you feel that you have recovered from self-harm. Can you tell me what recovery means to you? 3) On a scale of 0–10, where 0 is not at all and 10 is very strong, how strongly do you feel you have recovered from self-harm? The scaling question was a pre-post question, which was asked prior to the exploration of incidents as well as at the end of the interview. The purpose of the scaling question was to examine whether the exploration of one’s self-harm recovery process would influence the perception of the extent one has recovered from self-harm. Following the contextual and scaling questions, the participants were asked, “What has helped your self-harm recovery process in the context of your bicultural identity?” An example SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 41 of a helping factor may be parental support, whereas a hindering factor may be a lack of parental support. This process also included wish list factors, which encompass events and factors the participant would like or would have liked to receive. Throughout this section of the interview, care was taken to ensure incidents shared were relevant to the participant’s self-harm recovery process. Once the participant responded with a factor, I would ask them to describe why or how that factor was helpful or hindering for them, as well as to provide an example of a time when they experienced that factor as helpful or hindering. Some examples of questions I used to facilitate the complete description of a factor were: 1) What about that factor was particularly helpful/hindering for you? 2) How was that factor helpful/hindering for you? 3) Could you elaborate a bit on how that factor was helpful/hindering for you in terms of your recovery process? 4) Can you recall a time in your life where you experienced that factor as helpful/hindering? 5) Is there an example that comes to mind when you think about how that factor has been helpful/hindering for you? Care was also taken to refrain from asking leading questions to prevent my own thoughts, opinions, and biases from influencing the participants’ descriptions of the incidents. To provide participants with the opportunity to fully recall and describe as many factors as possible, I would continue to ask them whether there has been anything else that has been helpful or hindering for their recovery process. I would also take notes throughout each interview to ensure that each SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 42 factor was adequately described. This process continued until the participants could no longer recall any further helping, hindering, or wish list factors. After the interview, the scaling question was asked once more. Again, this was done to determine whether participants’ reflection on their recovery process affected their perception of the extent of their recovery process. Then, participants were asked to complete a brief demographics questionnaire (see Appendix E), which consisted of seven questions corresponding to their age, gender, ethnic background, country of residence, education level, average household income, and type of community. Follow-Up Interview The follow-up interview was conducted after all the data from the first interviews were transcribed, coded, and placed into categories. Unlike the first interview, the follow-up interview was not recorded or transcribed. The follow-up interview was a credibility check with three parts: (a) getting input on the helping, hindering, and wish list factors extracted from the participant’s first interview, (b) obtaining feedback regarding the categories into which they have been placed, and (c) following up on questions arising from analyzing the participant’s data from the first interview. This entailed emailing the participant a list of all the factors extracted from their interview, along with a list of the categories within which their factors were placed. The participant was then asked to review the list of incidents and to answer the following questions: 1) Are the helping, hindering, and wish list factors correct? 2) Is anything missing? 3) Is there anything that needs revising? 4) Do the category headings make sense to you? SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 43 5) Do the category headings capture your experience and the meaning that the factors had for you? 6) Are there any factors in the categories that do not appear to fit from your perspective? If so, where do you think they belong? 7) Do you have any other comments? Data Analysis Following the collection of data, the process of data analysis was followed according to the steps identified by Flanagan (1954) and Woolsey (1986). Flanagan (1954) described the purpose of this stage as “to summarize and describe the data in an efficient manner so that it can be effectively used for many practical purposes” (p. 344). The first step was to determine the frame of reference from which to decide on the categories that will be most representative of the data. For this study, the frame of reference is the research question itself—the factors that help and hinder in self-harm recovery for second-generation Asian Canadians. Subsequently, the next steps were to transcribe the interviews, extract the critical incidents, and formulate the categories. Braun and Clarke’s (2006) method of thematic analysis was also used to analyze the contextual questions posed to participants at the beginning of the interview. Transcription Procedure To ensure trustworthiness of the method, the researcher’s supervisor reviewed the initial two transcripts and provided feedback that was used to improve the remaining interviews. Through Zoom, the interview was recorded, transcribed, then manually checked by the researcher for accuracy. Extraction of Incidents SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 44 Once all interviews were transcribed, the critical incidents and wish list factors were extracted. This process was facilitated by use of the qualitative data analysis software, Atlas.ti. The text in which a participant named a factor, described how that factor was helpful or hindering, and shared an example of that factor being helpful or hindering was coded according to the procedures as outlined in Appendix F. Subsequently, all online Zoom recordings of the interviews were deleted. Formation of Categories The critical incident steps outlined by Butterfield et al. (2009) were followed to create the helping, hindering, and wish list categories. Using a process of inductive reasoning, the incidents collected from the interviews were analyzed to search for themes and similarities. This was done in batches of threes, repeating until the categories clearly represented the entirety of the data (Butterfield et al., 2009). Thematic Analysis Braun and Clarke’s (2006) method of thematic analysis can be organized into six phases. They are as follows: (a) Familiarizing oneself with the data, (b) Generating initial codes, (c) Searching for themes, (d) Reviewing themes, (e) Defining and naming themes, and (f) Producing the report. Through this recursive process, the responses to two contextual questions were analyzed for themes, followed by a detailed exploration of each theme. Rigour and Validity Once the categories were created and their definitions determined, the nine credibility checks were conducted as part of the data interpretation and reporting process. The nine credibility checks help to increase ECIT’s rigour and validity. They are as follows: (a) Recording the interview audio in order to preserve the participants’ voice and increase descriptive validity, SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 45 (b) Utilizing an interview guide with an ECIT expert listening to every third or fourth interview in order to ensure the method is being followed accurately, (c) Independently extracting the critical incidents to reduce researcher bias and differences in perception, (d) Exhausting the data to the point at which no new categories can be generated to allow researchers to feel confident that participants’ perspectives have been fully expressed, (e) Calculating participation rates in order to ascertain the relative importance of each category, (f) Independently placing incidents into categories to reduce researcher bias and increase interrater reliability, (g) Cross-checking the data analysis with a second participant interview in order to allow participants to endorse or clarify the generated categories, (h) Requesting that two or more experts in the field comment on the potential usefulness of the categories and if they think anything is missing, and (i) Considering how well the results of the study fit with the existing literature (McDaniel et al., 2020). Audiotaping Interviews For the first credibility check, all participant interviews were recorded through Zoom, which allowed for participant voices to be preserved and to increase descriptive validity. Interview Fidelity Secondly, a structured interview guide was used to ensure the ECIT method was followed consistently and accurately. This ensured that (a) the research method was being followed, (b) the interviewer was not asking leading questions or prompting the participant, and (c) the interview guide was being followed (Butterfield et al., 2009). Independent Extraction of Critical Incidents Afterwards, incidents were extracted independently by four peer researchers, who were provided with four separate transcripts (25% of the total number of transcripts) to analyze. Out of SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 46 a total of 63 incidents, there was a total of 10 small discrepancies due to semantics and choice of words in labelling an identified incident. There were also 11 larger discrepancies due to differences in identifying incidents, primarily due to uncertainties around whether the participant was mentioning a new incident, or simply recalling another example of a previously shared incident. This resulted in an accuracy rate of 83%. Each discrepancy was then discussed with the peer researchers to resolve any uncertainties regarding an incidents’ context and importance. Exhaustiveness For the fourth credibility check, the final number of participants was determined once reaching the point of saturation; otherwise known as exhausting the data. This occurred after 13 participants, upon which no new categories were generated, providing the researcher with confidence that the participants’ perspectives have been fully expressed. A table tracking the emergence of new categories is outlined in Appendix G. Participation Rates Subsequently, the participation rates for each category were calculated to determine their relative importance. A participation rate of 25% (four participants) was used when developing categories, which organized the categories in terms of relative importance. Placing Incidents into Categories by an Independent Judge The next credibility check consisted of sorting the incidents into categories by an independent judge. Fifty-five incidents (25% of the total number of incidents) were provided to the independent judge and the accuracy rate was calculated to be 84%. This is an acceptable accuracy rate as suggested by Butterfield et al.’s (2009) match rate guideline of 80%. Cross-Checking by Participants SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 47 Additionally, a second follow-up interview with the participants was conducted over email during which participants were provided with the opportunity to comment on the accuracy and representativeness of their incidents and the categories in which they were sorted. Of the 15 participants, 14 participants (93%) opted-in to complete a follow-up interview, where they crosschecked their factors and categories and expressed that the results felt representative of their selfharm recovery processes. The follow-up interviews also resulted in a total of 12 new critical incidents being added, bringing the final number of critical incidents to 219. Expert Opinions Feedback was obtained from Registered Psychotherapists Jen Watt (CRPO #009701) and Helen So (CRPO #009671). The categories were submitted to these individuals, due to their extensive work and clinical experience regarding emotion regulation concerns and Asian Canadian clients. Both experts confirmed that the categories were congruent with their knowledge of the research and professional experience and believed the categories to be useful. Theoretical Agreement The final credibility check consists of two parts (Butterfield et al., 2009). The first is concerned with articulating and reporting the assumptions underlying this study. In this study, three main assumptions are (a) self-harm recovery is a subjective construct that can be achieved, (b) individuals who consider themselves to be recovered can be aware of it and have the capacity to articulate their experience, and (c) the experience of second-generation Asian Canadians contains insight unique to this population that cannot be uncovered from the experience of other populations. The scholarly literature was reviewed within the appropriate disciplines to determine whether the above assumptions were supported. The literature for this study was reviewed, SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 48 which included non-suicidal self-injury, developmental psychology, counselling psychology, ethnic identity, and other relevant areas, finding support for these underlying assumptions. The second part of this credibility check requires that the categories be compared with relevant scholarly literature. However, while theoretical agreement is desired, it is also important to note that ECIT by nature, is exploratory. Thus, lack of support for one or more categories may indicate a novel finding, rather than the categories being unsound. The categories from this study were compared with the literature and are discussed in more detail in the Discussion chapter. SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 49 CHAPTER 4: RESULTS Overview of Results In this chapter, the summary of participant responses throughout the three main components of the interview is presented below. This includes the contextual component, the ECIT component, and the pre- and post- interview scaling questions. Contextual Results At the beginning of the interview, participants were invited to respond to two contextual questions regarding their personal understanding and definition of the terms “biculturalism” and “recovery”. The purpose of the contextual questions was two-fold—to build rapport with the participants while also understanding the reference point from which each participant experiences their bicultural identity and recovery process as a second-generation Asian Canadian. Since each participant self-identified as bicultural and recovered from self-harm, clarifying these definitions aimed to provide a deeper and more nuanced understanding of the helping, hindering, and wish list incidents. As outlined in Chapter 3, Braun & Clarke’s (2006) method of thematic analysis was used to code and group participant responses into themes. Biculturalism When participants were asked what being bicultural means to them, they were encouraged to provide their own subjective definition and informed that the researcher was interested in how their personal and environmental context may have shaped that definition. A total of 66 codes emerged from participant responses, resulting in the creation of four themes: a sense of belonging, tension and balance, a connection to self, and growth and learning. SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 50 Sense of Belonging. This was the largest theme, with a participant rate of 80% and a total of 23 items. When asked what being bicultural means to them, many participants described a longing to belong to a group of people, a culture, or a community. Growing up, many participants recalled feeling as though they did not belong, with one participant sharing how “being othered by classmates” (Participant 10) enhanced uncomfortable thoughts and emotions regarding their Asian Canadian identity. Feeling “different” (Participant 3), “separate” (Participant 4), and “rejected” (Participant 8) were some of the words used by participants when describing their experience of being bicultural. Then, this initial feeling of “not belonging” (Participant 5) seemed to transition into a feeling of “belonging to both” (Participant 5). This transition was echoed by many other participants, who began sharing how their sense of belonging seemed to correspond with their own developmental trajectory. One participant shared how they now enjoy “sharing my experiences and what it means to be Chinese with other people” (Participant 4), with another participant sharing how “finding solidarity with other Asian Canadian people” (Participant 10) has allowed them to define more strongly what being bicultural means to them. Thus, this desire to belong and journey of belonging was a theme that emerged for many participants and was considered an important dimension in the definition of what it means to be bicultural. Tension and Balance. The second theme identified was tension and balance, with a participant rate of 73% and a total of 24 items. Along with a sense of belonging, many participants also identified feelings of tension and balance when describing what being bicultural means to them. Participants shared how constantly “juggling norms” (Participant 2) and experiencing “cultural conflicts” (Participant 10) contributed to feeling unsure of how to navigate a bicultural identity. Often opposing cultural norms and expectations also led to SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 51 participants feeling a need to “balance” (Participant 6) their Western and Eastern identities. For instance, one participant disclosed how they felt certain traits, such as “self-confidence” (Participant 8), are not as emphasized in Eastern cultures, whereas it tends to be more emphasized in Western cultures, leading to tension and confusion when attempting to integrate this trait into their own life. Navigating relationships with others also resulted in “a lot of tension, just struggle” (Participant 2), with one participant describing how a desire to be accepted by others led them to “overcompensate” (Participant 4) socially. Moreover, similar with the first theme, participants also described a transition process in which they found this tension and balance “more blendable” (Participant 13), that they felt more able to “relate to both” (Participant 8), and that they now believe they have the “best parts of both” (Participant 9). Therefore, this theme demonstrates how holding this tension and having to balance two cultures is an important aspect of how the participants define being bicultural. Connection to Self. Thirdly, a theme of connection to self was identified, with a participant rate of 53% and a total of 10 items. Participants also described this theme as a process that evolved over time, beginning with feeling “self-conscious” (Participant 14) and “self-hating” (Participant 4), and transforming into feeling “more comfortable” (Participant 14), more “myself” (Participant 9), and “proud” (Participant 12). One participant elaborates on their own experience, sharing how they feel more able to “be myself in a way that feels representative of where my family comes from” (Participant 6). Another participant shared initially feeling as though they were playing a role with the different parts of their identity. They describe how they felt they were wearing a “mask” or a “costume” (Participant 13); however, they were eventually able to come to a place where they felt more themselves. As a result, the participant responses SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 52 seem to indicate that this process of connection to themselves influences how they view being bicultural and is another important dimension in conceptualizing this definition. Growth and Learning. Lastly, growth and learning was another theme identified from the participant responses, with a participant rate of 53% and a total of 8 items. Participants described how growing and learning helped them “accept the difference” (Participant 14) and “appreciate both sides” (Participant 8) of their identity; a process that shaped how they viewed themselves and what it means to be bicultural. Being open to this process seemed to help participants feel more able to embrace their evolving identities and to engage in self-reflection on how this growth and learning has impacted them. For instance, according to one participant, “over time, I learned more about how other people experience being Filipino and what it might mean in different ways that my family didn't talk about, and so now, I feel very proud to be Filipino” (Participant 12). This openness to growth and learning also provided another participant with the opportunity to “appreciate my Chinese heritage more” (Participant 4); an appreciation they reflected was not present previously. Participants described how their realizations and reflections occurred over an extended period of time, demonstrating that defining what it means to be bicultural feels intertwined with engaging in a continuous process of growth and learning. Therefore, this was another important dimension that emerged when discussing what it means to be bicultural. Recovery When participants were asked what recovery means to them, they were again encouraged to provide their own subjective definition and informed that the researcher was interested in how their personal and environmental context may have shaped that definition. A total of 66 codes SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 53 emerged from participant responses, resulting in the creation of 4 themes to describe the term recovery: elusive and process-oriented, cognitive, behavioural, and emotional/somatic. Elusive and Process-Oriented. The first theme that emerged as participants described recovery was that it is an elusive definition and extremely process-oriented. This was the largest theme, with a participant rate of 80% and a total of 22 items. Participants used words such as “abstract” (Participant 5), “complex” (Participant 14), “not definitive” (Participant 3), and “ongoing” (Participant 9) to define recovery. This uncertainty around defining recovery was expressed by one participant, who questioned aloud, “I think in terms of recovery, it's unclear. Is it that I’m not doing it in the same ways that I used to? Is it that I have that urge and I don't?” (Participant 12). Many participants shared similar thoughts, with another participant referring to recovery as an “umbrella term for a lot of different things,” reiterating how it can be difficult to clearly define the boundaries of recovery. Moreover, another participant shared their thoughts on this elusive definition, who said, “I don't think recovery is very unipolar. I think there’s flexibility in what that means to people, so I think that's important too” (Participant 6). As such, the participant responses only emphasize the elusive and process-oriented quality of recovery. Cognitive. The second theme that emerged when describing recovery was a cognitive component, with a participant rate of 73% and a total of 20 items. While many participants shared uncertainties and difficulties in defining what recovery means to them, many were able to provide concrete examples of how they are aware of their own recovery in their own lives. This took the form of cognitive, behavioural, and emotional/somatic examples. Beginning with the cognitive component, one participant shared how “recovery means more being at peace with what happened, understanding what happened, and kind of accepting what happened” (Participant 5). This shift towards increased insight, understanding, and acceptance was SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 54 expressed by other participants as well, who discussed feeling more able to “focus on other things” (Participant 13), “redirect energy and attention” (Participant 9), and being more “conscious” (Participant 3) of how certain decisions, such as self-harm, impact their lives. As a result, participant responses demonstrated how their cognitive experiences are an important dimension of how recovery is defined. Behavioural. The third theme present when participants described what recovery means to them was a behavioural component, with a participant rate of 53% and a total of 15 items. In this theme, participants described how part of the recovery process includes a shift in their behaviour, such as “better coping mechanisms” (Participant 11), “doing something else” (Participant 15), and “not cutting” (Participant 2). Another participant shared how they conceptualize their recovery, which included changes in behaviour, stating, “that means not doing it and not even seeing it as an option … I used to cut myself with razors, just not even having those around” (Participant 4). Furthermore, “relapse” (Participant 15) and “staying clean” (Participant 2) were also mentioned as part of the behavioural component of self-harm. It also makes sense that part of the recovery process for these individuals would include a reduction in the frequency of their self-harm behaviour because participants had to have refrained from selfharm for a minimum of one year in order to meet the inclusion criteria for the study. Therefore, behaviour is another important dimension to consider in the definition of recovery. Emotional/Somatic. Lastly, an emotional/somatic component of recovery also emerged as a theme from participant responses, with a participant rate of 53% and a total of 9 items. Along with a cognitive and behavioural component, participants also shared how their emotional and somatic relationship with self-harm was an important dimension of what it means to be recovered. Participants mentioned feeling more “alleviated” (Participant 1), more “compassion SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 55 and love” towards themselves (Participant 10), and “more secure” (Participant 12). One participant also mentioned how managing physical sensations was a part of their recovery process, sharing that recovery meant “not itching to do it again” (Participant 6). Another participant commented on how their self-harm experience often included the belief that emotions should be suppressed, including positive emotions. They state, “I wasn't feeling allowed to feel these emotions that are positive and good … now it's shifted, and I am able to be like “that's okay, I deserve to feel this,” instead of trying to push it away constantly” (Participant 13). Therefore, this emotional/somatic component of self-harm emerged as a fourth dimension in what it means to be recovered. Critical Incident and Wish List Categories To answer the central question of this research study, participants were invited to describe the factors that were helpful, harmful, and wished for throughout their self-harm recovery process as a second-generation Asian Canadian. From the 15 interviews, 207 incidents were identified. After the follow-up interviews were completed, 12 more incidents were added, bringing the final total to 219. Of this total, 80 were identified by participants as helpful for selfharm recovery, 76 were identified as hindering, and 63 were identified as wish list factors. The 219 incidents were sorted into 19 categories: 7 that were helpful, 7 that were hindering, and 5 that were wished. The categories were strategically named to accurately capture and represent the contained incidents. These categories will be more thoroughly discussed throughout the remainder of this chapter. Categories that Help with Self-Harm Recovery Seven categories were identified by participants as being helpful in self-harm recovery for second-generation Asian Canadians. Table 2 contains a summary of the categories and SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 56 corresponding participation rates for each category. While the categories are described in order of decreasing frequency of incidents, this is not to be equated with level of importance. Instead, it is to observe a high degree of commonality that indicates the category may also be found in other individuals as well. Table 2 Categories that Help with Self-Harm Recovery Category Number of incidents Number of participants (% of total) (% of total) 1. Activities and Alternatives 17 (8%) 9 (60%) 2. Friends, Peers, and Other Social Supports 15 (7%) 10 (67%) 3. Intrapersonal Factors 14 (6%) 10 (67%) 4. Professional Supports 12 (5%) 9 (60%) 5. Family Members 5 (2%) 5 (33%) 6. Romantic Partner 5 (2%) 5 (33%) 7. Financial/Life Stability 5 (2%) 4 (27%) Category 1: Activities and Alternatives (17 incidents, 9 participants). This category includes incidents of participants engaging in any action or pursuit that prevents, alleviates, or postpones their desire to and/or behaviour of self-harm. For instance, helping incidents in this category ranged from art, volunteer work, mindfulness, music, keeping busy, and having a structure or routine. Participants described how these incidents were instrumental in reducing the intensity and immediacy of self-harm, with one participant expressing that “in the moment you want to, it's like you're in this type of frenzy because you can't control your emotions. So, if enough time had passed where my rational brain just starts kicking in, then I wouldn't” (Participant 8). SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 57 Completing other tasks in place of self-harm also acted as a physical barrier to the behaviour, with one participant describing how keeping busy resulted in distraction. “So, even if I wanted to self-harm, I don’t even have time” (Participant 11). In addition to being a physical barrier, some participants described how activities and alternatives could have an emotionally transformative quality, with one participant sharing how their practice of painting and ceramics was particularly helpful in relieving themselves of emotional distress. They stated it was “extremely cathartic and healing for me … reflecting on all of these experiences I’ve had” (Participant 10). Consistent engagement in activities was also observed to help participants maintain recovery, by helping participants cultivate adaptive coping strategies for emotion regulation, processing, and mindfulness. One participant described how yoga helps ground them mentally and emotionally: It helps with a routine. I do really well with structure … So, I think instilling in my head that I do yoga every day at around this time for a certain amount of time, I know that that's my time to slow down and to observe my thoughts and focus on myself and how I’m doing, how my body is doing, how my brain is doing, whereas before I didn't have anything like that. I didn't have a routine to sit and meditate, I was just really anxious and floated around to different places and different things and different activities all the time … it's a form of maintenance care too, especially on days that I don't feel like doing yoga, I know that if I do it, regardless of that feeling, that it'll be a lot better for me and that it'll help me push through those waves of being low … that kind of consistency really, really helps me. (Participant 9) Category 2: Friends, Peers, and Other Social Supports (15 incidents, 10 participants). This category includes incidents revolving around the presence of a friend, peer, SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 58 or other social support; a person whom the participant knows and with whom they have a bond of mutual affection and/or a person of similar age, status, or ability, typically exclusive of sexual or family relations. Helping incidents in this category primarily consisted of close friends, with many participants expressing how sharing their experiences and feelings around self-harm was particularly helpful in receiving emotional support, understanding, insight, and guidance. According to one participant, “my friends, they helped me a lot. I mean, we built a very solid bond, so I feel like I could tell my friends anything … I can share my experience with them, I can get support from them” (Participant 5). Another participant shares the many ways in which their friends played a pivotal role in their recovery process: My friends are so nice, they're all so sweet and they don't invalidate your feelings whenever you're talking about something. I’m a very emotional person, so a lot of my close friends are able to root me in reality and ground me whenever my mind starts racing a million miles per hour … And they remind me that self-harm doesn't actually do much for me in terms of what I’m trying to escape from, or what I was trying to escape from in terms of why I self-harmed in the first place. They help me realize that this is just hurting me like further, this isn't going to get me the result that I wanted … just their presence and also them talking to me about this in the first place is like a reminder of hey, I matter to people. These people are taking their time out to talk to me and to hear me out, and that meant the world to me, especially when I felt like I was so alone and like I hadn't nothing to turn to or no one to turn to. It was an overwhelming wash of relief, knowing that people care about me. (Participant 2) Moreover, friends, peers, and other social supports were also described as helpful due to their ability to model and facilitate healthy attachments; to others and to oneself. One participant SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 59 shared how developing healthy friendships was helpful because they “didn't expect me to justify my life and what I was feeling and to be cheery or to prove my self-worth to them,” which in turn “made it more possible for me to believe that I had self-worth on my own” (Participant 12). Another participant expressed a similar sentiment, stating: I think that it's definitely helped me also accept myself a lot more. Because at the beginning when I was self-harming the most, I went through two years where I was not at all okay with feeling the emotions I was feeling. I was blaming myself a lot and questioning why I was like this or why things are the way that they are and just a lot of self-hatred. But having people around me to remind me that that's not the case, or that it's normal and it's okay to feel the way that I feel has definitely allowed me to also have a little bit more compassion for myself … just supporting me, sometimes not even saying anything, sometimes just listening, makes things feel so much more normal and okay and bearable. (Participant 10) Category 3: Intrapersonal Factors (14 incidents, 10 participants). This category includes incidents originating from within the participants themselves, such as their emotional or cognitive awareness, willingness/readiness, and sense of self. Many participants identified increasing insight and self-awareness as a helpful factor in their self-harm recovery process, with one participant expressing that gaining more insight allowed them to “focus on things to take care of myself a bit more” (Participant 4), while another participant described that “by understanding it better, I feel like I had a better vantage point for helping myself recover … the more you understand something, the less ambiguous it is” (Participant 11). SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 60 A change in mindset was also observed to be a helpful intrapersonal factor, with one participant sharing how this change helped them realize that they are worthy of recovery. They stated: When you're in that space of wanting to hurt yourself and being in such a dark headspace, you think a lot of things about yourself and about what you do and don't deserve. I think with eventually changing my mindset and my outlook towards myself, I recognized I deserve to not be in pain all the time. I deserve to not cause myself pain purposefully all the time. (Participant 9) Other helpful intrapersonal factors focused on the participants’ emotional experience, where gaining emotional maturity and a willingness to express one’s emotions helped them cope with intense emotions as they emerged. One participant describes this process by stating: As you get older, you understand that how you feel is not always going to be the case, and of course when you're younger, you just don't have that understanding as much, so when you're older, you are more aware that the really terrible, frenzied feelings are going to go away, so you're better at dealing with it. (Participant 8) Category 4: Professional Supports (12 incidents, 9 participants). This category includes incidents related to seeking and receiving professional help and services. Professionals that most participants perceived as helpful were mental health professionals and, in particular, counsellors and psychotherapists. Participants described individual therapy as helpful for their self-harm recovery process through alleviating and processing thoughts and emotions that they felt unable to express with others. One participant stated that “talking about painful memories with someone else, just talking about it and sharing just makes me feel better” (Participant 1), and another participant shared how “having someone that consistently knew me … Someone that SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 61 could recognize my patterns and listen to me … I never felt like I was going to them with anything like too big or too small” (Participant 4). Individual therapy was also identified as being helpful due to being a safe space for modeling, learning, and practicing more adaptive ways of relating and coping beyond the therapy room. One participant described how they would draw upon their therapy sessions at home, stating, “being able to be like “you're not in session right now but envision that you are” … deep breathing, all the mindfulness things I would do, I would try to do at home” (Participant 6). Lastly, participants identified therapy as being helpful in challenging the thought patterns that would often lead to instances of self-harm. Specifically, one participant shared that they learned “how I can challenge those thoughts instead of letting those thoughts consume me” (Participant 2). Category 5: Family Members (5 incidents, 5 participants). This category includes incidents related to immediate family members of the participants, such as experiences and relationships with a participants’ parents and siblings. Some participants mentioned appreciating the financial assistance provided to them by their parents, with one participant expressing that “there's a lot of financial stressors my parents have been able to take care of for me. So, that's never been an external factor or an external stressor for me” (Participant 9). Other participants identified their siblings as being helpful for their self-harm recovery process, sharing how their presence often represented a source of comfort, support, and motivation to refrain from further instances of self-harm. For instance, one participant shared how receiving an encouraging letter from their brother was impactful, stating, “it was like having somebody look out for you and take care of you in a way that you aren't doing for yourself, and to see how you are hurting other people by doing that. Not just yourself” (Participant 8). Another participant mentioned how reminding themselves of their sister is particularly helpful in SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 62 managing thoughts and feelings of self-harm, sharing that “whenever I feel like I’m in a bad spot, I try to just remind myself ‘hey, what have you told your sister? You should be telling yourself as well.’ It's very reflective in those situations” (Participant 14). Category 6: Romantic Partner (5 incidents, 5 participants). This category includes incidents related to individuals with whom the participants had a romantic or sexual relationship. Participants shared how their healthy relationships promoted recovery through connection and communication not experienced in other types of relationships. This intimacy was described by one participant, who said: For someone who hasn't gone through self-harm or self-harm recovery themselves … I think he does a really great job in terms of trying to help me through if I spiral, or just gives me my space, which allows me to go back to making my own choices … I don't feel pushed, I don't feel like I have to quickly make a decision, or if I’m suddenly starting to feel really down and under the weather, I’ve never felt at fault for ruining a date or something … And I think understanding all of that and being okay with that and then accommodating that on top of it, without making me feel guilty or without trying to make me feel guilty, is another layer of me being able to work through my own journey without any interference. (Participant 13) Another participant elaborated on the support received by their partner and how they felt it differed from other types of relationships. They stated: Having common ground and being able to talk about [self-harm] with someone who loves me and cares about me has been a relief, and in romantic relationships, I feel there's a lot less filters, a lot less things I have to worry about saying wrong because the communication feels so much more enhanced. (Participant 2) SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 63 Category 7: Financial/Life Stability (5 incidents, 4 participants). Lastly, this category includes incidents related to a participants’ ability to generally remain financially and/or independently stable in life. Participants described how financial and/or life stability helped them experience more independence, autonomy, and control, which resulted in a decreasing desire to self-harm. For instance, one participant shares: I think in terms of recovery, it was helpful because I felt like all my decisions were my own. There was no one trying to push decisions on me or anything like that, no one was trying to force me to recover … Being able to go on my journey dictated by myself, I felt in a sense that a lot of my life had been dictated by my parents or by the people around me, so by having this chance, it was really valuable to me and it meant a lot to me. (Participant 13) Another participant identifies how achieving financial independence was particularly helpful in alleviating feelings of guilt and dependence. They state: I no longer had to feel guilty that I was asking [my parents] for money when I can make my own, so they really had no excuse to say no to me if I wanted to buy something or go out with my friends. They just had a lot less control over what I did and chose to do growing up, once I got a job. (Participant 14) Categories that Hinder Self-Harm Recovery Seven categories were identified by participants as being hindering in self-harm recovery for second-generation Asian Canadians. Table 3 contains a summary of the categories and corresponding participation rates for each category. While the categories are described in order of decreasing frequency of incidents, this is not to be equated with level of importance. Instead, SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 64 it is to observe a high degree of commonality that indicates the category may also be found in other individuals as well. Table 3 Categories that Hinder Self-Harm Recovery Category Number of incidents Number of participants (% of total) (% of total) 1. Intolerance from Others 16 (7%) 9 (60%) 2. Family Members 10 (5%) 8 (53%) 3. Professional Supports 10 (5%) 7 (47%) 4. Cultural and Contextual Factors 9 (4%) 7 (47%) 5. Intrapersonal Factors 9 (4%) 8 (53%) 6. Media and Role Models 8 (4%) 7 (47%) 7. Activities and Alternatives 5 (2%) 4 (27%) Category 1: Intolerance from Others (16 incidents, 9 participants). This category includes incidents where participants perceived others as being unwilling or incapable of accepting or showing compassion towards them, their self-harm, their thoughts, and/or their feelings. Many participants identified lack of understanding from others as particularly hindering for their self-harm recovery process, with one participant stating: Before, when it was ongoing and I was new to the whole situation, when people would ask about it or question it, it definitely made it worse because it gave me a feeling of “oh, I’m weird, I’m standing out, people don't get it, people are judging, people are assuming, they're talking about me” … it just gave me more of an isolating feeling like “okay, so I can't talk to people about my emotions.” (Participant 3) SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 65 Another participant shared how lack of understanding of mental health and the general public’s perception of self-harm was hindering because “it just felt most stigmatizing, right? I was already ashamed … you're just putting fuel to the fire as to why it would feel like crap” (Participant 6). This was echoed by yet another participant who described how they experienced feelings of shame resulting from the harsh words of others. They shared: There are people who are like “if you cut yourself, you’re a loser … If you cut yourself, that's such a weak way to go about it. You should confront your problems” … it just makes you feel worse and more prone to doing it. (Participant 10) Lack of empathy, stigma, rumours, and labelling were also cited as being unhelpful, which influenced the way others reacted and responded to the participants and their self-harm. This ranged from family and friends, to strangers, as well as health care practitioners. One participant provides an example of how the stigmatization behind self-harm was particularly hindering for them: It being taboo meant that nobody had a really good understanding of what was happening with self-harm, including health care practitioners. They weren't asking me “why,” so I wasn't interrogating “why.” I wasn't trying to figure out what it was giving me. They also assumed that they knew why and that it was to get attention … That’s still something that people believe. That if you're seeking mental health support, you're doing it to get attention and not also that maybe that person needs attention. Needs care. (Participant 12) Category 2: Family Members (10 incidents, 8 participants). This category includes incidents centred around the relational dynamic between the participant and a family member. Specifically, many participants identified their relationship with their parents as hindering their self-harm recovery process. Participants described how a distant, inconsistent, and conflictual SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 66 relationship contributed to a desire to withhold information about themselves, suppress their emotions, and further distance themselves from their family. For one participant, they said: I felt like I didn't have anyone in my family that I could rely on or that I could talk to, or that I could just express myself. So, I would be very closed off from my family. And it felt very isolating if I can say, you know? I felt persecuted in a way that I can’t show what I was really feeling. I always have to put a mask on. (Participant 5) Participants also shared how this dynamic enhanced their experience of certain emotions, such as anger. This was hindering for their self-harm recovery process because it further contributed to instances of emotion dysregulation, increasing their desire to self-harm. According to one participant, “it just made me so angry, because I was like ‘you're so oblivious to what's happening, and you're supposed to be my mother’ … just makes me feel gross” (Participant 3). Another shared how after their mom found out about their self-harm behaviour, they were refused therapy. They elaborate on how this interaction made them feel, stating: It was like you have to hide your pain over again, and you just want to hide it more because of course you're going to get in trouble. You don't want them to know, and you become more secretive about it. At the same time, you're angry because why would you not get your child help after that? (Participant 8) Other aspects of the parent-child dynamic that were identified as hindering included their parents’ expectations and parenting style. Feelings of shame and a desire to resist were two additional responses felt by participants. One participant describes how the weight of their parents’ expectations impacted them, stating: SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 67 I felt a lot of shame that I was going through this because I was very much like “I shouldn't be like this, this shouldn't be me, I’m not like this, in a sense” … I felt like I had let down my own parents. (Participant 13) Category 3: Professional Supports (10 incidents, 7 participants). This category includes incidents related to experiences with members of a profession. This includes those working in the field of mental health, physical health, and education, as well those working within the participants’ own occupation. Many participants cited poor experiences when seeking professional supports, which further discouraged their self-harm recovery process and prolonged their feelings of isolation. Two participants discussed how mandatory reporting requirements and the limitations around confidentiality by mental health professionals felt particularly hindering at the time because of a lack of clarity and assurance when informing the participants of these requirements. For one participant, a negative experience with a school psychologist left them feeling uncertain and skeptical. They state, “I feel if he didn't do that, my recovery would probably go a lot smoother. But it's okay, I understand he was just doing his job, but I felt a lot of mistrust towards him after that” (Participant 5). Another participant shares how learning about the limits of confidentiality posed as a barrier in terms of their mental health treatment: You're always scared to disclose because you're afraid that you're going to get hospitalized. I think it took a while for me to disclose that I was self-harming as much as I did … Then not feeling secure enough to disclose past abuse that was experienced. In a way, that felt like it would impact everybody in my life … It just impacted my ability to be truthful in a way that I think would then allow me to grow in treatment. (Participant 6) Other participants shared how a lack of access to mental health support and resources was also hindering for self-harm recovery as it directly impacted the quality of services available to SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 68 them, as well as how they felt about accessing services overall. One participant shares how they felt, stating, “You feel more alone, and also what right do you have when so many other people are struggling right now”? (Participant 8). According to another participant, this lack of accessibility felt particularly hurtful, expressing that it felt like “there was like no place for me. And that was like rejection, but on a systemic level” (Participant 10). Category 4: Cultural and Contextual Factors (9 incidents, 7 participants). This category includes incidents related to the participants’ cultural and contextual experience. Specifically, participants identified feeling a tension between a variety of traditionally Eastern values in contrast with more traditionally Western values. For instance, one participant described how the value of filial piety and a sense of obligation towards one’s parents was experienced as a lack of autonomy. They stated: That just made me more miserable … just pushed me down even more. There were some days where I struggled not to cut over and over again because I just felt like I couldn't have anything in this house, like I had let my parents down somehow. (Participant 2) According to another participant, their parents’ cultural view of mental health also hindered their self-harm recovery process. A more traditional, biological view of mental health impacted how much of their emotional experience the participant wanted to share with their parents. They recall how they felt in their earlier years: I remember when I was younger, I was under the impression they didn't believe that depression was real or that anxiety was real … And so, I know even from a very young age, I didn't feel comfortable being emotionally vulnerable to my parents. (Participant 9) Feelings of cultural isolation was also identified as being hindering for self-harm recovery. Living in a community in which the participant and their family was relatively isolated SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 69 from other families of colour, one participant mentions that it “normalized things that really shouldn't have been normalized” and that it “individualized the issue as well” (Participant 12). Specifically, it resulted in the participant equating unhealthy relational dynamics and instances of abuse with her parents’ culture of origin. Additionally, one participant shared how Asian beauty standards impacted their selfesteem. They describe how their appearance was often compared with others of the same ethnicity, and how their East Asian culture tends to prefer a slimmer figure and lighter skin colour. They share that this constant comparison hindered their self-harm recovery because: It was something that would drag me back into the self-harm territory because I wanted to be like that so badly. It made me feel a lot of emotions and it would make me drag myself back into that place. (Participant 13) Category 5: Intrapersonal Factors (9 incidents, 8 participants). This category includes incidents primarily originating from within the participants themselves. Examples of intrapersonal factors that participants identified as hindering ranged from lack of self-awareness, low self-esteem, insecurities, and expectations of self. One participant said, “Overthinking usually ends up where I’m upset over a situation that happened, or even a scenario I’ve made up in my head, and then it just pushes me back to thinking about self-harm” (Participant 15). Another participant expresses how devaluing their physical appearance resulted in an increase in instances of self-harm. They state, “my physical appearance is already crap, I might as well add scars to it” (Participant 6). A lack of self-awareness was also cited as a hindering factor in participants’ self-harm recovery process. For one participant, this lack of awareness meant an inability to acknowledge and seek support for their self-harm. They said: SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 70 I can't confront a problem if I don't acknowledge that there is one, and I think that's very true. So, I would just bury my feelings repeatedly and I felt so badly, but in my mind, was like there's nothing wrong with me I just like am, you know, deficient in some way, I guess. And that was the dominant narrative in my mind for a long time. (Participant 10) A similar sentiment was also expressed by another participant, who described how “as long as I don't acknowledge the fact that I’m suffering and that I’m in pain, as long as I’m in denial of it, as long as it doesn't come to conscious awareness, then it would help me cope” (Participant 1). Category 6: Media and Role Models (8 incidents, 7 participants). This category includes incidents surrounding the media and role models. For instance, social media was mentioned by many participants to be hindering for their self-harm recovery process, with one participant sharing that “you start degrading yourself and then it adds to the depression and stress. Negative stress you don't need” (Participant 7). In fact, several participants identified Tumblr specifically as the social media platform that felt the most hindering. One participant described how online communities on Tumblr promoted and encouraged the self-harm behaviour of its members, which furthered their emotion dysregulation and maladaptive coping strategies. They stated: I was on the eating disorders community and on the self-harm community and just selftriggering myself; pictures of self-harm and talking about my own self-harm. It was a network of bad energy of all these people that were doing so unwell that were just feeding off of each other. We all needed help, but we're all struggling, we're all not in a place to be helping each other. (Participant 4) SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 71 These communities on Tumblr felt hindering for another participant as well, who shared how the pressure and desire of wanting to connect with others impacted their recovery process: It just felt like for a period of time, I wanted to not make progress … it was so negative, to the point where people would take pictures of their self-harm and post. So, to a certain degree, it felt like if you wanted to post, you needed content, and so, peer pressure to do it and then not only to do it, but then show off proof that you did it. (Participant 6) A third participant reiterates many of the same thoughts and feelings shared previously, describing how impressionable they were and how although these communities were born from an intention to support one another, it had become a place that felt “really destructive, enabling” (Participant 9). Category 7: Activities and Alternatives (5 incidents, 4 participants). Lastly, this category includes incidents where a lack of activities and alternatives felt hindering for participants. This category also encompasses activities and alternatives that increased a participant’s likelihood and desire of engaging with self-harm. Many participants expressed feelings of isolation, and although wanting to engage in other activities and alternatives, feeling unable to or being restricted from doing so. For instance, one participant explains: I didn't have any resources or support, or even the ability and the option to engage in activities that would help me feel better. I was basically locked up at home every day. I’d go to school and come back, and I was ordered to stay at home and not step a foot outside. So, I literally didn't have any options to go for a run or meet up with friends or play an instrument or whatever. Again, I was only able to read, write and self-harm. That was my option. I lacked the freedom to engage in healthy ways of coping with stress. (Participant 1) SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 72 This was expressed by another participant, who described feeling “trapped” at home with self-harm as their only option. They state: I'd be stuck in my room and just cry, and everything that I used to self-harm was in there, so if I got my cell phone taken away, or my laptop, or whatever, there wasn't somebody that I could then reach out to for help or to even be distracting like “hey, I’m having a bad day, tell me something stupid.” (Participant 6) Lastly, another participant discloses how experimenting with substances became an additional way of coping, which led to an increase in emotion dysregulation and isolation. They share that as they were under the influence, they were “more impulsive and irrational and emotional” (Participant 4), leading to further instances of self-harm and hindering their recovery process. Wish List Categories for Self-Harm Recovery Five categories were identified by participants as wish list items in self-harm recovery for second-generation Asian Canadians. Table 4 contains a summary of the categories and corresponding participation rates for each category. While the categories are described in order of decreasing frequency of incidents, this is not to be equated with level of importance; rather, to observe a high degree of commonality which indicates that the category may also be found in other individuals as well. SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 73 Table 4 Wish List Categories for Self-Harm Recovery Category Number of incidents Number of participants (% of total) (% of total) 1. Professional Supports 19 (9%) 9 (60%) 2. Family Members 13 (6%) 11 (73%) 3. Friends, Peers, and Other Social Supports 11 (5%) 10 (67%) 4. Intrapersonal Factors 6 (3%) 4 (27%) 5. Activities and Alternatives 5 (2%) 5 (33%) Category 1: Professional Supports. This category includes incidents related to experiences with members of a profession. Participants wished for improved access to mental health services, additional supports and mental health education within schools, and more positive experiences with those in the mental health field. Having access to a mental health therapist was wished by participants in both the past and the future, with one participant sharing that they believe it would be helpful for them to “understand why you feel certain things and why you might think certain ways, and then just another outlet to express what's going on in your life. Just to have some more support as well” (Participant 15). A desire for humanization and validation was also expressed by another participant, who wished they had had a therapist in the past to “tell me that it's okay for me to be doing that. I’m not doing anything wrong, I’m not weird, I’m not abnormal, I’m also human” (Participant 1). Furthermore, one participant shared their wish to one day participate in group therapy again. When asked what they find appealing about group therapy, the participant responded that “I really liked the camaraderie aspects and support. Therapists are great, but there's just something very unique and special in my experience of going through that with somebody who's been in your position” (Participant 6). SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 74 Participants also wished for earlier and better-quality supports within schools and the education system. One participant expressed how earlier support would have been beneficial, stating that: If I just had access to some kind of brochure, flyer, presentation, or workshop available at the schools, it would have given me a head start in beginning my mental health journey. I would have been able to learn about what I was experiencing a lot earlier than 20. (Participant 1) Another participant shares a similar wish, in which they wonder whether mental health education could have served as a bridge of connection and conversation between them and their parents. They state: If we had had mental health education back then, things could be different. I could maybe be able to talk to my mom about like “Oh, this is what we're doing in school.” So, if the school is doing it, it creates that bridge that you can then connect over. (Participant 9) Lastly, participants wished for physical health resources and support as well. Other incidents mentioned include improving one’s own physical health, being hospitalized, and more separation between mental health and physical health records. One participant shares how bettering their own physical health would improve their self-harm recovery process because they would have a “stronger foundation to work off of” (Participant 13), whereas another participant wished that their therapist has chosen to hospitalize them, which would have provided them with the opportunity to “focus on recovery and not have access to all these bad things and not have the negative things in your daily normal life impact you too” (Participant 6). Category 2: Family Members. This category includes incidents centred around the relational dynamic between the participant and a family member. Many participants described SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 75 how they wished to receive more understanding from their parents, with one participant stating that it would have helped their self-harm recovery process because “looking back, I remember just feeling so alone and that nobody felt this way” (Participant 14). Another participant also expressed wanting more understanding and space from their parents because “I feel like I would probably maybe open up a little bit more with my family and get the support that I needed from them as well” (Participant 5). Other aspects wished for by participants included receiving more physical touch from their parents. One participant shared how they longed for more physical touch and that it would have been beneficial for their recovery process because “being hugged feels so nice and reassuring and I don't even have to express my emotions to you, but if I can get a really nice hug, it feels the same as being listened to” (Participant 3). More communication with one’s parents was also mentioned as a wish list item, with one participant expressing a desire to eventually discuss their mental health with their parents. In sharing how this would be helpful in continuing and maintaining their self-harm recovery, they share: There's definitely a lot that I want to learn from my parents and learn about my parents before they get too old. And I’ve always struggled with the idea of keeping the self-harm secret from my mom for so long and keeping it forever and just never ever telling her. That's something I struggle with time to time. Is it worth telling her? Do I need to tell her? Do I want to tell her? Or do I just want to leave it as an ignorance is bliss situation and just not tell her at all? And it brings into question how much vulnerability I want with my parents and how much vulnerability I want from them to me, which I think is really hard for Asian families, because that's not something that you talk about ever, emotional and being vulnerable. You just don’t talk about it. (Participant 9) SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 76 Several participants also named their siblings as important wish list items in their selfharm recovery process. One participant shared how simply knowing her younger siblings are doing well in life would be helpful because: If they don't find [their places in life], I know I would feel so guilty that I wasn't able to do more. And, of course, that isn't attached to what they decide to do with their lives, but I know that it would bother me to the point where I feel so much guilt and frustration towards myself. (Participant 13) Whereas another participant shared how they wished they had had a closer relationship with their sibling growing up because “just having one ally, especially with that family, me and him went through the same thing with our parents’ divorce, all our family drama. So, just having someone … who could understand, who I could go to for support” (Participant 4). Category 3: Friends, Peers, and Other Social Supports. This category includes incidents revolving around the presence of a friend, peer, or other social support; a person whom the participant knows and with whom they have a bond of mutual affection and/or a person of similar age, status, or ability, typically exclusive of sexual or family relations. Participants expressed how they wished they had had stronger support systems, better-quality friendships, and received more compassion and empathy from others. One participant describes how cultivating a strong support system would be helpful moving forward because “you’re reflective of your friends and your friends are reflective of you. So, I don't want to surround myself with terrible people who bring me down” (Participant 3). Another participant shares that they wished they had met their current group of friends sooner because they would have been able to receive more emotional support whilst navigating self-harm recovery. They state: SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 77 When I started to open up, there wasn't really much reciprocation from my older friends. It was more just that they didn't pry, they didn't really ask many questions … but when I tried to open up, there wasn't any kind of comfort. I wanted to feel that sympathy, but there was nobody to really give it, versus in my new group of friends, it's kind of a mix of both. Nobody really pries unless someone decides to open up, and when they do decide to open up, it's a very welcoming atmosphere. (Participant 13) Participants also identified how they wished to receive more compassion, empathy, and understanding from others. One participant describes how what they wish for stands in stark contrast with what they had received, saying: I think compassion can come whether or not people understand. And a lot of what I received was shaming. I think if somebody had been able to say, “I see that you're hurting a lot and it sucks,” that might have made a really big difference. (Participant 12) This longing for connection was echoed by another participant, who described how receiving emotional, mental, and spiritual support would be helpful for continued self-harm recovery. They said it would contribute to a “better mentality. I wouldn't feel so depressed or alone as much. I wouldn't have to … fill that void” (Participant 7). Category 4: Intrapersonal Factors. This category includes incidents originating from within the participants themselves. Wish list items mentioned by participants revolve around being able to express one’s emotions, enforcing boundaries, reaching out to others, and fostering self-respect. One participant described how being able to express their emotions would have helped them sort through their feelings and ground themselves in times of emotion dysregulation, reducing their need to cope through self-harm. They state: SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 78 I feel that was definitely my turning point to when I got better is when I self-taught myself to express my emotions. So, I feel like obviously I wouldn't know, but if I was raised in a family where I was taught how to express your emotions and that it was okay, then maybe I would have never gotten into this situation. (Participant 3) Another participant shared how they hope to continue enforcing boundaries with others and with themselves. When asked how boundaries with themselves would be helpful for their self-harm recovery process, they said: Boundaries within myself, it's also resisting the urge to go to what I know, or go to what is easy, or go to what is learned, which is toxic coping mechanisms or self-harm in the first place … realizing that is a way to cope, yes, but it's unhealthy and it's detrimental, and being able to like tell my own intrusive thoughts like “no, we're not doing this.” (Participant 2) Reaching out to others was also identified as an intrapersonal factor that requires the capacity to acknowledge and accept help from others. According to one participant, taking the initiative to reach out in times of need would be helpful in being able to receive emotional support during dysregulation rather than afterwards. They share: Whenever I spiral, it's always by myself and I just don't like telling people. And I think moving forward that's something I really have to be able to deal with. Being able to acknowledge when I want to talk to someone and have them give me advice, because it's almost always that after I spiral, I message people. I’m like “hey, like I felt this way last night. I’m good now, but last night was really tough.” (Participant 14) Category 5: Activities and Alternatives. Lastly, this category includes incidents of participants engaging in any action or pursuit that prevents, alleviates, or postpones their desire SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 79 to and/or behaviour of self-harm. Participants shared how creating goals, seeking adventure, and implementing lifestyle changes would be helpful in maintaining self-harm recovery moving forward. One participant shared how focusing on goals would be helpful because it would allow them to: Use my mental space to focus on positive activities instead of focusing on negative things … I focus a bit too much on how poorly things are going, but I think having goals just keeps me focused on the next step and things that I can control, and it just keeps me away from those really negative thoughts. (Participant 4) Adventure was another wish list item that a participant identified as being helpful for future recovery. In accordance with their values, one participant shared how seeking adventure would alleviate feelings of isolation and provide them with “enlightenment, seeing the beauty of the world, of nature, of cultures” (Participant 7). Moreover, another participant shared how implementing lifestyle changes would be helpful in cultivating more adaptive coping mechanisms and ensuring an environment conducive for growth and self-reflection. They mention how they believe journaling would be helpful in order to “marinate in my thoughts at the end of the day” (Participant 14). They also mention how they would like to take steps to reduce the number of triggers they might experience, such as muting specific key terms on social media, because “you’re allowed to put a barrier between you and something that might hurt you” (Participant 14). Scaling Results At the beginning and end of the ECIT interview, a scaling question was posed to the participants to provide them with the opportunity to reflect on how recovered they feel. The scaling question ranged from 0–10, with 0 representing not recovered at all and 10 representing SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 80 completely recovered. The researcher aimed to investigate whether the interview would impact how participants viewed their recovery and hypothesized that the ratings of participants would differ the second time. This was hypothesized due to the rationale that reflecting on one’s own recovery process would facilitate self-reflection on the specific experiences that have contributed towards one’s self-harm recovery process. This assumption follows narrative theory literature in which recalling and narrating life events both reflects and creates modes of meaning-making of the perceived event (Fivush et al., 2017). The participant ratings and its changes are summarized in Table 5. The results of the scaling question were evaluated using the pre-test/post-test design (Butterfield et al., 2009). The null hypothesis was that there would be no difference in participant ratings at the beginning and end of the ECIT interview. The null hypothesis was tested using a ttest with the sample of 15 participants. Although the mean rating at the end of the interview was higher than at the beginning of the interview (𝑋"! = 7.90, 𝑆𝐷! = 1.61; 𝑋"" = 8.13, 𝑆𝐷" = 1.74), there was no significant difference between the ratings before and after the interview (t (28) = .38, p = .71). Therefore, the null hypothesis cannot be rejected. SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 81 Table 5 Summary of Participant Ratings and Changes on the Scaling Question Participant no. Lowered ratings Increased ratings No change 1 ü 2 ü 3 ü 4 ü ü 5 ü 6 7 ü 8 ü 9 ü 10 ü ü 11 12 ü 13 ü 14 ü 15 ü Conclusion Following an analysis of the interviews from 15 participants regarding the factors that help and hinder self-harm recovery for second-generation Asian Canadians, this chapter reviews the responses provided for each of the three components of the interview—the contextual questions, the ECIT questions, and the scaling question. For the ECIT questions, the results are summarized according to whether they were described as a helpful, hindering, or wish list item. From both internal and external factors to social and cultural influences, participants discussed the many aspects that have shaped their self-harm recovery process. This resulted in a total of 19 categories, which were created to organize and capture participant responses, with direct SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 82 quotations being utilized throughout to represent the responses as accurately as possible. In the following chapter, the results will be examined in relation to existing literature, and the findings and implications will also be discussed. SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 83 CHAPTER 5: DISCUSSION This chapter discusses the many findings that emerged from analyzing the interviews of 15 participants in relation to the factors that help and hinder self-harm recovery for secondgeneration Asian Canadians. Beginning with a discussion on participant responses to the two contextual questions posed at the beginning of the interview, this chapter will then discuss participant responses from the ECIT section of the interview. The results will also be compared with existing literature as part of the ninth credibility check, theoretical validation. Following this discussion, this chapter will also explore the new findings, clinical and practical implications, benefits and limitations of the research, as well as implications for future research. Contextual Results There were two contextual questions posed to participants at the beginning of the interviews. Participants were asked to define what being bicultural means to them, as well as what recovery means to them. These questions were posed with the aim of better understanding the context of the participants’ experiences when discussing the helping and hindering factors that influenced their self-harm recovery processes. What Does It Mean to Be Bicultural? Four themes emerged that summarized the responses of participants when asked what it means to be bicultural: (a) a sense of belonging, (b) tension and balance, (c) a connection to self, and (d) growth and learning. The existing literature was then reviewed to assess the level of support for each of these themes. The themes of belonging and tension and balance were found to have extensive support in the literature, connection to self was observed to have some support, whereas growth and learning was found to be minimally addressed within the literature. SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 84 Biculturalism is complex and multifaceted construct and has been discussed extensively in the literature by many psychologists and researchers (Benet-Martínez & Haritatos, 2005; Berry, 1990; Gardner, 1985; Nguyen & Benet-Martínez, 2013; Spiegler & Leyendecker, 2017; Tadmor et al., 2009; Tirone & Goodberry, 2011). Biculturalism was initially identified as one of four possible acculturation outcomes (Berry, 1990), with recent work further recognizing that individuals can strongly identify with both their host culture as well as their culture of origin. This has resulted in an increase in researchers exploring how this construct is subjectively experienced both intra and interpersonally (Benet-Martínez & Haritatos, 2005; Tanenbaum et al., 2013), with Benet-Martínez & Haritatos (2005) developing the BII model to describe how bicultural individuals simultaneously move between two different dimensions: (a) cultural blendedness versus compartmentalization; and (b) cultural harmony versus conflict. Since then, other studies have continued to explore this construct, with a review by Cheng, C.-Y. et al. (2014) summarizing how this construct can be influenced by the individual and contextual factors. The dimension of compartmentalization and blendedness is emphasized throughout the participant reflections, especially in the theme of belonging. Participants recalled experiencing difficulties when attempting to connect with either culture and that feelings of rejection and lack of belonging resulted from them not feeling as though they fit in. Bicultural identity is inherently contextualized and is influenced by a variety of factors, including family and school—two areas where social bonds are extremely important. Particularly in the periods of adolescence and young adulthood, this theme of social belonging tends to take priority (Hall-Lande et al., 2007). This is consistent with participant reflections, where many echoed how this theme felt especially salient during their younger years. Then, as participants aged and matured, many described a shift SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 85 towards more belonging by finding solidarity with other second-generation children, sharing their experiences with others, and reframing their lack of belonging as belonging to both. It was only until they felt some semblance of belonging that they felt more able to integrate their Western and Eastern cultures together and find value in its differences. The dimension of conflict and harmony are also emphasized by participants, which carries similarities to both the themes of tension and balance and a sense of belonging in this study. Cheng, C.-Y. et al. (2014) described how the dimension of harmony and conflict captures the extent to which bicultural individuals feel their two cultures relate compatibly to themselves. Participants described difficulties in simultaneously holding different traditions, values, and norms, which resulted in them feeling as though they had to separate themselves into two halves in order to navigate each culture. This separation is representative of the tension and compartmentalization experienced by participants; a tension which has been observed to negatively affect the mental health bicultural individuals (Tikhonov et al., 2019). Another theme that emerged as participants reflected on what it means to be bicultural was a connection with oneself. This shares similarities with the theme of belonging; however, is more focused on intrapersonal rather than interpersonal connection. While not extensively discussed throughout the literature, it is also recognized that cultivating and deepening relationships with others is inseparable from cultivating and deepening relationships with oneself (Cheng, C.-Y. et al., 2014). It is no surprise then, that participants who may have been struggling interpersonally also struggled intrapersonally. Indeed, participants described feelings of self-hate and self-consciousness during their earlier years as they were navigating biculturalism, which impacted their mental health severely in ways such as self-harm. Then, as participants developed SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 86 more adaptive ways of relating to themselves, their thoughts and feelings about their bicultural identity shifted towards more acceptance and appreciation. Lastly, the fourth theme that emerged from the participant responses was identified as growth and learning. This theme is not explicitly discussed within the biculturalism literature, which thus far, has largely focused on the previously mentioned themes of distance and blendedness, and conflict and harmony. Nonetheless, participants in this study shared how a growing willingness to learn and embrace the different parts of their bicultural identity had a lasting impact on the other three themes. This demonstrates how interconnected these themes were throughout the development of the participants’ bicultural identities, as growing and learning reportedly allowed participants to be open to new experiences and gradually integrate the often-opposing traditions, norms, and values. Since the construct of BII involves two independent psychological constructs, cultural compartmentalization vs. blendedness, and cultural harmony vs. conflict (Benet-Martínez & Haritatos, 2005), these results illustrate how both compartmentalization and blendedness strategies can result in either conflict or harmony. Participants shared stories and experiences in which cultural compartmentalization helped them safely navigate their environment when they were younger; finding harmony in being able to adapt to different situations, people, and places by keeping their bicultural identities separate. However, as they matured, participants described how this strategy of compartmentalization evolved into one of conflict, in which participants experienced difficulties in attempting to understand the wholeness of their identity and how the different aspects of their identities could fit together. Conversely, strategies of blendedness also brought about both conflict and harmony during different periods of the participants’ lives, demonstrating the presence of both benefits and consequences of each strategy that are SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 87 dependent on the participants’ circumstances at the time of use. These four themes also reveal that participants’ perspectives on what it means to be bicultural might have impacted how the participants viewed cultural factors playing a role in their self-harm recovery process during those pivotal years. Given that culture is intertwined with many other areas of life, their responses provide insight into how their bicultural identity may have influenced how they experienced and perceived the factors that were helping and hindering throughout their self-harm recovery process. What Does Recovery Mean? Four themes also emerged that summarized the responses of participants when asked what recovery means to them. Recovery was identified as consisting of (a) behavioural; (b) emotional/somatic; (c) cognitive; and (d) elusive and process-oriented qualities. The existing literature was then reviewed to assess the level of support for each of these themes. The behavioural theme was found to have extensive support in the literature, the emotional/somatic and cognitive themes were observed to have some support, whereas the theme of recovery being elusive and process-oriented was found to be minimally addressed within the literature. Traditionally, researchers and practitioners have identified self-harm recovery as the complete cessation of any self-harm behaviour (Gelinas & Wright, 2013; Tofthagen et al., 2017; Wadman et al., 2016). Viewed as a maladaptive coping strategy often aimed at regulating emotions, self-harm recovery is often discussed as a behavioural change. Participants in this study agreed on the importance of a behavioural component for self-harm recovery. For instance, participants described how developing more adaptive coping strategies, removing self-harm tools, and refraining from the urge to engage in self-harm helped them take practical and SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 88 concrete steps towards recovery. However, participants recognized that while changing their behaviour was necessary for them to feel recovered from self-harm, it was not sufficient. Participants also identified an emotional/somatic component to self-harm recovery. While most of the research around self-harm recovery focuses on its behavioural component, many also acknowledge and discuss the emotional aspect of recovery (Gelinas, 2015; Gray et al., 2022; Tofthagen et al., 2017; Wadman et al., 2016). For individuals engaging in self-harm, the feelings, urge, or desire to self-harm may linger despite the individual not having self-harmed in quite some time. Indeed, participants, shared how recovery also meant addressing some of the more emotional and somatic pieces around their self-harm, such as becoming more secure with oneself, finding more compassion and love for oneself, and not experiencing an “itch” to continue self-harming. This indicates that the emotional and somatic states of the participants influenced whether they perceived themselves as recovered, and that recovery may consist of more than just a behavioural change. Participants also identified a cognitive component when describing what recovery means to them. The cognitive component of recovery is not as extensively discussed in the literature as the previous two themes, yet many participants in this study described how understanding their thoughts, recognizing the personal and relational consequences, and no longer perceiving objects as tools to hurt themselves helped them take steps towards self-harm recovery. Gray et al. (2022) echoes a similar observation, in that those who are recovered from self-harm view recovery with more nuance than merely the cessation of self-harm (Gray et al., 2022). Lastly, the fourth theme that emerged during participant responses when asked what recovery means to them, was that recovery is elusive and process-oriented. Many participants described recovery using words such as “abstract,” “a journey,” “ongoing,” and “unclear.” This SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 89 theme of recovery is also not extensively discussed throughout the literature, with researchers tending to define and conceptualize recovery using specific outcome measures (Gelinas, 2015; Gray et al., 2022; Tofthagen et al., 2017; Wadman et al., 2016). With participant responses differing from the responses of those in clinical services, it may demonstrate how different conceptualizations of recovery can influence how an individual perceives their relationship with recovery. These four themes that emerged throughout participant responses help provide some context for how the participants in this study conceptualized and perceived the self-harm recovery process. Their responses provide insight into how complex and multifaceted recovery can be and that this complexity may have influenced how they experienced and perceived the factors that were helping and hindering throughout that process. Critical Incident and Wish List Categories For a systematic but comprehensive discussion of the results, the 19 categories were divided into three groups. This was based on the similarities between the categories and the incidents that the categories contained in terms of what the participants perceived as helpful, hindering, or wish list factors. The three groups are intra and interpersonal factors, experiential and external support and resources, and cultural and contextual influences. These three groups are discussed in light of the current literature, which includes non-suicidal self-injury, developmental psychology, counselling psychology, ethnic identity, and other relevant areas. Intra and Interpersonal Support This group includes 10 categories revolving around intra and interpersonal support. Specifically, friends, peers, and other social supports, family members, intolerance from others, intrapersonal factors, and romantic partners. This group also contains some of the most SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 90 commonly mentioned helping, hindering, and wish list factors by the participants, which are explored from a broader perspective against the current literature. Friends, Peers, and Other Social Supports. Social support has consistently been identified as playing a key role in the recovery process for self-harm (Khan & Ungar, 2021; Mackenzie et al., 2006; Shepherd, 2020; Wadman et al., 2018). With adolescence being commonly considered as the period of onset (Gillies et al., 2018; Nixon et al., 2007), the impact of friend and peer support on self-harm is frequently discussed within the clinical and counselling psychology literature (Gelinas, 2015; Hambleton et al., 2020; Wadman et al., 2018). This is because adolescence is the period in which individuals often begin to seek greater autonomy, freedom, and separation from their families of origin, investing more heavily in their relationships with friends and peers (Berger et al., 2017; Copeland et al., 2019). However, this developmental transition can bring with it an increased perception of and sensitivity towards social isolation, with high rates of perceived social isolation placing adolescents at increased risk of various mental health concerns, including self-harm (Hall-Lande et al., 2007). A behaviour shrouded in stigma and secrecy, self-harm can also reinforce feelings of social isolation and shame (Hambleton et al., 2020). Therefore, social connection and positive relationships with friends and peers can be helpful in reducing feelings of isolation and instances of self-harm (Gelinas, 2015; Shepherd, 2020; Wadman et al., 2018). Although the above literature surrounding self-harm and social supports predominantly consists of White samples, the results from this study support similar conclusions. Participants often referred to friends as crucial for reducing feelings of isolation, providing a distraction, as well as receiving emotional validation, insight, and advice/guidance, which continues to suggest that the presence and absence of healthy friendships and peer support can affect self-harm SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 91 recovery across cultures. Moreover, the results from this study demonstrate that secondgeneration Asian Canadians do consider their friends and peers to play a significant role in their self-harm recovery process. This bridges a gap in the current literature, which to date, has largely focused on comparing the help-seeking tendencies of European American samples against Asian American samples. Unfortunately, these comparative studies failed to differentiate between generations and address whether Asian Americans still perceive social supports as helpful or unhelpful – merely that they perceive social supports to be less helpful than European Americans (Kim, H. S. et al., 2008; Taylor et al., 2004; Wang, S.-W. et al., 2010). For one study that did differentiate between generations, the researchers observed that second-generation Asian Americans were more likely than their parents to seek support from friends and peers for stress-related concerns (Taylor et al., 2004). Other studies have also demonstrated that Asian nationals and immigrants are less likely than European Americans to perceive friend and peer support as helpful overall (Taylor et al., 2007; Wang, S.-W. et al., 2010). While this study did not directly examine multiple generations, most of the secondgeneration Asian Canadian participants identified friends, peers, and other social supports as a significant helping and wish list factor in their self-harm recovery process. This suggests that while the prioritization of saving face and maintaining social harmony with the group may deter Asian nationals and immigrants from seeking or receiving social support, second-generation Asian Canadians may not identify as strongly with this traditional cultural ideal. Instead, with friends and peers playing a largely influential role during the period of adolescence and beyond, second-generation Asian Canadians may be more willing to turn to these social supports and perceive them as helpful and desirable. These findings indicate that friend and peer support serve SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 92 as an important means of facilitating psychological health and wellness for second-generation Asian Canadians that overcomes cultural stigma and perceptions around self-harm. Family Members. The family unit is often regarded as one of the most foundational sources in shaping an individual's growth and development (Phinney, 1989). Thus, it is perhaps unsurprising that the effect of family support on self-harm recovery has been extensively researched, with family being continuously identified as a significant factor in both self-harm maintenance (Gelinas, 2015; Wadman et al., 2018) and recovery (Gelinas, 2015; Gelinas & Wright, 2013; Hambleton et al., 2020; Wadman et al., 2018). By providing tangible support, actionable steps, and steadfast emotional support, family members can help facilitate the selfharm recovery process. However, family members can also hinder this process when remaining disconnected, disinterested, and misinformed (Gelinas, 2015). While the literature surrounding family support on self-harm recovery continues to be dominated by White samples, the results from this study are consistent with the existing literature. Support from immediate family members was observed to be a significant helping, hindering, and wish list factor for this study’s second-generation Asian Canadian participants, who discussed the many financial, emotional, physical, and cognitive features of their familial relationships and its impact on their self-harm recovery process. Particularly, financial support was a frequently mentioned helping factor in this study, whereas a lack of emotional validation, support, and connection with one’s family was a frequently mentioned hindering factor. This reflects the literature surrounding traditional Eastern Confucian beliefs and what it means to demonstrate love and support, with Asian parents tending to express such devotion through the fulfillment of action and mutual obligation rather than through words or physical displays of affection (Hsu, 1985; Wu, C., & Chao, 2017). Paying for SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 93 therapy may have been one way that first-generation parents felt able to provide support; a tangible resource which allowed some of the participants to seek mental health care and remain unburdened by other financial stressors. This may exemplify an intergenerational conflict experienced between first-generation parents and their second-generation children, as parents attempt to navigate raising their children outside of the culture of origin. With research observing cultural differences in terms of which emotions are valued and promoted (Lim, 2016), this difference may result in first-generation parents feeling unaware of how to meet their children’s emotional needs and second-generation children feeling emotionally distant from their parents, with many participants expressing a reluctance to disclose their self-harm to their parents or seek comfort from them in times of distress. In instances where participants’ family members had knowledge of their self-harm behaviour, many participants shared experiences of unhelpful suggestions, reprimands, and reactions, ranging from mild indifference and avoidance to more serious concerns around abuse and neglect. Since one of the most common reasons for wanting to self-harm is to relieve interpersonal concerns (Hambleton et al., 2020; Klonsky et al., 2014), this can create a vicious cycle, whereby individuals utilize self-harm as a means to cope with unsupportive and invalidating family dynamics, only to be met with further invalidation once the self-harm has been revealed. Exacerbating feelings of loneliness and mistrust, the desire to self-harm can intensify. This intergenerational conflict and difference in cultural values between parent and child has been discussed throughout acculturation literature (Tirone & Goodberry, 2011; Stroink & Lalonde, 2009) and may serve to explain why some of the participants in this study viewed their parents’ reactions and behaviours as hindering. SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 94 Apart from parents, siblings were identified as another integral component of the family unit that emerged in this study. In the literature surrounding self-harm recovery, few studies addressed the influence siblings can have on those engaging in self-harm. However, the relationship between siblings and emotional support has been well-investigated, with one study observing that when parents were inaccessible and siblings were more accessible, the emotional support between siblings increased (Voorpostel & Blieszner, 2008). Other studies have observed that despite intergenerational conflict, siblings still report experiencing high levels of intimacy and comfort with one another (Hank & Steinbach, 2018; Wu, K. et al., 2018). Indeed, participants in this study who disclosed having siblings described how they provided a sense of solidarity and served as a reminder of enduring support, especially compared to parents who held more traditional Asian cultural perspectives. Thus, the results from this study fill a gap in the current literature in which siblings carry significant potential for substantial emotional and social support for self-harm recovery, particularly in the absence of parental emotional support. Lastly, several comparative studies have investigated cultural differences with respect to family support. Researchers reported that Asian samples sought and received less family support in comparison to White samples (Polanco-Roman et al., 2014; Wang, S.-W. et al., 2010) and that Asian samples experienced family support as less helpful (Kim, H. S. et al., 2008). This may be due to a preference for seeking support from more indirect ties (i.e., friends and peers) rather than direct ties (i.e., parents and other family members) in order to save face and maintain group harmony (Wang, S.-W., & Lau, 2015). Furthermore, second-generation Asian Americans have also been observed to report seeking and receiving more family support in comparison to their first-generation parents (Taylor et al., 2004; Wang, S.-W., & Lau, 2015). While this study did not directly compare generational differences, the second-generation Asian Canadian participants SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 95 still reported experiencing family members as a significant helping factor in their self-harm recovery process, highlighting that the presence and absence of family support remains an important means of influencing psychological health and wellness for second-generation Asian Canadians. Overall, these findings indicate that despite the hinderances that can emerge from generational differences, aspects of familial relationships and bonds remain inherently helpful when navigating self-harm recovery. Intolerance from Others. As previously stated, stigma is defined as a “cooccurrence of its components—labeling, stereotyping, separation, status loss, and discrimination” in a situation where power is exercised (Link & Phelan, 2001, p. 363). When stigmatized, research suggests that individuals can be placed at further risk of experiencing various adverse social, emotional, and economic effects (Burke et al., 2019). For those engaging in self-harm, this stigma can be associated with scarring, the intentional nature of self-harm, or the perception that it is a manipulative behaviour (Burke et al., 2019). As a result, many individuals have reported avoiding disclosure of their self-harm, fearing negative reaction or treatment from others (Gelinas, 2015). Indeed, many participants in this study described instances where labelling (i.e., a “cutter” or being “emo”), stereotyping, judgment, and a lack of understanding and empathy exacerbated the distress, shame, and isolation they were already experiencing. This reinforced the belief that they were alone in their pain, with participants feeling less inclined to reach out for support. The results from this study are consistent with the current literature, in which blame, judgment, and trivialization are frequently identified as barriers to seeking mental health treatment and support (Fortune et al., 2008; Gelinas, 2015) and, therefore, recovery. Furthermore, the experience of stigma can be particularly challenging for individuals of ethnic minority backgrounds. Mental health continues to be an extremely stigmatized subject in SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 96 East Asian cultures, with many emphasizing moral or biological explanations for people with mental illness (Krendl & Pescosolido, 2020; Ng, 1997). Since much of today’s mainstream psychiatry and psychology is rooted in Western culture and understandings, minority firstgeneration parents are less likely to have significant education and awareness of these alternative perspectives. Consequently, the reactions and responses of first-generation parents to self-harm can be perceived as unhelpful, critical, and judgmental. Second-generation Asian Canadian children may then unintentionally internalize the belief that poor mental health is the result of a personal failing. This increases their negative self-perception when considering seeking support for mental health concerns and they may become less likely to utilize mental health services. With self-harm continuing to be highly stigmatized in both Western and Eastern cultures, wanting oneself and one’s family to remain free from embarrassment, shame, and judgment may have increased second-generation Asian Canadians’ desire to hide their self-harm behaviour, making recovery much more out of reach. The findings from this study further demonstrate how experiencing intolerance from others, whether that be from within the family home or outside of it, is largely perceived as unhelpful for those attempting to recover from self-harm. Moreover, experiencing intolerance from both their Western and Eastern cultures may have a compounding effect on second-generation Asian Canadians, who may feel trapped and further isolated from potential support and resources. Intrapersonal Factors. Intrapersonal qualities and factors are known to be an important component of mental health recovery, with one review by Dell et al. (2021) generating a model of recovery that included intrapersonal themes of autonomy and personal responsibility. Other studies have also identified acquiring hope, shifting of identity, self-compassion, and a change in mentality as integral to moving towards recovery (Gelinas, 2015; Gregory et al., 2017; Khan & SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 97 Ungar, 2021). In this study, participants referenced increasing self-awareness and understanding, reframing their behaviour, shifting focus, and improving self-confidence as some of the characteristics that played a helping role in their self-harm recovery process. On the other hand, participants also described how having a lack of self-awareness and understanding, having low self-esteem, engaging in self-justification, and maintaining high expectations of self were extremely unhelpful in taking steps towards recovery. Therefore, the results from this study are consistent with the existing literature that intrapersonal/internal qualities and factors can have a strong impact on an individual’s recovery process. Research has also observed that those who engage in self-harm may recover naturally over time (Gelinas & Wright, 2013; Gelinas, 2015), with one study observing a theme of maturity when participants discussed their reasons for ceasing self-harm (Hambleton et al., 2020). This may be because intrapersonal factors are particularly sensitive to an individual’s mental and emotional development. The period of adolescence is when many behavioural and psychosocial developments occur, with processes such as risk taking, decision-making, and emotion regulation being affected. This is often linked to mental and emotional immaturity, with the literature on emerging adulthood observing that as an individual moves from adolescence to adulthood, these developmental processes mature and further integrating one’s personality, cognition, and emotion (Arnett, 2007). Indeed, participants in this study also identified a theme of cognitive and emotional maturity, which allowed them to gain more perspective and understanding of themselves and their circumstances. These results indicate that while it does not solely underlie this process, age and developmental changes may play an important role in intrapersonal factors mediating self-harm recovery. SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 98 Few studies have examined the effect of intrapersonal factors on self-harm recovery for the second-generation population, let alone second-generation Asian Canadians. One study by Wang et al. (2020) aimed to investigate the interpersonal and intrapersonal factors that affect self-harm initiation and recovery among overseas Chinese adolescents. They observed that in contrast to Western samples where self-esteem played a significant role in recovery, beliefs in adversity was the more important intrapersonal factor for overseas Chinese (Wang, H. et al., 2020). This may indicate another example of the bicultural tension experienced by secondgeneration Asian Canadians. Being raised in a family environment and culture that recognizes the influence of adversity over self-esteem, second-generation Asian Canadians may feel misunderstood by their first-generation parents and unsure of how to translate this intrapersonal factor into their own lives. For both positive beliefs around adversity (such as that an individual can overcome adversity and that adversity makes one stronger), as well as negative beliefs (such as the outcome of adversity depends on fate or that adversity prevents success; Shek et al., 2003), second-generation children may feel heightened pressure to overcome their adversities and become successful. Then, when second-generation children inevitably encounter personal, professional, or relational difficulties, it may be further internalized as a personal failing and elicit feelings of shame and hopelessness. With Western peers and culture placing more importance on strengthening one’s self-esteem, second-generation children may also hold this value in similar regard. In this study, many participants highlighted its importance, expressing that developing and strengthening their self-esteem, self-worth, and self-respect was both a helping and wish list factor throughout their self-harm recovery progress, and that having low self-esteem, self-worth, and self-respect was hindering. None of the participants identified beliefs around adversity as a significant helping, hindering, or wish list factor. This demonstrates that SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 99 cultural beliefs around intrapersonal factors influence how individuals engaging in self-harm draw upon their internal resources, thereby impacting their self-harm recovery process. Romantic Partners. Another form of interpersonal support identified by participants as a significant helping factor for self-harm recovery was that of romantic partners. While much of the literature has revolved around examining friends and family as main sources of support for mental health, relatively little attention has been given to romantic relationships as a potential source of support. Instead, romantic partners are often grouped with friends, peers, and other social support (Gelinas & Wright, 2013; Wang, S.-W., & Lau, 2015; Wang, S.-W. et al., 2010). However, Dakof and Taylor (1990) and Lee, C. S., and Goldstein (2016) found that individuals experience social support differently depending on the source of the support. In terms of self-harm, one study aimed to investigate the interpersonal changes that contributed to recovery, with participants reporting that entering a positive and supportive romantic relationship was notably helpful in ceasing self-harm behaviour (Hambleton et al., 2020). In this study, participants also reported that the presence of a healthy and supportive romantic relationship was significantly helpful in recovering from self-harm. It is important to note, however, that in contrast to some of the other categories (such as friends, peers, and other social supports, family members, and intrapersonal factors), participants who disclosed having a romantic partner described having one as helpful, but participants who did not disclose having a romantic partner did not describe the absence of one as unhelpful. It was also not identified as a wish list factor. Thus, these results indicate that having a romantic partner may be beneficial, but not necessary for recovery. The results are also consistent with existing literature in that there the support received from a romantic partner is experienced as different than that received from a friend, peer, or family member. SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 100 Similar to the research surrounding how culture impacts whether social supports are perceived as helpful, it has been reported that in comparison to European Americans, Asian Americans are more concerned about the relational implications of asking for help from their romantic partners and, therefore, more hesitant in utilizing those supports (Kim, H. S. et al., 2008). Again, however, researchers did not differentiate between generations and address whether second-generation Asian Americans might perceive their romantic partner as helpful or unhelpful when navigating self-harm recovery. The participants in this study shared multiple reasons for finding their romantic partner helpful, which included feeling as though there were less filters, more enhanced communication, and increased comfort within their relationship, as well as that their partners’ presence acted as a strong motivator to cease self-harm. This is consistent with other literature surrounding the potential benefits of a romantic relationship and general mental health, in which improvements in romantic relationships improves one’s mental health (Lee, C. S., & Goldstein, 2016). The results from this study may also be indicative of another intergenerational difference between first-generation parents and second-generation children. Given that culture influences how emotions are felt and expressed (Lim, 2016), culture may then influence how individuals give and receive emotional support within romantic relationships. With one study reporting that Asians and Asian Americans experience less benefit from forms of support that involve explicit disclosure of personal stressful events and feelings of distress (Kim, H. S. et al., 2008), and another study observing lower levels of emotional intimacy in Chinese Canadian couples relative to European Canadian couples (Marshall, 2008), first-generation parents may be more accustomed to traditional Eastern values and norms and feel less inclined to seek and receive emotional support from a spouse or romantic partner. On the other hand, second-generation SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 101 children may feel more of a longing to seek and receive emotional support from their romantic partner due to more Western conceptualizations of emotional intimacy (Marshall, 2008). The results from this study demonstrate that second-generation Asian Canadians do consider their romantic partner as playing a significant role in their self-harm recovery process, and that culture may have an impact on how support in a romantic relationship is felt and perceived. Experiential and External Support and Resources The second group of factors identified as influential in self-harm recovery are the experiential and external support and resources reported by the second-generation Asian Canadian participants. This included activities and alternatives, the media and role models, as well as professional supports. Activities and Alternatives. One of the categories most identified by participants in terms of impacting their self-harm recovery was activities and alternatives. In the positive psychology literature, being engaged with activities and integrated with one’s community has been observed to improve psychological well-being (Froh et al., 2010; Lyubomirsky & Layous, 2013). This remains consistent with the literature around self-harm, in which studies have observed that alternative coping mechanisms and strategies are beneficial in helping participants take steps towards recovery from self-harm (Berger et al., 2017; Fortune et al., 2008; Gelinas, 2015; Hambleton et al., 2020). Given that self-harm is often rooted in emotion dysregulation (American Psychological Association, 2013), finding more adaptive alternatives and strategies can be an effective way to cope with distressing emotions. Participants in this study identified similar themes, with activities and alternatives emerging as a significant helping and wish list factor throughout their self-harm recovery process. Ranging from volunteer work, exercise, mindfulness, art, music, and keeping busy, participants described how these activities helped SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 102 them relieve stress, distract them from self-harm thoughts, feel less alone, and regulate their emotions. Although most of the research around self-harm consists of White samples, the results from this study remain consistent with the existing literature in that the second-generation Asian Canadian participants shared similar thoughts and feelings about the importance of activities and alternative coping strategies with respect to self-harm behaviour. Activities and alternatives were also observed to be a significant hindering factor for the self-harm recovery process, with participants sharing how they felt a lack of activities and alternatives prevented them from feeling more engaged and productive, as well as less willing to cease self-harm. This is also consistent with the existing literature, in which the lack of an alternative coping strategy is a significant barrier for self-harm recovery (Gelinas & Wright, 2013; Tofthagen et al., 2017). As such, these results indicate that the presence and absence of adaptive activities and alternative coping mechanisms can affect self-harm recovery across cultures. Moreover, for those of ethnic minority backgrounds, access to activities and alternatives may be more difficult to obtain and cultivate due to many sports, arts, experiences, and opportunities often being a privilege only some can afford. It can be difficult for many firstgeneration parents to secure a job that will allow them to wholly invest in their secondgeneration children (Louie, 2001). Indeed, the participants in this study shared how they did not have the knowledge or awareness of activities and alternatives they could engage in, and others mentioned feeling as though they had no support in pursuing desired activities or alternatives. Therefore, these results highlight the challenges that can arise when an individual feels as though they have few options when navigating recovery. These results also highlight the importance of improving knowledge, awareness, and access to various activities and alternatives for individuals SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 103 of ethnic minority backgrounds to become further engaged and integrated within themselves, their communities, and the environment. Media and Role Models. Another category that emerged within the experiential and external support and resources group was the media and role models. Following the explosion of technology and social media, large amounts of research has been dedicated to investigating the effects of media on mental health (Baker & Fortune, 2008; Biernesser et al., 2020; Dyson et al., 2016). For instance, social media has been observed to carry many risks and benefits, with Dyson et al. (2016) noting that social media can both act as a sense of community and avenue for support and resources, but also become a space where the behaviour is normalized and encouraged. However, in this study, media and role models were only identified as a significant hindering factor for self-harm recovery, with participants expressing how social media would glorify and romanticize self-harm on various blogs and community pages. In fact, multiple participants identified Tumblr specifically as being a form of social media where it seemed normal to view images and videos of other’s self-harm, post content of one’s own self-harm, and enable other’s self-harm thoughts and behaviours. Participants stated that engaging with this content and these communities resulted in becoming emotionally dysregulated, feeling that they needed to continue self-harming to provide content, wanting to not make progress, and continuing to compare and devalue oneself, among other consequences. Tumblr was originally conceived as a content-centred website, which intended users to be able to post and blog about content of interest to them. Over time, many communities were created consisting of members who may not know each other personally aside from their shared interest. As a result, communities began emerging with depression, suicidal ideation, disordered eating, and self-harm as its focus (Cavazos-Rehg et al., 2017). This resulted in Tumblr SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 104 implementing new policies and community guidelines against the promotion of self-harm in 2012 (Lewis & Seko, 2016), yet despite these policies and warnings in place, many individuals on Tumblr and other social media platforms continue to find ways to circumvent these restrictions (Dyson et al., 2016). The results from this study are consistent with the literature surrounding the potential harms of social media and Tumblr in particular, indicating that the presence of and engagement with social media can have a significant impact on the self-harm recovery process. Other types of mainstream media (such as television and music) have been identified as playing a small role in self-harm recovery due to sensationalized perceptions on self-harm and its manifestations (Fortune et al., 2008). In this study, participants did not identify mainstream media as a significant factor in their self-harm recovery process. To this day, mainstream media, including news coverage and Hollywood productions, continues to be limited in its storytelling, representation, and development (Besana et al., 2019; Cui & Kelly, 2013; Erigha, 2015). These stereotype-confirming representations often portray individuals of Asian descent as timid, submissive, unsocial, and nerdy which may have an impact on second-generation Asian Canadians’ identity development (Cui & Kelly, 2013; Besana et al., 2019). When one feels constantly excluded and misrepresented in mainstream media and society, there is the potential for ethnic minorities to feel further isolated within their communities and experience less belonging in Western culture. However, the results from this study indicate that while the literature may observe that a lack of representation in the media can affect ethnic identity development, the participants from this study may have had a capacity to reconcile and overcome this lack of representation when navigating their self-harm recovery. SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 105 Professional Supports. Another category that emerged as a significant helping and hindering factor for self-harm recovery was professional supports. Over the years, professional supports have been consistently cited as an important factor when discussing self-harm recovery (Berger et al., 2017; Fortune et al., 2008; Gelinas, 2015; Gibson et al., 2019; Hambleton et al., 2020; McHale & Felton, 2010; Sass et al., 2022; Wadman et al., 2018). This ranges from physical health professionals, mental health professionals, academic supports, to other formal online resources and supports. For those who self-harm, seeking professional services has often been one of mixed results. Some individuals reported feeling further stigmatized, negatively treated by health care professionals, and believed it to be a waste of time (Gelinas, 2015; McHale & Felton, 2010; Wadman et al., 2018), while others advocated for professional help and praised its ability to provide more practical and tangible sources of support (Berger et al., 2017; Gelinas, 2015; Hambleton et al., 2020). The results from this study are consistent with the existing literature, as participants also recalled both positive and negative experiences with formal service use. Some described how medication helped stabilize their mood, therapists helped lift a weight off their shoulders, and group therapy helped them feel less alone. Other participants shared how easy access to prescription medication facilitated an increase in suicidal ideation and self-harm thoughts, teachers at school ignored requests for help, and that mental health workers generalized and invalidated their experiences. The lack of access and availability of professional supports was also noted to be particularly hindering for participants. This exacerbated participants’ feelings of aloneness, leaving them confused and uncertain on where to go for support. Notably, regardless of whether a participant recalled helpful or hindering experiences with professional supports, many of the same participants also identified them as a significant wish list factor. Participants speculated that accessing and utilizing professional supports earlier on in their self- SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 106 harm recovery process would have helped them recover sooner, while also helping them maintain recovery moving forward. This indicates that the presence and absence of professional supports and services can significantly impact the self-harm recovery process and that despite negative experiences, many participants may still recognize their largely beneficial potential. These results also demonstrate how varied professional services and supports can be and highlights the importance of finding a good fit between clients and service providers. Unfortunately, most of the literature on professional supports and self-harm continues to be dominated by White samples. Few studies have investigated the relationship between professional supports for self-harm and ethnic minorities, let alone the second-generation. When reviewing this literature, some researchers have observed that formal service use with Asian Canadians and other ethnic minorities is relatively low in comparison to European Canadians (Chang & Chen, 2014; Chen et al., 2009; Lee, A. M. S., 2016; Zhou et al., 2009). In one study by Chen et al. (2009), researchers observed that regardless of generation status, Asian immigrants as well as second-generation Asian Canadians were equally less likely to seek mental health services (Chen et al., 2009). Another study by Chang and Chen (2014) observed a similar result, with Latinos and Asian Americans being less likely to seek out formal treatment in comparison to White Americans, regardless of generation status (Chang & Chen, 2014). In fact, other literature has stated that Asian Americans perceive nonmutual support to be less helpful than European Americans (Wang, S.-W., & Lau, 2015). Thus, the literature to-date has largely focused on professional services being less sought after and experienced as less helpful by those of Asian descent. While this study did not directly compare different generations or ethnicities, the results from this study demonstrate that there is great variability in how professional supports are perceived by this population and that second-generation Asian Canadians do perceive SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 107 professional supports as significantly helpful. It is important to note, however, that the participants in this study all self-identified as being recovered from self-harm and may have had greater access and opportunity to professional supports and services when navigating their selfharm recovery. As a result, this sample may be more naturally likely to identify professional supports as significantly helpful in comparison to the general population. Cultural and Contextual Influences The final group of categories identified as significantly influencing the self-harm recovery process for second-generation Asian Canadians includes the cultural and contextual factors as well as financial/life stability. These influences describe the unique experiences of these participants being part of an ethnic minority while also recovering from self-harm. Financial/Life Stability. Social economic status and financial instability can have a significant influence on mental health, with studies observing that people with lower socioeconomic status are at greater risk of experiencing mental health problems, including depression and anxiety (Oskrochi et al., 2018; Sandstrom & Huerta, 2013; Stein et al., 2013). This can disproportionately affect those of ethnic minority backgrounds, including Asian Canadians, who may face additional challenges due to economic and social barriers that make it difficult to access resources and support. For instance, Asian Canadians who are recent immigrants or have limited English proficiency may struggle to find employment or access healthcare, contributing to financial instability and social isolation. Similarly, participants in this study shared how gaining more independence, both financially and relationally, allowed to feel more in control of their life and less trapped. These results are consistent with the existing literature and provide further evidence that experiencing greater stability in one’s life can have a SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 108 significant impact on one’s mental health and, more specifically, one’s self-harm recovery process. Cultural and Contextual Factors. While the previous groups and categories intertwined cultural and contextual factors, this category more explicitly discusses the distinctive bicultural experiences that the second-generation Asian Canadian participants identified as significantly influencing their self-harm recovery process. Participants in this study identified cultural and contextual factors as a significant hindering factor, which may be evident of the bicultural conflict experienced by many second-generation children when navigating adolescence and young adulthood. Corporal punishment, filial piety, more rigid gender roles, cultural beliefs around mental health, Asian beauty standards, and cultural isolation were mentioned by participants as specific features of their Eastern culture that felt difficult to reconcile. Especially in contrast with their Western host culture, many of the participants shared feelings of shame, rejection, confusion, and tension as they attempted to understand their lives and determine sources of support. As a result, many of the participants stated that these feelings were hindering because they prolonged their recovery process and acted as barriers in seeking and receiving support. Research has explored why several constructs may be perceived as hindering for secondgeneration Asian Canadian children (Costigan et al., 2009; Krendl & Pescosolido, 2020; Lee, A. M. S., 2016; Stroink & Lalonde, 2009; Wang, S.-W., & Lau, 2015). Although many values and attitudes are passed down from first-generation parents to their second-generation children, second-generation children’s preference for social norms, values, and attitudes becomes more strongly developed with the introduction of school, friends, peers, and mainstream media (Lee, A. M. S., 2016). This may have influenced how second-generation children perceived and SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 109 interpreted their families and cultures of origin, with intergenerational differences becoming more pronounced as they entered adolescence and young adulthood. First-generation parents may have reacted and responded in ways that their second-generation children experienced as unhelpful. For instance, research has observed that the tendency to conceal personal, distressing, or negative information is more prevalent in Asian cultures and may be influenced by a desire to save face and avoid shame (Lee, A. M. S., 2016). In response to the self-harming behaviour of their second-generation children, first-generation parents may have attempted to enforce this value; however, with second-generation children wanting their feelings and experiences validated in accordance with Western norms and customs, their parents’ responses and reactions may have been interpreted as invalidating and isolating. Another source of intergenerational difference may stem from the concept of filial piety. The concept of filial piety brings with it moral connotations for parent-child relationships and is typically regarded as a sense of duty and obligation of children towards one’s parents in return for the sacrifice and resources spent on raising them (Yoo & Kim, 2010). A common expectation and value within many Asian cultures, filial piety is aimed at regulating intergenerational attitudes and behaviours, emphasizing family harmony and responsibility (Yoo & Kim, 2010). With filial piety being an example of another value less pronounced in Western cultures, this can create intergenerational difference and conflict between first-generation parents and secondgeneration children when disagreements arise regarding conflicting values, beliefs, and behaviours (Ying & Han, 2007). Along with self-harm continuing to be highly stigmatized in many Asian cultures, second-generation children engaging in this behaviour may be interpreted as not being respectful, grateful, or honouring of their parents’ sacrifice and resources. This difference was strongly expressed by participants in this study, who shared that following SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 110 parental awareness of their self-harm behaviour, strong cultural expectations often felt hindering due to parents reinforcing constraints around behaviour, reacting and responding in ways that did not align with collectivistic values (such as autonomy and independence), as well as eliciting feelings of shame when the self-harm was interpreted as damaging to the family’s reputation. These results highlight how intergenerational conflict and different values systems can have a profound impact not only on the ethnic identity development of second-generation Asian Canadians, but also their self-harm recovery process. Surprisingly, cultural and contextual factors were not identified as a significant helping factor. Previous research has shown that despite the intergenerational conflict that can occur between first-generation parents and second-generation children, many second-generation Asian Canadians still report experiencing their Asian cultural values as positive and feel a desire to continue practicing collectivistic values in their own lives (Costigan et al., 2009; Yoo & Kim, 2010). Thus, while there can be harms that result from these social constructs, values, and norms, it is important to recognize that they are not inherently problematic. There may be multiple contributing factors as to why second-generation Asian Canadian children may experience and perceive cultural and contextual factors as significantly hindering for their self-harm recovery process. The second-generation participants in this study all self-identified as recovered and were retroactively reflecting on a period of their life where they may have been experiencing heightened bicultural conflict within themselves and their families. This study did not explore how participants’ thoughts and feelings towards these cultural values evolved over time, with the results merely indicating that more collectivistic values was perceived as significantly unhelpful for participants recovering from self-harm when in conflict with more individualistic values. New Findings SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 111 The results from this study contribute to the existing bodies of literature surrounding selfharm or NSSI and the second-generation Asian Canadian population. These contributions may not be entirely novel or unique; however, may further confirm or express already existing views and relationships. This study expands upon how self-harm recovery may be facilitated in the context of a bicultural environment. With both Eastern and Western cultural traditions, norms, values, and beliefs, second-generation Asian Canadians are in the unique position of navigating these two cultures while simultaneously developing their own identity as an individual. Thus far, the literature has largely focused on utilizing White samples in the research surrounding selfharm recovery and, if minority samples have been included, the studies have been comparative in nature and have failed to fully explore the perspectives of Asian Canadians. Moreover, Asian samples have predominantly consisted of Asian nationals and/or immigrants, rather than highlighting the unique experience of the second-generation population. As a result, this study was an opportunity to examine the relevance of the existing knowledge of self-harm recovery and its applicability to the second-generation Asian Canadian population. The results from this study also highlighted the importance of social connection as a significant factor in the self-harm recovery process. Many of the categories included an element of human connection, understanding, and solidarity, with the presence and absence of it being felt as helpful and hindering for self-harm recovery, respectfully. Specifically, these relational factors and categories included the relationship the participants had with themselves, as well as their relationships with friends, family, peers, romantic partners, and professionals. Self-harm tends to be rooted in feelings of aloneness, with cultural and societal stigma enveloping this behaviour in further secrecy and isolation. This demonstrates that despite previous research reporting that Asian samples experience social supports as less helpful and desirable, the results SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 112 from this study reinforce the transformative power of social ties and indicate that self-harm recovery is deeply relational across cultures. With existing self-harm treatment and approaches largely prioritizing behavioural and individual-level interventions, the results from this study offer an alternative, more relational way of viewing self-harm recovery. Second-generation Asian Canadians struggling to reconcile their bicultural identity often experience feelings of isolation and disorientation when attempting to determine a sense of belonging within both their culture of origin as well as their dominant, host culture. With the second-generation Asian Canadian participants repeatedly emphasizing a desire for deepened connection with themselves and others, these results demonstrate that relationships are an integral element of self-harm recovery for this population, and highlights how a relational approach may provide second-generation Asian Canadians with numerous avenues for connection and support the further integration of their bicultural identity. Especially as increased awareness of and questions around one’s identity tends to emerge during the period of adolescence, second-generation Asian Canadians are also tasked with having to navigate the added layer of their bicultural and ethnic identity. This simultaneous navigation coincides with the period in which individuals attempt to grow and strengthen their social bonds and connections, expanding beyond the boundaries of their families of origin. As a result, this study demonstrates that self-harm recovery and ethnic identity development are extremely intertwined with relational development and exploration. Intrapersonal factors also emerged as a significant helping factor. This is a new finding in that relatively little attention has been given to how an individual’s internal world can impact the self-harm recovery process in a positive manner. Much of the literature surrounding self-harm recovery has focused on external treatments and influences and, if intrapersonal factors were SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 113 included, the research more strongly considered the effect of intrapersonal risk factors rather than protective factors. The results from this study indicate that there are intrapersonal factors that can be significantly helpful and, as an individual grows and matures, these intrapersonal factors can help an individual resolve their self-harm behaviour naturally. This particular study also highlights how an individual’s perception and experience of cultural traditions, values, norms, and beliefs can strongly impact the self-harm recovery process. In the context of growing up in Western society, these results demonstrate the bicultural conflict faced by second-generation children when they feel disconnected and misaligned with the traditions, values, norms, and beliefs of their culture of origin. This disconnect and misalignment then contributes to the intergenerational conflict that occurs between first-generation parents and second-generation children, where the responses and reactions provided by first-generation parents may not be the type of support requested for and desired by second-generation children. Lastly, a study specifically categorizing the helping and hindering factors for the process of self-harm recovery for second-generation Asian Canadians has not been completed before. While many of these factors have been included throughout the existing literature when investigating self-harm recovery, this study more comprehensively explores how these factors are helping and hindering and considers how the cultural and contextual experiences of the second-generation may also impact this process. Therefore, this study provides a unique source of additional information on the factors that help and hinder self-harm recovery for secondgeneration Asian Canadians. Implications for Practice and Policy The results from this study have encouraging potential to inform practitioners of counselling psychology in working with second-generation Asian Canadians engaging in self- SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 114 harm. Increasing the body of knowledge around the factors that facilitate self-harm recovery will help practitioners feel better equipped to provide psychological support for those struggling with self-harm. These results can not only help practitioners, but also other caregivers such as family members, friends, teachers, and other health care workers by building awareness of the factors that significantly impact what an individual may be experiencing throughout recovery. Building awareness is an important step towards destigmatizing self-harm, which continues to be a barrier towards individuals receiving understanding and compassion from others. The results from this study highlight the importance of strengthening both inter and intrapersonal bonds. With human beings’ natural desire for social connectedness, this provides insight into where individuals engaging in self-harm might be struggling relationally. Interpersonally, themes revolving around communication, intimacy, and emotional safety appeared to be most salient for participants. On the other hand, developing emotional awareness and introspection, fostering mindfulness, and cultivating self-compassion were some key themes that emerged from participants when describing the intrapersonal factors that were most influential. This suggests that individuals engaging with self-harm might benefit from treatment that prioritizes these themes and that caregivers can both understand and encourage individuals struggling with self-harm to cultivate these themes within themselves and others. Since most of the treatment options revolving around self-harm tends to be individualistic, combined with treatment for borderline personality disorder or depression, and focus on behavioural measures or changes, this study provides some insight on why some individuals might find existing treatments as ineffective. Supplementing individual treatment with group treatment may be one example of a way for individuals engaging with self-harm to continue to process their experiences and practice emotion regulation strategies while in a context where they can make SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 115 connections with others, feel accepted in their communities and families, and receive feedback on themselves that is both constructive and compassionate. Another important theme that emerged from this study is the impact that the bicultural experience can have on an individual’s self-harm recovery process. As previously mentioned, second-generation Asian Canadians are in the unique position of simultaneously navigating their Western and Eastern cultures and identities. As individuals struggle to determine their place in their families and external environments, this can influence how individuals experience and perceive the various cultural differences that arise between themselves and their first-generation parents. These results highlight the importance of helping second-generation Asian Canadians integrate these two cultures and identities, as well as helping them build knowledge and awareness of how these cultural and intergenerational differences may be impacting their lives and emotional experiences. Practitioners and caregivers can help second-generation Asian Canadians learn about themselves, integrate their bicultural identity, and find compassion for the cultural and intergenerational differences. Doing so may ease the recovery process and help individuals struggling with self-harm feel more connected both with themselves and others. Implications for Future Research Since this study provided an overall identification of the helping and hindering factors of self-harm recovery for second-generation Asian Canadians, many directions for future research are available. It may be beneficial to explore the experiences of those currently engaging in selfharm, and to see how they compare with the participants who self-identified as recovered. The similarities and differences between the two groups may lead to further refinement and expansion of the existing categories. In fact, many of the 19 categories could be developed into their own research question, further investigating the nuances of how each category can SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 116 influence the self-harm recovery process. For instance, as the results of this study observed that intrapersonal factors are both a significantly helpful and hindering factor for self-harm recovery, it may be worthwhile to assess how various intrapersonal factors in second-generation Asian Canadians impact self-harm recovery, explore potential gender differences, and investigate how different contextual experiences moderate these factors. It may also be worthwhile to conduct a longitudinal study to examine how self-harm recovery evolves over time, and how these categories are experienced and perceived throughout different stages of life. This could illuminate whether certain factors are particular helpful or hindering during the earlier stages of recovery in comparison to later stages of recovery. Lastly, since Asian Canadians are not a homogenous group and not representative of other ethnic minorities, it would be interesting to conduct ECIT interviews with samples consisting of other ethnic minorities to see the similarities and differences that emerge. The bicultural conflict is also not uniquely experienced by second-generation Asian Canadians and there may be different cultural and contextual factors that influence how the bicultural conflict is experienced and perceived by other samples. Limitations of the Study Although this study consisted of multiple rigour and validity checks, there are still some limitations that may influence how the results can be perceived and interpreted. Firstly, the participants in this study may not be entirely representative of the second-generation Asian Canadian population. 40% of the participants were born and raised in the United States of America, which may limit the transferability of the study, as the host culture and context of the United States of America may differ from the culture and context of Canada, despite both being North American countries. With around 73% of participants still in college or completing their SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 117 undergraduate degrees, the study’s results may also be limited in terms of generation. Generation Z may have experiences and perspectives that differ from those of previous generations, which may have influenced their perception of helping and hindering factors for self-harm recovery, such as the growing influence of social media. Furthermore, this study was intended to examine the helping and hindering factors of self-harm recovery for those who self-identified as recovered. As a result, this study is not able to suggest that the factors and categories that emerged from this study may be applicable with those still engaging in self-harm. This is because retroactively reflecting on one’s self-harm recovery process may have resulted in some memories and experiences becoming forgotten or distorted. Having participants self-identify as recovered may pose an additional limitation, as the scaling questions completed by participants were subjective in nature and may not accurately reflect the level of recovery of some of the participants. The structured interview format of ECIT may also have posed a limitation in that while participants may take comfort in an organized and straightforward approach, certain perspectives and topics may not have been exhaustively explored. The organized and structured nature of ECIT also aimed to limit the subjective judgment of the researcher. However, there may still have been a few instances in which the researcher’s subjective judgment influenced the data collection and analysis process. Moreover, while care was taken to provide a comfortable and nonjudgmental environment, self-harm is a behaviour that remains extremely stigmatized. As such, it is likely some participants felt reserved and hesitant to discuss the fullness of their experiences. Lastly, this study assumed a post-positivist worldview, which while not inherently a limitation, may be seen as a limitation by those who employ a more constructivist or transformative worldview. SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 118 Benefits of the Study Despite its limitations, this study demonstrates some strengths with respect to its methodology. Specifically, several practices were used throughout the data collection and analysis process to help increase the rigour and trustworthiness, such as having a clear and purposeful sampling design, reaching a point of saturation with the data sample, conducting structured interviews, and completing nine credibility checks. Firstly, having a clear and purposeful sampling design enabled this study to include the participants with the most appropriate context to respond to the research question. Several inclusion and exclusion criterion allowed for a clear definition of this context, which included parameters around the participants’ demographics as well as their previous self-harm behaviour. The data recruitment process was another avenue where purposive sampling took place, where advertisements for the study were uploaded onto Asian Canadian/American social media pages. This allowed for individuals with particular experiences and expertise to respond to the advertisement, demonstrating an intentional selection of research participants in order to optimize the data sources. Additionally, continuing to interview research participants until reaching a point of saturation helped ensure a thick description of the results, whereas conducting structured interviews helped ensure a rich description. This allowed for sufficient opportunity to collect relevant data until no new themes or categories emerged. Furthermore, despite the conceptual narrowness in defining second-generation Asian Canadians, the participant sample did include individuals who deviated slightly from this definition. As a result, these results demonstrate relevance not only with those specifically falling under the conceptual definition, but also others who may resonate with experiencing a bicultural conflict throughout their upbringing. Lastly, completing the nine credibility checks as part of the analysis process SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 119 was another thorough way of maintaining rigour in this study. By having a peer independently review each step of the analysis, it helped ensure that interpretation, assertions, themes, and study conclusions were limited in terms of researcher bias. These credibility checks enhanced the study’s confirmability and increased the results’ credibility. Conclusion The aim of the current study was to determine the factors that play a role in the process of self-harm recovery for second-generation Asian Canadians. Self-harm is the most significant risk factor for future self-harm and suicide and continues to be prevalent within adolescent populations. With rates of self-harm reportedly increasing in recent years, it remains a common clinical concern. However, few studies have researched the relationship between self-harm and ethnic minority populations. Particularly, the second-generation Asian Canadian population. This population is raised with both Western and Eastern cultures, resulting in a bicultural conflict that can affect various domains of life, including relationships, career, and academics. Therefore, this study sought to explore how being bicultural might affect the self-harm recovery process and, more specifically, what is helpful and hindering for second-generation Asian Canadians when navigating this process. This ECIT study was conducted utilizing Flanagan’s (1954) CIT methodology. Fifteen second-generation Asian Canadian participants were interviewed, providing information regarding the helping, hindering, and wish list factors that impacted their own self-harm recovery processes. Based on the participant interviews, 7 helpful, 7 hindering, and 5 wish list categories were identified, which also underwent several reliability and validity checks to ensure the dependability of the results. SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 120 The results provided information and insight regarding this population’s experiences with self-harm recovery. Specifically, the results indicated that the following categories significantly impact the self-harm recovery process: (a) activities and alternatives, (b) cultural and contextual factors, (c) financial/life stability, (d) friends, peers, and other social supports, (e) immediate family members, (f) intolerance from others, (g) intrapersonal factors, (h) media and role models, (i) professional supports, and (j) romantic partners. These categories contribute to the existing body of literature by emphasizing areas of focus for counsellors to integrate into their practice, family members to be aware of when supporting their loved ones, teachers to consider when observing their students, and other health care professionals to understand when coordinating care for their patients. 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Psychology in the Schools, 46(3), 290–298. https://doi.org/10.1002/pits.20375 143 SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS APPENDIX A: Recruitment Poster 144 SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 145 APPENDIX B: Phone Screening Interview Note: Wording may be adapted. Thank you for your interest in this study. My name is Carissa, and I am currently a student in counselling psychology at Trinity Western University. The purpose of the study is to explore the factors that help and hinder the self-harm recovery process of second-generation Asian Canadians. I am looking for second-generation Asian Canadians who are willing to share their stories about self-harm recovery. Do you mind if I ask a few questions to see whether you would be a fit for this study? 8) Do you self-identify as an East Asian or South-East Asian Canadian? 9) Are you over the age of 18 years? 10) Do you have prior lived experience with self-harm or non-suicidal self-injury (NSSI)? 11) During the time when you were engaging in self-harm, did the behaviour(s) fall under the following definition: Directly and intentionally inflicting damage to one’s own body tissue without intention of suicide and not consistent with cultural expectations or norms? 12) Have you been recovered from self-harm for at least one year? 13) Were you raised in North America? 14) Have you ever experienced symptoms of psychosis (i.e., hallucinations, delusions)? Participating in the study will require about 2 hours of your time, and we would be meeting twice. The main interview will be 60-90 minutes long and will be audio recorded. After I have collected all the participant’s stories, I will examine them for common themes and factors. There will also be a follow-up interview that will be 30-45 minutes long, so I can share what I have learned with you and to ensure that the themes and factors found are representative of your story. This will be an opportunity for you to provide feedback. As a token of appreciation for participating, I will provide you with a $15 Starbucks gift card. Do you have any questions for me? Are you interested in participating in the study? (If yes, arrange a date and time for the main interview.) Do you know anyone else who might be interested in participating? I would appreciate it if you could provide them with my contact information. Thank you for your time and interest. SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 146 APPENDIX C: Informed Consent and Confidentiality Note: Wording may be adapted. Self-Harm Recovery in Second-Generation Asian Canadians: Helping and Hindering Factors Principal Investigator: Carissa Ng, Counselling Psychology, Trinity Western University, [CONTACT INFO]. Purpose: [Explain in simple lay terms exactly the purpose of the research. It may also be appropriate to provide an explanation of why they have been asked to participate.] Procedures: [Explain in simple lay terms exactly what will happen to participants if they participate in the study. If applicable, describe how many sessions or visits, amount of time required for each visit, amount of time required for interviews, questionnaires, etc. Provide details about any plan to contact participants for follow-up sessions or subsequent related study. Include a statement of whether or not research findings will be available to participants and how/where they will be made available to participants.] Potential Risks and Discomforts: [Describe any reasonably foreseeable risks, discomforts, inconveniences (including, for example, physical, psychological, emotional, financial and social), and how these will be managed. If there are significant physical or psychological risks to participants that might cause the researcher to terminate the study, please describe them.] Potential Benefits to Participants and/or to Society: [Describe benefits to participants expected from the research. If the participant will not benefit from participation, clearly state this fact. State the potential benefits, if any, to science or society expected from the research]. Confidentiality: [Include a statement such as "Any information that is obtained in connection with this study and that can be identified with you will remain confidential and will be disclosed SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 147 only with your permission or as required by law." Describe how this will be accomplished; e.g., "All documents will be identified only by code number and kept in a locked filing cabinet. Research participants will not be identified by name in any reports of the completed study." Or "Data will be collected anonymously and names will not be linked with any information." If the data records are kept on a computer hard disk, describe how the security of the computer record will be maintained. Describe length of retention. Note: Do not say that the information will be kept confidential, since it might be published. If data will be stored anonymously for future use, that must also be stated.] Remuneration/Compensation: [State any remuneration or compensation for travel, etc. If course credit is available to University students, explain the process.] Contact for information about the study: If you have any questions or desire further information with respect to this study, you may contact Carissa Ng at [EMAIL ADDRESS]. Contact for concerns about the rights of research participants: If you have any concerns about your treatment or rights as a research participant, you may contact the Office of Research, Trinity Western University at 604-513-2167 or researchethicsboard@twu.ca. Consent: Your participation in this study is entirely voluntary and you may refuse to participate or withdraw from the study at any time without jeopardy to your ... (examples: employment, class standing, access to further services from the community centre, day care, etc.). Also include a statement indicating the steps to be taken in order to withdraw from the study along with a clear indication of any point after which withdrawal is no longer possible. This would be a point in the study in which is it not possible for the researcher to identify the research participants’ responses in order to remove them. For example, if the participants were filling out an online survey where no identifying data was being collected, once the collection period for the survey SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 148 had ended and the survey was closed to new submissions, there would be no way for them to go back in and delete their answers, and no way for the researcher to determine which survey was filled out by them. Signatures Your signature below indicates that you have had your questions about the study answered to your satisfaction and have received a copy of this consent form for your own records. Your signature indicates that you consent to participate in this study and that your responses may be put in anonymous form and kept for further use after the completion of this study. (On parental consent forms include a statement of choice; for example: "I consent/I do not consent (circle one) to my child's participation in this study." Please note that parents must be provided with a copy of the parental consent form.) Research Participant Signature (or Parent or Guardian) Research Participant Printed Name (or Parent or Guardian) Date SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 149 APPENDIX D: Interview Guide Self-Harm Recovery in Second-Generation Asian Canadians Participant Code #: Date: Interview Start Time: * To the interviewer: This guide contains material that should be read to each participant. Material that does not need to be read is demarcated with brackets ([]); Otherwise, it should be read out loud. Purpose of the Study [Welcome the participant to the study]. Our purpose in this study is to understand the the factors that helped and hindered self-harm recovery for second-generation Asian Canadians. Specifically, we are looking at how secondgeneration Asian Canadians navigate recovery from non-suicidal self-injury in the context of their bicultural identity. [At this point, please review the informed consent form with the participant and answer any questions they have that pertain to informed consent]. Part One: Contextual Questions: Meaning of Biculturalism and Recovery As mentioned earlier, in this study we are interested in how second-generation Asian Canadians navigate self-harm recovery in the context of their bicultural identity. But first, we want to know how you define culture and biculturalism in your own life. We are not just interested in solely your Canadian identity or your East Asian identity, but in the way that both intersect with one another socially, financially, academically, vocationally, religiously/spiritually, or in any other capacity that you can think of. 1. Can you tell me what being bicultural means to you in the context of your own life? 2. Because you are here, I know that you feel that you have recovered from self-harm. Can you tell me what recovery means to you? In the last section, we discussed what recovery means to you. On a scale of 0 – 10, where 0 is not at all and 10 is very strong, how strongly do you feel you have recovered from self-harm? ________________________________________________ 0 1 Not at All 2 3 4 5 6 7 8 9 10 Very Strong SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 150 Part Two: Enhanced Critical Incident Interview In this part of the interview, we will discuss your self-harm recovery and what helped or hindered you throughout that process. 1. What has helped your self-harm recovery process in the context of your bicultural identity? (Probes: What was the incident/factor? How did it impact you? – e.g.: “a friend’s support is helping. How is it helping?” Can you give me a specific example where your friend’s support helped? How did that help facilitate the recovery process?) Helpful Factor & What it Means to Participant (What do you mean by..?) Importance (How did it Example (What led up to help? Tell me what it was it? Incident. Outcome of about...that you find helpful.) incident.) This concludes another set of questions regarding your experience. Before we move on to the next set of questions about what hindered you in your self-harm recovery process in the context of your bicultural identity, I would like to make sure I have not missed anything you have said up to this point. [Summarize helping items up to this point]. 2. Now, I’m wondering what factors have made your self-harm recovery process more difficult in the context of your bicultural identity? [Alternative question]: What kinds of things have happened that made it harder for you to recover from self-harm? Hindering Factor & What it Means to Participant (What do you mean by ..?) Importance (How did it hinder? Tell me what it was about .. that you find unhelpful.) Example (What led up to it? Incident. Outcome of incident.) SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 151 This concludes another set of questions regarding your experience. Before we move on to the next set of questions, I would like to make sure I have not missed anything you have said up to this point. [Summarize hindering items as indicated by the participant]. 3. We’ve talked about what’s helped your recovery process [name them], and some things that have made it more difficult [name them]. Are there other things that would have helped in the past that were not available to you, or that will help in the future if they become available? [Alternative question]: I wonder what else might be helpful to you that you didn’t have access to? Wish List Item & What it Means to Participant (What do you mean by ...?) Past (p) or Future (f) [Would have helped or would help] Importance (How would Example (In what it help? Tell me what it circumstances might is about ... that you this be helpful?) would find helpful.) Thank you. Before we move on to the final set of questions, I want to make sure I didn’t miss anything. [Summarize items regarding what would have helped and what would potentially help]. Now that you’ve had a chance to reflect back on what’s helped and hindered, where would you place yourself on the same scale we discussed earlier? On a scale of 0 – 10, where 0 is not at all and 10 is very strong, how strongly do you identify with your North American heritage? ________________________________________________ 0 1 Not at All 2 3 4 5 6 7 8 9 10 Very Strong On a scale of 0 – 10, where 0 is not at all and 10 is very strong, how strongly do you identify with your East Asian heritage? ________________________________________________ SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 0 1 Not at All 2 3 4 5 6 7 8 152 9 10 Very Strong What’s made the difference? [To be asked only if there is a difference between the first and second scaling question ratings] 4. When would you say that you started you started your recovery process from self-harm? 5. What advice do you have for youth currently engaging in self-harm struggling with their recovery process? 6. What, in your opinion, should educators, counsellors, policy makers, or the government do differently to help facilitate the recovery process for second-generation Asian Canadians engaging in self-harm? Interview End Time: Length of Interview: Interviewer’s Name: Interviewer’s Notes: SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS APPENDIX E: Demographics Questionnaire 1. What is your age? 18 – 24 25 – 30 31 – 35 2. What is your gender? M F Non-Binary Do not wish to disclose 3. What is your ethnic background? East Asian South-East Asian 4. What is your country of residence? USA Canada 5. What is your education level? High School College Undergraduate Graduate 6. What is your average household income level? < 20,000 20,000 – 49,999 50,000 – 99,999 100,000 – 149,999 150,000 – 199,999 > 200,000 7. What type of community do you live in? Rural Suburb Urban 153 SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS APPENDIX F: Coding Steps in Atlas.ti Step 1: Upload transcripts onto Atlas.ti, naming each transcript after the participant’s number. The transcripts will then be visible on the left-hand navigation panel under the section “Documents.” Step 2: On the left-hand navigation panel under the section “Codes,” create the following four folders by either right-clicking over the “Codes” section or by clicking on the “Codes” dropdown menu located on the toolbar at the top of the screen: 1) Helping 2) Hindering 3) Wish List (Future) 4) Wish List (Past) Step 3: Begin reading a transcript. Once a factor is observed, create a “New Code” using the “Codes” dropdown menu located on the toolbar at the top of the screen. For each factor, create the following codes: 1) “Participant #” “Name of Factor” 2) “Participant #” – “Name of Factor” 3) “Participant #”-IMP – “Name of Factor” 4) “Participant #”-CON – “Name of Factor” 154 SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS Step 4: The four codes will appear on the left-hand navigation panel under the section “Codes.” Drag and drop codes 2), 3), and 4) under code 1) to create one code with three subcodes. Step 5: Highlight the text in the transcript where the participant names the factor. Drag code 2) over the highlighted area to assign code 2) to the chosen quote. Step 6: Highlight the text in the transcript where the participant describes why/how the factor is helpful. Drag code 3) over the highlighted area to assign code 3) to the chosen quote. Step 7: Highlight the text in the transcript where the participant shares an example of when they experienced the factor as helpful. Drag code 4) over the highlighted area to assign code 4) to the chosen quote. Step 8: Drag the factor into the Helping folder. Repeat steps 3-7 for subsequent helping, hindering and wish list factors. Step 9: Once the first three transcripts have been coded according to steps 3-8, open the “Code Manager” by clicking on the “Codes” dropdown menu located on the toolbar at the top of the screen. 155 SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS Step 10: Expand all helping, hindering, and wish list factors. Group the factors together into a “Code Group” based on similarities (i.e., “Going to Work” and “Hobbies” could be grouped together as “Activities”). To create a “Code Group,” either right-click the left-hand side panel to “Add Group” or click “New Group” under the “New” dropdown menu located on the toolbar at the top of the screen. Step 11: Once the first three transcripts have been sorted into groups, repeat steps 3-8 for the next three transcripts. Step 12: Repeat step 9. Then, omitting the factors from the transcripts already sorted, sort the factors from the new set of three transcripts into the pre-existing Code Groups. Create new Code Groups as appropriate. Step 13: Continue coding transcripts in sets of three and repeat step 12 until all factors have been sorted into the appropriate Code Groups. 156 SELF-HARM RECOVERY IN SECOND-GENERATION ASIAN CANADIANS 157 APPENDIX G: Table for Tracking the Emergence of New Categories Date of CI/WL Extraction Participant # Date Categorized July 18, 2022 1 July 21, 2022 July 18, 2022 2 July 21, 2022 July 21, 2022 3 July 21, 2022 July 21, 2022 4 July 25, 2022 July 22, 2022 5 July 25, 2022 July 22, 2022 6 July 25, 2022 July 26, 2022 7 July 28, 2022 July 26, 2022 8 July 28, 2022 July 28, 2022 9 July 28, 2022 July 28, 2022 10 August 04, 2022 July 29, 2022 11 August 04, 2022 August 04, 2022 12 August 04, 2022 August 04, 2022 13 August 10, 2022 August 09, 2022 14 August 10, 2022 August 10, 2022 15 August 10, 2022 Note: HE = Helpful; HI = Hindering; WL = Wish List New Categories Emerged? All new categories emerged 2 HE; 4 HI; 1 WL categories emerged 1 WL category emerged 1 HE category emerged No new categories emerged