Does using substitutes or proxies for self-harm help?

  • August 10, 2019

An intriguing recent study was done no favours by melodramatic misreporting of its findings.

Substitutes or proxies for self-harm include doing painful but non-damaging things like holding on to ice cubes or eating hot peppers.  They are quite commonly cited in advice about self-harm.  For example, when I put <How can I stop self-harm?> into a search engine recently, using substitutes came up in the advice offered by my own Royal College, by a private healthcare chain and by a 3rd sector organisation.  There’s actually very little evidence behind this advice, so it was good to see a recent study exploring the experiences of young people with such approaches.

The study had two parts: an online questionnaire to which 758 people replied, and an interview with 45 people. What were the main findings? Only 7/758 people who completed the questionnaire said they had used any of the techniques; it isn’t known why the other 99% hadn’t. In the interviews, 29 people said they’d used at least one of the techniques – some found they didn’t help at all, some found they did. 

This sort of small numbers qualitative study can’t tell us how common certain experiences are, only what the nature of such experiences might be. So the Sky News opener “Many of the techniques used to reduce self-harm do not work for most people…” could only be accurate if the sentence had finished “…because most people don’t use them”. Unfortunately that wasn’t the message being conveyed.

There’s a further twist.  In the questionnaire study 18 people, and in the interview study at least 6 people, said they had used one of the techniques (snapping an elastic band against the skin) as a means to self-harm. Now, given that one sort of harm reduction involves “strategies that aim to ensure that the same method of self-harm [AOH: in this case damaging the skin] has less medically severe consequences” this might be less of a bad thing than it sounds – elastic bands do less harm than broken glass or razor blades.  The news report (of course) took the opposite tack “The therapies could even become abusive in their own right”.

My experience is that most mental health professionals are rather sceptical about proxy or harm minimisation approaches, thinking that if they do help some people then any effect is likely to be fairly weak or transient given that they don’t tackle underlying problems. They might provide a bit of breathing space but they can’t substitute for therapy. I don’t think most will mind very much that such techniques get a poor press through this report, although we could do with some more discussion about what part they might play in selected situations. However, what they should mind is yet another example of mental health reporting being slanted by poor understanding of science and a need for dramatic headlines.

Psychiatry’s worst idea

  • August 2, 2019

Here’s a typical news story from a local paper – about a police call that led to a house search prompted by smelling cannabis.

“The search of the property unearthed two dozen plants being cultivated with a hydroponic system in a cupboard and two more in a nearby wardrobe, said Mr David Swinnerton, prosecuting. Police estimated the crop had a potential yield of over £7,000.

However it was claimed at court that […] might have been pressured into growing the drugs. Mr Thomas Griffiths, defending, said unemployed […] who had several previous convictions and had recently become a father, suffered from a personality disorder and might have been exploited by others because of his naivety.

What does it mean to say that a defendant in a case like this has a personality disorder?  Here’s the answer from the NHS website

“A person with a personality disorder thinks, feels, behaves or relates to others very differently from the average person. There are several different types of personality disorder. This page gives some information about personality disorders in general, linking to other sources for more detail.”

In other words, personality disorder is a diagnostic label attached to who you are. To my mind this is psychiatry’s worst idea – the use of diagnostic labels to describe somebody’s personality.

Here’s an edited version of what I said in my book Undertstanding and Responding to self-harm

“There are real problems with this way of thinking. First, and rather obviously, it leads to an emphasis on the individual as the source of their problems and therefore downplays the role of other people and circumstances…

…Second, the diagnosis is often experienced as a way of saying ‘the problem is about who you are as a person’ and it is widely used in a critical or dismissive way by professionals in health and social care. The person on the receiving end can easily be stigmatised and become (rightly) angry – that anger then being used as further evidence of what’s wrong with them. Not surprisingly, lots of people given this diagnosis don’t like it and don’t like the effect it has on the way others treat them.

This isn’t to say that people don’t have recognisable and enduring characteristics. We all know somebody who is particularly obsessional, prickly, paranoid or prone to emotional outbursts. Sometimes these characteristics do indeed seem important in explaining self-harm. For example, impulsivity is a tendency to act on the spur of the moment, without much thought and without consideration of the consequences. This characteristic is quite commonly associated with self-harm, especially when it is coupled with negative ways of thinking.

What isn’t right is elevating these observations into diagnostic statements – putting people into categories as if somebody’s personality is a mental disorder – which is indeed where personality disorder sits in the main diagnostic systems used worldwide.

There’s another practical problem with this ‘diagnostic’ approach to personality, which is how little use it is in explaining anything… circular reasoning is really common in practice, [for example] using repeated self-harm as part of the basis for diagnosing a personality disorder and then using the diagnosed ‘condition’ to explain the repeated self-harm.”

And that’s not to mention the observation that a “disorder” that’s inherently part of who you are tends to “get better” over quite short periods of time.  

It’s perfectly possible to practice psychiatry, and the law, without this diagnostic practice. Time we all started doing just that.

Government White Paper: Online Harms

  • June 24, 2019

The Government White Paper: Online Harms has been out for consultation for the past three months. Its main proposal is to establish a regulator charged with ensuring that a duty of care is exercised by all those who produce, host or distribute potentially harmful online material.

This sounds like an idea with which few could disagree, and the consultation questions are mainly about how to make it work properly. There are however some real problems raised by the inclusion of online content about self-harm.  The other topics covered by the White Paper include incitement to terrorist activities, dissemination of child pornography, and drug dealing in the dark web. While it’s difficult to imagine a socially desirable component to the online presence of any of these activities, the same doesn’t apply to self-harm.  Here’s my own reply to the consultation’s Question 8…

Q8:  What further steps could be taken to ensure the regulator will act in a targeted and proportionate manner?

In relation to self-harm, the main need is for a clear and specific definition of the nature of harmful content.  It is responsible management of such content that constitutes the duty of care to be imposed on those who make self-harm content available online. The White Paper talks about “content and behaviour which encourages suicide and self-harm” (para 7.32) and “content that provides graphic details of suicide methods and self-harming” (para 7.34). Neither definition is specific enough to inform practice and without a tighter definition the regulator is at risk of idiosyncratic or inconsistent intervention.

What is the challenge in coming up with a workable definition of harmful self-harm content?

There are three issues here:

  • Examination of online material about self-harm reveals substantial diversity in form and content. Those who post and those who respond to posts are engaged in conversations not just about the manifest topic of self-harm and suicide, even when the relevant posts are explicitly tagged as self-harm: content is also about emotional problems more generally, about relationships, fitting in or belonging, and about attractiveness, sexuality and body image. The mixture of textual and visual messaging leads to communication the ambiguity and irony of which can be missed by reading one without the other.
  • Much of this is regarded as helpful by those who access it, and that includes direct communication about self-harm including images of self-injury. Such images can help an isolated person (anything up to a half of people who self-harm don’t confide the fact to anybody in their personal life) feel less alone. The images may come with messages about self-care or harm minimisation. It is reasonable to conclude that content some people find unhelpful is found helpful by others, and that whether a particular content is found to be helpful or unhelpful by a particular individual depends upon the immediate circumstances in which it is accessed.
  • It isn’t clear what the pathway to harm is, following exposure to self-harm material online. Words like graphic, explicit or glamorising are in themselves not tightly defined but they imply that the underlying mechanism is an invitation to copy the behaviour. Linking this argument to suicidal behaviour is problematic – for example most online images of self-harm are of self-injury (cutting or burning) and yet these are extremely rare methods of suicide, especially in young people. If the putative pathway to suicide isn’t copying then presumably it is by exposure leading to low mood and hopelessness – in which case it isn’t clear that images of self-injury are more problematic than other mood-influencing content.

What is the risk of disproportionate or untargeted action?

For much of the content covered by the White Paper, there really isn’t much doubt about what’s bad and needs to be suppressed – drug dealing, distributing child pornography, inciting terrorism. In the case of self-harm however there are risks of going too far in suppressing content. Those risks reside in the diversity of material that comes under the online rubric of self-harm; the likelihood of blocking access to material experienced as beneficial by isolated and unhappy people, and the uncertainty about what’s genuinely harmful in self-harm form and content. Clumsy, excessive or inconsistent intervention – in the name of reducing harmful exposure and (by implication) habituation or normalization – may have the unintended damaging consequence of increasing the sense of disconnectedness and burdensomeness experienced by people with mental health problems who self-harm.

What steps to take?

There are two steps:

If the White Paper is to include action on self-harm content then the regulator needs expert and specific advice on what content should be regulated and limited immediately – even taking into account the considerably uncertainty outlined above. That is, the advice should identify that material for which we can be confident that harm is likely to accrue from accessing it and the risk of harm obviously outweighs the possibility of benefit.  This advice should be provided by an expert panel that consults a diverse range of academics and mental health specialists. Its recommendations should be for limited immediate action given how little we know about harms.

As a second step, the regulator should seek regular reports on emerging research findings that support changes to its practice – to ensure that practice is evidence-based rather than opinion-based.


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