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.

Self-harm – book review (guest post)

  • July 30, 2019

Most booksellers and libraries stock a range of self-help books. In these straightened times the NHS insists that: “Self-Care is Good For Us”. Books on prescription is a clinical intervention nowadays, with GPs ‘prescribing’, that means recommending, a book from a list of titles available in local libraries. Mental health features most commonly in books on depression, anxiety and eating disorders.
Books on self-harm have long been missing from the shelves. The exceptions are handbooks aimed at parents of teenagers. Self-harm is a chapter of its own in books on BPD, such as ‘Borderline Personality Disorder for Dummies’ or ‘Borderline Personality Disorder the Survival Guide’.  While there is powerful survivor literature including personal accounts of self-harm, this is found online only once you know the right publishers, blogs and websites.
This weekend I was surprised to come across a book that is all about self-harm. It is called ‘Understanding and Responding to Self-Harm, The One Stop Guide.’ The author is Professor Allan House, a psychiatrist with a clinical and academic background in Liaison Psychiatry. The note on the front says it all: “A clear, thoughtful, essential guide.”
The book is intended for a wide readership; people who are newer to self-harm to those who may have harmed repeatedly, as well as their friends and families. The case studies and quotes cover a range of ages, whereas most interest in society is focused on young people and self-harm.  I would add that many mental health professionals, including those working in Liaison teams within Accident and Emergency (A&E) departments, would benefit from reading this book and thinking again about their fixed ideas about self-harm.
I fall into the category of someone who has self-harmed repeatedly. I do feel the worst is behind me. I am now in my early 40s and still have times where in moments of desperation I will hurt myself, mainly by cutting my skin. I took paracetamol overdoses for a few years in my twenties. I developed anorexia as a teenager and it has been a seesaw relationship around eating distress and self-injury ever since. I don’t hate myself or meet the stereotypes that are presented about self-harm and BPD. I am shy but have good friends. I am very diligent in my full-time job. I don’t often feel angry but mostly feel sad and deep thinking.
In some ways I know too much about self-harm and live with the emotional and physical scars. But still I am excited about this book and have recommended it to my private psychologist, friends and other health professionals I come across.
The best feature of the book is that it does not label people who self-harm or dismiss their distress. One section starts “To my mind, one of the most unhelpful ways that psychiatry has of talking about people and their problems is the use of diagnostic labels to describe somebody’s personality. Psychiatrists talk about personality disorder..” The author then outlines the problems of this approach which “downplays the role of other people and circumstances.” The circular diagnosis as ‘explanation’ is described. This insight feels brave and far reaching, especially written by a psychiatrist.
The book feels very current and live. There are pages about taking care around social media. There is analysis about the misleading reporting of statistics about young people and rates of self-harm.
While there is a huge amount of information included the most unhelpful assumptions have been left out. I despair when reading about the endorphine theory around self-harm. The ‘science’ goes that people who cut will feel a rush of adrenaline. I was in a minor injury unit yesterday and the nurse suturing my arm asked if I got a ‘whoosh’ from doing it. I felt a lot of pain, distress and tiredness so a ‘whoosh’ would have been mere fantasy. The book does not make a link with addiction as some people, even service user organisations, insist is the case. Their position is that people who self-harm do it as they are addicted to the ‘behaviour’ and pain. I do everything I can to avoid pain so this idea again makes me uncomfortable. Given the stigma around drug and alcohol addiction, I do feel an addiction model makes our lives even more challenging. I wish that cutting my body, with all of the pain and consequences, were as physically easy as drinking from a bottle.
It is positive that the book covers all levels of self-harm. The author even highlights how ‘superficial’ self-harm counts and brings a different kind of pain: “There has been a tendency to be dismissive about (this) scratching.. However, it’s worth bearing in mind the common observation that superficial cuts can be considerably more painful than sharp deep cuts, and that the person who self-injures in this way may be putting themselves through much greater pain over a long period of time, suffering for longer, and feeling even more stressed and constrained to keep their psychological and physical pain secret”. I have never read a more validating few sentences than these words. I wish that my own self-harm hadn’t become more serious, largely a result of meeting others who self-harmed in residential treatment settings. I was in as much emotional pain when my self-harm didn’t require outside help as I was later in life sustaining more significant injuries even leading to blood transfusions. The severity of self-harm really doesn’t correlate to the level of distress.
From the outset the author makes clear that self-harm isn’t done for ‘attention.’ I wish this book could put an end to this prevailing view. Many people who repeatedly self-harm will be discouraged from going to A&E or asked “What are you doing here again?” We are told to ‘take responsibility.’ The most help available is a dismissive ten minute chat after several hours wait on a chair in hospital. It is as though we are treated in a cold way as too much ‘attention’ would provide an incentive to return.
There are questions the book raises which warrant further discussion. While the majority of those who self-harm may not have a ‘serious mental illness’ there is still individual suffering which should not be ignored. No diagnosis at all though means that someone in great distress may struggle to access treatment and welfare benefits. There does need to be more written about those of us who self-harm repeatedly since a marginalised group. It is repetition which results in the heartsink reaction from health professionals, diagnosis of BPD and eventual withdrawal of help as we are seen to have ‘capacity’. The author recognises that through self-harm we may become less ‘seen’ and taken much less seriously. I think of my own self-harm as getting the same response as the boy who cried wolf. In time people turn away and don’t believe the pain as it happens too frequently. Health services often seem to wish we would just quietly go away, which we often do but just take our pain to other places. 
The book is realistic about the help available on the NHS. While recommending talking to someone and speaking to the GP, there is no automatic referral to secondary care community mental health services. In fact these services are still more likely to focus on psychotic conditions. I often feel like it is a human rights issue that those who self-harm can be turned away from treatment as they don’t meet the criteria or should simply learn better coping strategies. If someone with a different diagnosis than BPD was suicidal or doing serious harm to their body the response may be very different. My experience is that the risks go beyond an injury especially with physical depletion and anaemia. It feels as though perceptions of others change once they know and it’s possible to disclose too much when in crisis.
There are practical steps which are life saving, including harm minimisation. The book is realistic about progress sometimes being slow, but remembering the person isn’t a label or their self-harm. It is all too easy to dehumanise those who self-harm, to see us as a limb to be stitched, a personality disorder, someone taking up a bed unnecessarily, a patient wrongly assumed to have a high pain threshold. The author sees us as people for whom self-harm may be just a small aspect of lives that matter.
I needn’t say how well researched the book is since written by an academic yet it explains things in a clear, concise way including data sources which indicate prevalence of self-harm. The writing is informed by years of talking to people who self-harm and trying to understand. He also touches on psychological explanations including the influence of early life experiences and the impact of emotional abuse and neglect for some, though certainly not all, later driven to self-harm. There is also acknowledgement of the environments in which self-harm surges, especially in women’s prisons.
This is a book written in a sympathetic way. You feel the author is on your side. You wish that there were professionals like him in local services who cared about self-harm and wanted to reduce the immense pain. I hope that at least by more people reading the book there will be education, reevaluation of current attitudes and awareness of self-harm affecting people beyond teenage years. This may be a first step towards achieving the understanding and compassion that we deserve.


Do we actually know how to talk about self-harm?

  • July 1, 2019

Stories about self-harm are everywhere. One of the recurring features of these stories is that they include calls for more mental health services – especially for young people.  A few suggest that self-harm is something to which we should all be able to respond. For example, 3rd sector organisations such as Young Minds and Samaritans recommend being open to talking with people who self-harm – surely that’s right if up to a quarter of young people are affected.

There’s nothing wrong with this advice except that it doesn’t come with much help to guide people in what they should actually say.

Here for example is what BBC say at the bottom of a typical news item about self-harm:

What adults can do to help a child who is self-harming:

  • Show you understand
  • Talk it over
  • Discover the triggers
  • Build their confidence
  • Show you trust them
  • Choose who you tell carefully
  • Help them find new ways to cope

Difficult to disagree with, but how does it help a worried parent or friend who can’t show they understand because they don’t understand, or doesn’t know what “talk it over” means or how to “help them find new ways to cope”?

After a look around for sources specific advice, I decided that some direct simple and specific advice was needed and so I wrote my book Understanding and Responding to Self Harm, just published by Profile Books. The book offers practical suggestions:

  • For a person who self-harms [1] planning to disclose to friends or family [2] planning to talk to your GP [3] managing contact with a hospital emergency department [4] getting help from the mental health services
  • For a close friend or family [1] how to respond if you learn somebody you know is self-harming [2] what you can do that helps practically.

National media and self-harm

  • June 28, 2019

Coverage of self-harm in our national mainstream media is unhelpfully unbalanced. News stories almost always report that there’s a massive crisis/epidemic of self-harm in young people underway. There does seem to have been an increase but the coverage rarely says exactly what it is that’s increasing. The accompanying story is pretty much always about a young woman with a long history of self-cutting with the implication that’s what it’s about. See for example this BBC news item. To balance up a bit…

  • A recent report in Lancet Psychiatry, based on 2014 results from the Adult Psychiatric Morbidity Survey, which is published by NHS Digital, was widely covered as showing this dramatic rise in self-harm in young people. It did indeed report on a marked increase in young people but it also showed that people of all ages and both genders report higher rates than they did a decade ago. Self-harm is presented in the media as almost entirely a problem for young women but 5% of all men say they have self-harmed at some time.  Self-harm is also presented as almost entirely affecting teenagers but 5% of those over 35 say they have self-harmed at some time. UK figures show that a quarter of those who go to hospital Emergency Department after self-harm are aged 40-59 years.
  • Self-harm is presented as almost always about cutting, but when asked in the Adult Psychiatric Morbidity Survey more than half people who say they have self-harmed say they have swallowed something or done something else other than cut themselves. Similar findings emerge in the Millennium Cohort Study, widely publicised by the Children’s Society.
  • Social media use is presented as clearly a cause but studies show that people can find it helpful and supportive, a non-judgemental environment in which to discuss worries about eg social or sexual identity. Important when something like a third of people who self-harm don’t confide in anybody they know.

 The truth is that we won’t help people with self-harm until we start taking a more balanced approach to discussing the real issues. “What’s fuelling the terrifying rise in self-harmers?” screams Mail Online 6 March. That’s not a great way to start a conversation, nor indeed a great way to label people who self-harm.


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