Twenty five years ago my colleague David Owens and I wrote a lament for the state of NHS responses to self-harm – noting little research investment, haphazard service provision and no evidence of central strategy. Revisiting the scene recently in an editorial for the British Journal of Psychiatry , we found little to celebrate in the way of real progress. My friend and colleague Nav Kapur wrote a riposte which was less of a counterblast and more an invitation to peer at glimmers of light at the end of the tunnel.
A recent post on the Recovery in the Bin site puts some flesh on the bones. The author sees an explanation for her experience of poor care in an intimate connection between inadequate service provision and negative attitudes among mental health professionals. This isn’t a self-centred social media rant, but a reasoned account of what it’s like to be on the receiving end as a person whose self-harm requires physical and mental healthcare.
There’s a lot of catching up to do, and three organisations should contribute:-
NHS England should invest in comprehensive outpatient follow up services for self-harm, where therapy is offered regardless of diagnosis. These services could be a part of liaison psychiatry services, since that is where most acute assessment goes on. In a recent straw poll conducted during a webinar for liaison psychiatrists, more than 80% agreed with the idea of liaison psychiatry providing such a service.
The National Institute for Health Research (NIHR) should make a strategic commitment to fund self-harm and suicide intervention research – perhaps as part of one of their themed calls. Ad hoc responses to researcher-led proposals is not driving the necessary improvement in the research evidence needed to support change.
The Royal College of Psychiatrists should campaign assertively in this area, tackling negative attitudes among its own members and lobbying for policy change, intervention research and investment in services. Alliance with the Royal Colleges of Nursing and of General Practice would bring support from the other two clinical practitioners most directly involved.
We need to move beyond words to make action on self-harm a national priority.
Another missed opportunity in the Molly Russell case
are two views of how people with mental health problems experience social media.
In one view they are places where you wander alone, drawn into an immersive atmosphere
of depressive messages and images – self-harm and enticement to suicide
everywhere you look. In the other they offer a space where you can come out of
hiding, share otherwise secret fears with peers, gain an element of support and
In the former view, risk of suicide is increased by the mood lowering effect of the content and by a sort of creeping familiarity with the idea of self-harm or suicide – called sometimes desensitisation or normalisation – and greater awareness of the methods involved. In the latter view the social or networking function creates opportunity for reducing the sense of disconnection or lack of belonging, and the sharing of detail allows some alleviation of the burdensomeness of feeling uniquely troubled 1.
The Janus-faced nature of social media is outlined in a report by Barnardo’s about young people, social media and mental health – Left to Their Own Devices. The natural conclusion is that different people are likely to be affected differently by their online experiences, and the same person may be affected differently on different occasions. Which raises the question – how to minimise risk without at the same time suppressing useful content? It’s a tricky question and one that requires (you might hope) a careful public debate involving as many interested parties as possible in coming to a solution that considers all the competing demands of the situation.
In the UK, a fair bit of this public debate has centred recently around the suicide of teenager Molly Russell, not least because her father has pressed forcibly the case for the damaging effect of social media and the need to suppress content that might (in his view definitely does) encourage suicide.
Once the case surfaced, the early signs were not encouraging for those of us looking for a wide-ranging and informed discussion. The BBC opened their coverage with an oafish interview of Steve Hatch, the MD for Facebook in Europe, by the BBC’s Media Editor Amol Rajan who, as far as I am aware, knows nothing about self-harm or suicide.
After some grandstanding political outrage by the likes of health secretary Matt Hancock the government produced a White Paper – Online Harms – that bundled encouraging self-harm or suicide with incitement to terrorist activities, dissemination of child pornography, and drug dealing in the dark web. The main direction hasn’t therefore been about self-harm and suicide prevention at all, it’s been about steps to regulate the tech giants.
The response from the principal player in this case – Facebook/Instagram – has been as dispiriting as one might expect. After a laughable attempt to use Nick Clegg as a front man to reassure us of their good intentions, they announced earlier this year a ban on images of self-harm described as graphic or explicit – with no definition of either offered by way of clarification. Now Instagram has announced a ban on drawings or cartoons. There’s again lack of clarity about exactly what this means; in the linked article the specific example is of text linked to an innocuous drawing.
is the commission-like meeting of organisations, clinicians, academics, people
with personal experience, that should be leading the debate and informing the
decisions? The social media companies don’t want it – they want to manage the
debate and avoid swingeing statutory regulation. The government doesn’t seem want it – they’ve
had long enough to organise it if they did. The mainstream media don’t want it –
they just want a story to tell, sentimental or sensational if possible. Samaritans
has an interest but it’s a slow train coming.
are the professional bodies in all this – my own Royal College of
Psychiatrists, the British Psychological Society, the Royal College of Nursing,
the Health and Care Professions Council? I don’t mean where are they in
offering uncontentious opinions, I mean where are they in organising the high
profile, mature debate that’s needed to replace what’s going on now? They are nowhere, and that failure of
leadership is what represents the real missed opportunity.
other ideas about risk of suicide are covered in Thomas Joiner’s book Why People
Die by Suicide (Harvard UP 2005)
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.
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.
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  planning to disclose to friends or family  planning to talk to your GP  managing contact with a hospital emergency department  getting help from the mental health services
a close friend or family  how to respond if you learn somebody you know is
self-harming  what you can do that helps practically.
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…
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.
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
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.