Self-harm – book review (guest post)

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.

R.B.