Self-harm in (General) Practice

Reflections on diagnosis, self-harm and suicide; and how the complexity of defining self-harm relates to a new (open access) paper addressing General Practitioners’ accounts of responding to self-harm.

Sociology has a long history of engagement with the meanings of suicide (Douglas 1967), and a more recent history of critically exploring the meanings of self-harm (Adler and Adler, 2011; Brossard 2014). Emile Durkheim (1952/1897) famously used an analysis of official rates of suicide to demonstrate the then new science of sociology. Durkheim’s analysis rejected attempts to identify the ‘motives’ of people who appeared to have died by suicide – accounts of motivation were, he argued, untrustworthy, and changeable; while the rates themselves could be viewed as ‘social facts’.

Suspicion of motivational accounts of self-harm is preserved in many contemporary discussions of self-harm and suicide in psychiatry and health policy. For instance, the UK’s National Institute for Clinical Excellence (NICE) defines self-harm as “self-injury or self-poisoning, irrespective of the apparent purpose of the act”. This approach contrasts starkly with the proposal in the latest Diagnostic and Statistical Manual of the American Psychiatric Association, that ‘Non-suicidal Self-Injury’ (NSSI) be treated as a distinct psychiatric disorder.

Contrary to initial impressions, ‘self-harm’ – like NSSI – is defined in part by its relationship to suicide; though the key difference here is the outcome, rather than the ‘stated or inferred motivation’. Further, while self-harm is defined by the absence of suicide, it is also understood as closely related; people who are treated in hospital for self-harm (the minority) are statistically more likely to die by suicide in future, though still in very small numbers. The relationship between self-harm and suicide is further complicated by qualitative research with people who have self-harmed, which reports diverse and contradictory motivations. In some cases, self-harm is framed as having nothing to do with suicide – indeed it is the ‘opposite of suicide’; while other reports suggest more ambivalence or variation in their motives when self-harming (Solomon and Farand 1995).

To date, very little research had addressed how clinical practitioners – especially those working in General Practice, rather than psychiatry – navigate the complex, and contested, relationship between self-harm and suicide. In a project completed in 2014, and recently published in Crisis, myself and colleagues Caroline King, Chris Burton and Steve Platt, set out to explore just that. We interviewed 30 General Practitioners working in Scotland, exploring their experiences of treating patients who had self-harmed, and their accounts of addressing potential ‘suicide risk’ for these patients.

stethoscope

Potentially important differences in how self-harm and suicide risk were conceptualised emerged in the interviews. Our sample of GPs worked in diverse areas: cities, semi-rural and remote locations; areas of affluence as well as those characterised by significant socioeconomic deprivation. Those GPs who had experience working with patients who were marginalised and poor provided accounts of self-harm and suicide which addressed ambiguity and complexity: there was no clear distinction, self-harm could be suicidal, non-suicidal, neither, or both. This was related to what were termed the ‘difficult lives’ of patients living on the margins of society, many of whom indicated ambivalence about life and death. These findings reflect quantitative work which has highlighted significant inequalities in rates of suicide and self-harm between people living in affluent and deprived areas (Hawton et al 2003).

In contrast, GPs working with more affluent populations were more likely to describe self-harm and suicide as separate issues. In particular, patients who self-harmed were in some instances framed as highly unlikely to die by suicide – an account which reflects what some individuals who self-harm say (that self-harm is about ‘release’ or ‘coping’ rather than death) and official statistics which indicate that suicide is a (comparatively) rare occurrence, whereas self-harm is more frequent. What this distinction underlines is that how GPs respond to and work with definitions about self-harm and suicide may be affected by the socioeconomic contexts in which they work. For GPs working in more deprived areas, death of all kinds – including suicide – is more common, including among younger patients. In contrast, GPs working in more affluent communities are more likely to see suicides as a ‘one off’, ‘unpredictable’ event. In the paper, we argue that these different experiences, and different ‘working definitions’ of self-harm, has implications for the training of GPs around mental health, self-harm and suicide prevention.

Acknowledgement

The research was funded by the Chief Scientists’ Office of the Scottish Government, with research support from the Scottish Primary Care Research Network.

 

References

Adler, P. and P. Adler (2011). The Tender Cut: Inside the Hidden World of Self-Injury. New York, New York University Press.

Brossard, B. (2014). “Fighting with Oneself to Maintain the Interaction Order: A Sociological Approach to Self-Injury Daily Process.” Symbolic interaction 37(4): 558-575.

Chandler, A., et al. (in press, 2015). “General Practitioners’ Accounts of Patients Who Have Self-Harmed A Qualitative, Observational Study.” Crisis The Journal of Crisis Intervention and Suicide Prevention.

Douglas, J. (1967) The social Meanings of Suicide. Princeton University Press

Durkheim, E. (1952). Suicide: A Study in Sociology. London, Routledge & Kegan Paul.

Hawton, K., et al. (2001). “The influence of the economic and social environment on deliberate self-harm and suicide: an ecological and person-based study.” Psychological Medicine 31(05): 827-836.

Solomon, Y. and J. Farand (1996). ““Why don’t you do it properly?” Young women who self-injure ” Journal of Adolescence 19: 111-119.

 

 

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Mother’s Little Helper?

“Mother needs something today to calm her down
And though she’s not really ill
There’s a little yellow pill
She goes running for the shelter of a mother’s little helper
And it helps her on her way, gets her through her busy day”

Songwriters: JAGGER, MICK / RICHARDS, KEITH

Mother’s Little Helper lyrics © ABKCO Music Inc.

One of the things that I find fascinating about substance use is that the meanings attached to it can vary so widely, and with such far-reaching consequences. One example of this can be seen in the different policy, legal and social responses to alcohol and tobacco use, as compared to, for instance, LSD, heroin or cannabis. David Nutt, formerly a member of the Advisory Council on the Misuse of Drugs, for the UK Government, was famously sacked for challenging inconsistencies in legislation which did not, he argued, reflect the ‘objective’ harm caused by different substances. Social scientific work has a rich history of highlighting and challenging the variable ways in which substances are understood and given meaning both within and between different social and cultural contexts.

My own research draws on perspectives which address the diverse cultural meanings attached to substances, with a particular focus on opioids and opioid substitution – heroin, methadone, buprenorphine, subutex. An example I have used often in teaching is to encourage students to compare social responses to a morphine user who is in hospital, recovering from an operation, and one who is using heroin ‘recreationally’ at home. One is legitimate, the other illegitimate – but why? A more developed version of this is found in Helen Keane’s recent analysis of the stark differences in how medical literature approaches the same substance (methadone) when used in treating a) chronic pain and b) opioid dependence (Keane, 2013). Discourse addressing methadone use for chronic pain has to do a lot of work to try to avoid stigmatising patients, attesting to the highly negative meanings that methadone has come to imbue, associated as it is with: dependence, lack of control, lack of self-worth, epitomised in the cultural image of the underserving ‘junkie’.

Questions about the social construction of substance use often fade into the background in discussions about the impact of parental drug use on children. However, both parenting and substance use are clearly socially mediated, and given meaning in different ways according to a range of factors (social class, cultural background, religious belief etc.). Social scientific work on the dominance of middle-class models of ‘good’ parenting are one example of how this can play out in policy and practice (see e.g. Gillies, 2007).

In research completed in 2013 I was part of a team that explored accounts about parenting support among a group of opioid-dependent parents living in Scotland. A paper that has just been published in Drugs: education, prevention and policy, explores how parents accounted for their use of benzodiazepines compared to methadone. While policy often frames all drug-use as problematic among parents, in our research it became clear that some drugs were worse than others. In particular, while a range of problems can be associated with both methadone and benzodiazepine use; the latter was almost universally framed as unproblematic by parents who took part in the research. In particular, this applied to mothers – and several participants quoted the Rolling Stones song, Mother’s Little Helper (above), to support this view.

Benzodiazepine was described as helping parents to: sleep better, socialise, manage anxiety – so as not to impact negatively on children, and cope with traumatic histories. In contrast – methadone was associated with a range of difficulties, and almost all participants suggested they were committed to ‘coming off’ their methadone prescription. Though it was acknowledged that it was helpful in abstaining from illicit and/or injecting drug use – methadone was also framed as contributing to unpleasant physical symptoms, stigmatising identities (‘the junkie’), and the services connected with it (prescription pick-ups, monitored consumption) got in the way of ‘normal’ family life. Many of these constraining features were explored in more detail in an article published last year in the International Journal of Drug Policy (Chandler et al., 2013).

Different cultural images of drug-use and parenting (and especially mothering) highlight the importance of social context in shaping how we understand the impact of substance use on how we act, and who we are. For the parents we spoke to, these images had far-reaching impacts on their lives and on how they talked about parenting in the context of dependent drug-use. Those who continued to use methadone were tied in to services which monitored them and their children closely, as well as leaving them open to negative judgements from themselves and others. Benzodiazepine dependence was not seen as attracting the same level of scrutiny or stigma, and therefore stopping use seemed less pressing.

What I was left wondering when considering these findings, was whether methadone treatment could ever be viewed as benignly as benzodiazepine treatment seemed to be. I am far from an expert in the pharmacological make-up of these substances, but both can be ‘addictive’, both have psychoactive qualities, both have the potential (but not the promise) of impacting negatively on parenting. Yet one substance is imbued with (almost) positive qualities while the other has the opposite effect. Our research – and that of many others – has highlighted that these negative, stigmatising attitudes towards opioid treatment and dependence are ultimately damaging to both parents and their children: constraining help-seeking, leading to social isolation and lack of self-esteem. Can it ever be any different?

Chandler, A., Whittaker, A., Williams, N., McGorm, K. Cunningham-Burley, S. and Mathews, G. ‘Mother’s little helper? Contrasting accounts of benzodiazepine and methadone use among drug-dependent parents in the UK’ Drugs: Education Policy and Prevention

Chandler, A., Whittaker, A., Cunningham-Burley, S., Williams, N., McGorm, K. and Mathews, G. (2013), ‘Substance, structure and stigma: Parents in the UK accounting for opioid substitution therapy during the antenatal and postnatal periods’, International Journal of Drug Policy, 24, 6, e35-e42.

Gillies, V. (2007), Marginalised mothers: exploring working-class experiences of parenting, London, Routledge.

Keane, H. (2013), ‘Categorising methadone: Addiction and analgesia’, Int J Drug Policy, 24, 6, 12.

 

Self-injury and embodied emotions

This is a slightly edited version of the first blog I ever did, reproduced from CRFR’s blog, which you can see here. This post was originally posted in 2012, when the first article from my PhD research on self-harm was published in the BSA journal: Sociology.

Self-injury is an under-theorised and little understood behaviour, despite reports that rates of self-injury are on the increase. Measuring the prevalence of self-injury is notoriously difficult: the number of people who present at a hospital reporting self-harm and self-injury are only a small proportion of all cases. Studies that have sought to measure prevalence have tended to focus on adolescent groups, and to date, there is no data on the incidence of self-injury and self-harm among the general adult population in the UK.

This blog on self-injury and emotions, is based on an article published in 2012, in Sociology.

Self-injury is usually studied from a clinical perspective: however, sociological approaches have the potential to greatly improve understandings of the practice. Recognising the emotional aspects of doing self-injury or understanding more about the societal and life factors that might lead someone to injure themselves can be an important way of exploring self-harm. Such approaches challenge some clinical psychological and psychiatric perspectives which tend to frame self-injury as ‘a problem’ located within the individual.

I undertook research to explore the ‘lived experience’ of self-injury, gathering the life stories of 12 people who had self-injured. People involved in the study were identified from non-clinical community sites, to increase the chances of including people who had not engaged with formal support services. Participants were aged between 21 and 37 years old from mixed backgrounds, although the majority were studying for, or had gained, higher educational qualifications.

Self-injury was defined as the cutting, burning or hitting the outside of the body, resulting, in most cases, in visible, lasting and sometimes permanent marks on the skin. As part of the study people frequently explored the reasons they had self-injured and, in most cases, they referred to how it enabled them to ‘work on’ their emotions through their body:

Control and Release: Release, relief and control were used by many participants when describing their self-injury. For some it allowed them to regain ‘control’ over their emotions, and their lives, while for others it was about controlling otherwise uncontrollable feelings.

“when the situation seems to spiral and I’m whooo losing it. Em and it was like right, regain control, this is what I’m gonna do, I’m going to cut myself…and it’s like, releasing something…and then when that whatever it is is released then your sortie regaining control…” (Anna)

Participants in the research suggested that when they felt they had little or no control over their body or life, control enacted through self-injury could be experienced positively. These explanations for self-injury reflect tensions between being ‘in control’ whilst at the same time needing to have a ‘release’. Similar language is used when people describe other embodied practices such as drinking, smoking and exercising.

Eliciting or Creating Emotions: Others suggested that they had used self-injury to bring out emotions that were ‘missing’. Self-injury in these cases generated a feeling of ‘something’ in response to ‘emotional numbness’:

“I wasn’t pretending that I wasn’t upset but I would just, I wasn’t letting people to know I was upset, if you see what I mean…I wanted to be able to feel I wanted to, you know, live or experience stuff, or… and so, self-harming was, you know a way of, feeling, pain, you know feeling pain ‘cos it was something.” (Francis)

In contrast, some participants talked about self-injury generating positive feelings:

“I think the first time it was associated with kind of a rush and, and a buzz.” (Justin)

These accounts, by indicating that ‘work’ is done on the emotions, through the body, demonstrate the interconnected nature of mind and body, challenging idea that they are, or could ever be, separate.

Reference to the article below, and clicking will take you to the article itself. A pre-pubulication version is available via my academia.edu profile. The research was supported by an ESRC funded PhD studentship, at the University of Edinburgh (2005-2010).

Chandler, A., (2012) Self-injury as Embodied Emotion Work: Managing Rationality, Emotions and Bodies, Sociology, 46 (3).