Measuring self-harm and suicide

Measuring sticks

Measuring and recording self-harm and suicide is challenging, and yet claims about gender, suicide and self-harm are fundamentally reliant on an attempt to do so. However, concerns have been raised about the nature of statistical knowledge about self-harm and suicide for some time, especially where this relates to ‘official records’ (Atkinson 1978). For instance, researchers continue to acknowledge that official rates of suicide may be affected by the stigma that remains attached to suicide, particularly in some groups (e.g. children) or religious communities (Scowcroft 2017). This may mean that those charged with recording the nature of a death may be more likely to list the cause as ‘accidental’ rather than ‘suicide’.

Studying how suicide is determined

Sociologist Stefan Timmermans investigated how cases of possible suicide are decided through an ethnographic study of the professional lives and practices of medical examiners in the United States. He writes:

“the statistical suicide rate constructed by sociological and public health criteria is far removed from either the smell of death or the memories of the living” (2006 p. 107).

As a sociologist interested in how death, suicide, and self-harm are socially shaped and given meaning, this is an important reminder to maintain some focus on the ‘lived’ (and dead) body: how ‘facts’ such as suicide rates and decisions about motive or cause of death must often be gleaned from bodies, and the interaction between bodies – alive and dead.

In his study, Timmermans proposed that suicides could be understood in (at least) three ways:

  • biographical suicides – suicide as understood by families, in the context of the deceased person’s life – such deaths may not be recorded as suicides, but are nevertheless understood by families as such;
  • statistical suicide rates – which focus on objectivity and the attempted identification of the ‘true’ suicide rate – these may include undetermined deaths that may have been suicide;
  • medico-legal suicide – the ‘opinion’ of the medical examiner as to the likelihood of the death being caused by suicide.

These different ways of understanding suicide coexist, unsettling the idea that suicide is ‘one thing’, and that a suicide rate can ever reflect what suicide ‘really is’. Rather, Timmermans argued, suicide can mean different things to these different groups, who can have competing views. I would add a further layer and suggest that suicide may have meant something else again to the deceased (or in ‘near miss’ self-harm, the almost deceased). Motivations may fluctuate, and ascribing motivation – even where the person involved can be asked directly – is a notoriously tricky business (Arensman & Keeley, 2012).

Naming self-harm

If measuring suicide seems perilous, measuring self-harm is perhaps even more difficult. Self-harm has, historically and recently, had many different names – self-injury, self-mutilation, deliberate self-harm, non-suicidal self-injury, wrist cutting syndrome, and more (Chandler et al., 2011, Chaney 2017). Further, the term ‘self-harm’ (or something like it) can refer to a very wide range of different practices: cutting the skin, overdosing on prescribed medication, ingesting poisons, such as pesticides or cleaning chemicals, burning, inserting objects, breaking bones. Some definitions or understandings of what self-harm is might also include drug and alcohol use, risky sex, negative thinking about the self, or bullying the self online – known as ‘cyber self-harm‘.

The connection between the term used, and the practices it refers to, is not consistent. For instance in UK health policy and research, ‘self-harm’ tends to refer to ‘self-injury or self-poisoning, irrespective of the apparent purpose of the act’ (as defined in national clinical guidelines). In contrast, some US based literature has used the same term to refer to self-injury alone. Elsewhere, the proposed psychiatric classification of ‘non-suicidal self-injury’ is used – though this excludes self-poisoning (unlike the UK policy definition). All of this means that caution should be exercised when interpreting statistical knowledge about self-harm.

Studying self-harm

Leading from this definitional inconsistency, studies which report on ‘self-harm’ are not always looking at the same acts. As well as disciplinary and national variations in terms used, the types of self-harm addressed in research also varies across different clinical and community settings.

Many studies examine cases of self-harm admitted to or presented at Accident and Emergency departments (70-80% of whom will have taken an overdose of prescription medication) (Geulayov et al., 2016). Other, community-based studies using surveys may invite people (often school or university populations) to respond to questions such as ‘have you ever hurt yourself on purpose’ (Mars et al., 2014; O׳Connor et al., 2014). Some even combine questions about self-harm with a question about suicidal thoughts, and a recent NIHR study has raised concerns about the variability and imprecision of measures for self-harm used in surveys. Among young people who tick ‘yes’ in surveys, around 60-70% will report self-cutting, if asked about methods used (often they are not). In contrast, particularly in the US, researchers might use the proposed diagnostic criteria for ‘non-suicidal self-injury’ (featured in the DSM-5, diagnostic manual for the American Psychiatric Association) – criteria which excludes self-harm via overdoses and refers to a rather messy assortment of injuries largely to the ‘outside’ of the body (Chandler 2016).

Aside from the confusing array of different practices studied as ‘self-harm’ by researchers working in very different settings, and sometimes with quite different population groups, these studies also tend to result in rather different pictures of self-harm in terms of gender.

Studies which use surveys with groups of young people tend to find that many more women than men report self-harm. A 2017 study in the UK found that 32% of young women reported ever self-harming, compared to 11% of young men. This study, and others, have suggested that there is a current rise in young people (especially young women) reporting self-harm. However, the extent of this apparent rise varies. A report published in 2018 indicated a very small rise in the number of young women reporting harming themselves, but the survey report does not suggest what forms of self-harm participants were referring to (self-harm and suicide attempts were combined); and the numbers reporting were far lower than the 2017 report: 7.3% of girls and 3.6% of boys aged 11-16.

A study of General Practitioner (GP) records also reported an increased number of young women self-harming (Carr et al 2016). These studies raise some interesting questions though – for instance, are we seeing an increased number of young women self-harming, or an increased number of young women seeing their general practitioner about self-harm? Or even, an increased likelihood that GPs will record self-harm on female patients records? The same study found that 70% of cases recorded in the GP records were overdoses, but we know from community surveys that young people are far more likely to report self-injuring (via cutting, burning or hitting) and also very unlikely to report seeking professional medical care for this. It is possible that self-harm that is treated in hospital (often an overdose) may be more likely to also end up being recorded in GP records. As such, while the study does provide another useful perspective on potential rates of self-harm – it is still likely to be only part of the picture.

What people say, what people do, and what gets recorded

Self-harm and suicide are both hugely complex and difficult to measure. What people say may be different from what they do, which may be different again from what gets recorded. Measuring is important – it can point to inequalities in rates, which might help us to better understand the practices, or ask better questions at least. Care needs to be taken, though, when it comes to interpreting statistical knowledge about self-harm and suicide. Statistics about these practices are always partial, and researchers and practitioners know this. Statistics can also be very appealing in their simplicity; but this is dangerous, and towing simplistic lines of argument will lead to acts like self-harm and suicide being misunderstood, misconstrued. This is why it is vital that statistical knowledge is enhanced, complemented and tested by qualitative, interpretive knowledge as well.

American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Arlington, VA: American Psychiatric Association.

Arensman, E., & Keeley, H. (2012). Defining intent. Psychiatry Professional, Spring 2012, 8-9.

Atkinson, J.M. (1978). Discovering Suicide: Studies in the Social Organization of Sudden Death. London: Macmillan Press.

Carr, M.J., Ashcroft, D.M., Kontopantelis, E., Awenat, Y., Cooper, J., Chew-Graham, C., et al. (2016). The epidemiology of self-harm in a UK-wide primary care patient cohort, 2001–2013. BMC Psychiatry, 16, 53.

Chandler, A. (2016). Self-injury, medicine and society: authentic bodies. Basingstoke: Palgrave Macmillan.

Chandler, A., Myers, F., & Platt, S. (2011). The construction of self-injury in the clinical literature: a sociological exploration. Suicide and Life Threatening Behavior, 41, 98-109.

Chaney, S. (2017). Psyche the Skin: A History of Self-Harm. London: Reaktion Books.

Geulayov, G., Kapur, N., Turnbull, P., Clements, C., Waters, K., Ness, J., et al. (2016). Epidemiology and trends in non-fatal self-harm in three centres in England, 2000–2012: findings from the Multicentre Study of Self-harm in England. BMJ Open, 6.

Mars, B., Heron, J., Crane, C., Hawton, K., Kidger, J., & Lewis, G. (2014). Differences in risk factors for self-harm with and without suicidal intent: Findings from the ALSPAC cohort. J Affective Disorders, 168.

O׳Connor, R.C., Rasmussen, S., & Hawton, K. (2014). Adolescent self-harm: A school-based study in Northern Ireland. Journal of Affective Disorders, 159, 46-52.

Scowcroft, E. (2017). Suicide statistics report 2017. London: Samaritans.

Timmermans, S. (2006) Postmortem: How Medical Examiners Explain Suspicious Deaths. Chicago, University of Chicago Press

 

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Imperfect Cognitions Guest Blog: introducing Self-Injury, Medicine and Society

This post was originally published in June 2017 on the fascinating Imperfect Cognitions Blog  as part of their regular ‘New Books’ feature. The post introduces some of the key themes in my book, Self-Injury, Medicine and Society

The book is the culmination of over 10 years research, and a much longer period of engagement and interest, in the practice of self-injury. In the book I focus on the different ways that people make sense of self-injury, through an analysis of accounts – or narratives – about the practice.

si-m-s-book-cover-image

Self-injury is commonly associated with mental ill-health, seen as ‘irrational’ or ‘impulsive’. As such, the ways in which self-injury is explained might be understood by some as an example of an ‘imperfect cognition’. People report injuring their bodies in order to make themselves feel better – how could this be possible? In the book, I explore the diverse ways that people attempt to explain, justify or excuse self-injury, highlighting the central role of broader cultural ideas about bodies, emotions, and medicine in shaping what can (and cannot) be said about self-injury.

One increasingly common way that self-injury is explained suggests that the act of injuring the outside of the body (usually via cutting) serves to ‘transform’ emotional pain into physical pain. This narrative rests on a number of assumptions: that ‘emotional’ and ‘physical’ pain are or can be separate; that, simultaneously, these potentially separate pains are irrevocably linked – since causing ‘physical’ pain affects the intensity or presence of ‘emotional’ pain.

Such accounts of self-injury draw on well established, intractable, yet heavily critiqued dualisms – dualisms often linked to Descartes’ (in)famous maxim ‘cogito ergo sum’ (I think, therefore I am). The accounts both rely on and challenge the notion that our ‘minds’ and ‘bodies’ are separate; that the ‘physical’ body is distinct (or can be) from our ‘emotional’ self.

This ‘transformational’ narrative of self-injury also raises the question of why, for some who self-injure, the creation of a visible, tangible wound is required as a substitute for ‘emotional’ pain, or is seen as preferable. Accounts about self-injury draw on notions of discomfort and uncertainty about ‘internal’ emotions. Some perspectives interpret this as relating to a deficit in the self-injuring individual: they are unable to ‘regulate emotions’; they cannot ‘recognise’ or fail to effectively manage emotional states.

However, there are broader social contexts regarding norms of communicating about negative emotions which are also pertinent, and which may help to better understand such apparently individual deficits. Interviews with people who have self-injured frequently draw attention to silences: to families who do not want to talk about or acknowledge distress; to a desire to avoid ‘burdening’ friends with problems.

Discomfort with, or difficulty tackling emotional distress or mental disorder is also reflected in enduring stigma associated with mental illness, long-standing underfunding of mental health services, and frequent failure to acknowledge the problematic distinctions made between ‘mental’ and ‘physical’ health (Millard & Wessley, 2014).

In such a context, it becomes perhaps more understandable why ‘emotional pain’ might be difficult to acknowledge or discuss in interpersonal settings, and why individuals might see a physical wound as preferable to emotions that are understood as more intangible and, importantly, less ‘real’.

 

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.

 

 

Male suicides rising: exploring the role of alcohol and community support

This is a very much a ‘work in progress’ blog – reflecting on recent statistics on suicide in the UK, and thinking through how this relates to issues I am addressing in a new research pilot project (cross posted to the CRFR Blog).

New figures released by the UK Office for National Statistics show that suicides among men have risen, with levels now the same as in 2011 – a potential reversal of what had been a downward trend. Rates among younger men are often highlighted, since suicide in men aged 15-29 is the leading cause of death. These latest figures show that suicides among older men, aged 45-59, are now higher than any other age group.

guardian stats suicide rates

[Image from The Guardian]

I am currently at the start of a pilot project, funded by Alcohol Research UK, which is using biographical methods to study the life-stories of men in this older age group. The study will focus especially on men’s accounts of the complex interplay between alcohol use, self-harm, suicidality, and mental health.

The men I am speaking to are in some ways ‘lucky’ – they are all being supported by community-based mental health and substance use support services. Despite this, their accounts (so far) highlight difficulties they have faced in accessing and using support at various points across their lives. News stories about the latest suicide statistics were accompanied by coverage of one particular suicide, with a bereaved family keen to highlight what they see as limitations in current mental healthcare provision in the UK. The story of Martin Strain was, sadly, familiar when I read it – elements of his struggle are reflected in the accounts of the men I have spoken with so far. In particular, Martin’s history of drug and alcohol misuse is said to have resulted in him being denied access to one-to-one psychiatric support. This highlights a significant challenge in tackling mental ill health in general, but especially for men, who are more likely to turn to alcohol to manage distress.

Around 50% of deaths by suicide occur in the context of alcohol use; and those who are alcohol dependent are at increased risk of suicide. Despite this, those identified as having alcohol use problems are – like Martin Strain – in some cases, diverted away from psychological support, into alcohol use services. Unless appropriate community based support is available (which is patchy, and will be reliant on the whims of local authority funding), people who have both mental ill-health and alcohol problems may not receive any kind of ‘joined up’ support. One of the issues I am investigating in the current study is the extent to which mental health is supported by substance use services; and conversely, how well alcohol misuse is responded to by mental health services.

In a limited way, I will also be exploring the role that community based support can have for men, who are often framed as ‘hard to reach’ and ‘hard to engage’. Yet clearly, some are reached, and some do engage – how do men account for this? In particular, I will be building on existing research which has examined the accounts that men provide when they engage in potentially ‘un-masculine’ practices, such as accessing a talking therapy. Studies have suggested that there are important differences between men in how they deal with such issues: with some men more able than others to frame ‘talking’ or ‘connecting’ with others as a responsible reaction to depression and thoughts of suicide (Oliffe et al 2011).

Additionally, I am looking at the way in which men themselves talk about their use of alcohol in the context of mental ill-health. Not all suicides are related to alcohol, and not everyone who uses alcohol will have problems with mental health, self-harm, or suicide. Already, variations are emerging in how men talk about alcohol use, and this study will provide useful insights into the diverse ways in which alcohol and mental health are understood.