Reflecting on stigma, self-harm and young people

This blog originally appeared in September on the Scottish Universities Insights Institute blog to accompany their Stigma in Childhood seminar series. 

On 26th June I ran a workshop for the second Stigma in Childhood event, at the Scottish Universities Insight Institute at Strathclyde. This was an excellent opportunity to share some of my research on self-harm and young people, and hear from others about their views and experiences of the topic.

Self-harm (in the form of cutting, and overdosing mostly) is widely thought to be an increasing phenomenon among young people, though I would always urge caution when interpreting claims about ‘epidemics’ of self-harm. There is a similarly increasing amount of research addressing self-harm, the majority of which is carried out by clinical researchers working in psychiatry, or psychology. A smaller, but also growing, body of research uses qualitative, social scientific approaches to speak with young people themselves about self-harm. One of my research projects used a range of methods: an online, qualitative survey, interviews, and focus groups, in order to engage young people in Scotland, and further afield, in reflecting on self-harm.

A surprising theme that emerged in first few focus group discussions, and which I followed up in the qualitative survey, was that of ‘attention-seeking’.

Perhaps naively, I had expected that the (negative) phrase ‘attention-seeking’ might have fallen out of fashion, given that self-harm is so widely known and spoken about. Attention seeking had come up in my earlier research (interviews with adults who had self-injured, which I did in 2007-8) but since then information, awareness raising, and anti-stigma campaigns around self-harm have happened. Almost any information site, or leaflet on self-harm will emphasise that ‘it isn’t about attention-seeking’.

 

However, while I did find that young people who had self-harmed were critical of the idea of ‘attention-seeking self-harm’, my analysis also indicated that many still viewed any visible self-harm as potentially ‘attention-seeking’. Further, young people tended to emphasise the hidden nature of self-harm as a way of countering charges of ‘attention-seeking’. In a recently published paper, I discuss these findings further – suggesting that emphasising self-harm as a ‘hidden’ practice, may do more harm than good, by encouraging ideas that the ‘right way’ to self-harm is to hide it.

At the Stigma in Childhood workshop, I introduced some of the findings that are analysed in the paper, in order to prompt discussion among participants about the ways in which self-harm might be stigmatised.

Amy Stigma 1

The discussion between Christy, Samantha, Lily and Jessica (all pseudonyms) generated a lot of interesting reflections in the workshops. I argued that Lily’s caution to people not to ‘shout it from the rooftops’ was well-meaning, but quite telling – inadvertently demonstrating that issues like self-harm shouldn’t be spoken of – at least not publicly. However, one workshop participant noted that ‘rooftops are dangerous places’, and suggested Lily was showing ‘care’ towards people who self-harm, helping to keep them safe. This useful point acknowledges that people who self-harm do continue to face stigmatising responses, and that this may shape their ability to talk openly about self-harm.

In my paper, I also reflect on the challenges faced by young people (and indeed anyone) who has self-harmed in a way that leaves visible (sometimes permanent) marks. One of the young people I interviewed, Jay, talked about her discomfort in some contexts with taking off layers of clothing if she was hot – because of an awareness that such an act could be interpreted by others as ‘attention-seeking’. Relatedly, Conrad, who took part in one of the focus group discussions, suggested that people who ‘showed’ their self-harm might be seeking help, rather than attention.

Questioning what ‘attention’ meant was a theme in both the research, and in the Stigma in Childhood workshop discussions. It is a word that can have negative connotations, especially when framed as ‘attention-seeking’ – the implication is that people who are attention-seeking do not deserve the attention they seek, or are going about seeking it in ‘the wrong way’. In both the research and workshop discussions, there was some willingness to challenge these negative views on attention-seeking; but there was also clear evidence that for many, self-harm remains associated in a negative way with the idea of ‘attention-seeking’, and that this contributes to the stigma experienced by those who self-harm.

You can find out more about the research with young people here, or take a look at a short animated film, based on the research findings, created by Yasmin (then aged 15), and animator Jim Stirk.


*Chandler, A. (2017, in press). “Seeking secrecy: a qualitative study of younger adolescents’ accounts of self-harm.” YOUNG: Nordic Journal of Youth Research.

Chandler, A. (2014). A sign that something is wrong? Young people talking about self-harm. CRFR Briefing No. 74. http://www.crfr.ac.uk/assets/SASHwebbriefing.pdf.

*Article is behind a paywall, but anyone wanting a copy who doesn’t have access should feel free to email me directly.

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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’.

 

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.