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.

Advertisements

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.

 

 

Narrating the self-injured body

Re-posted from the CRFR Blog

Recent media reports have highlighted an apparent rise in the numbers of young people reporting self-harm. These reports should be treated with caution: surveys may well have identified a rise in the number of people who are harming themselves, but findings might also reflect an increased awareness of what self-harm is; meaning that self-harm can be more easily identified and named.

Naming self-harm can be a tricky business, and the recent debates about including ‘non-suicidal self-injury’ in the latest edition of the American Psychiatric Association’s Diagnostic and Statistical Manual (American Psychiatric Association, 2013) is just one example of this. My research, with people who have self-harmed, and General Practitioners, suggests that the type of practices self-harm is understood to involve, and the meanings they have, can vary widely. While for some people, ‘self-harm’ is taken to mean skin-cutting; for others it might refer to overdoses; misusing drugs and alcohol, attempting suicide, risk-taking, or maintaining an abusive relationship.

Surveys that collect data about rates of self-harm provide important information; but they do not tell us the whole story about how someone understands self-harm, what kind of practices self-harm involves, how self-harm affects and contributes to their day-to-day life. Even a particular type of self-harm, say, self-cutting, can be used and experienced in many different ways (Chandler, 2012; Chandler, 2013).

In a paper that was published recently (online first) in the BMJ journal Medical Humanities, I explore narratives about living with bodies scarred or marked by self-cutting. The paper uses Arthur Frank’s typology of illness narratives (Frank, 1995): restitution, chaos, and quest, to demonstrate the different ways in which people talked about the impact of scarring on their lives.

  • Restitution: For some participants, a focus of their story was to emphasise removal of scars, and attempts to ‘fix’ the problem of the scarred body.
  • Chaos: More rarely, people spoke of their scarred bodies as chaotic, indicating feeling out of control of their body and the scars.
  • Quest: A more optimistic account was given by others, who talked about the role of scars in ‘telling a story’ – to themselves and to others. Importantly, the story was one of hope, and of overcoming difficulties.

If rates of self-harm are increasing, there are likely to be more people living with scarred bodies in future. It is important to acknowledge that these scars may have very different meanings, and be experienced in different ways. Indeed, a common theme across the research I have done with people who have self-harmed highlights the pain caused by other people’s assumptions about what self-harm, or self-harm scars, might mean.

EDIT: The paper, Narrating the self-injured  body, is now open access in BMJ Medical Humanities.

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

Chandler, A. (2012), ‘Self-injury as embodied emotion-work: Managing rationality, emotions and bodies’, Sociology, 46, 3, 442-457.

Chandler, A. (2013), ‘Inviting pain? Pain, dualism and embodiment in narratives of self-injury’, Sociology of Health & Illness, 35, 5, 716-730.

Frank, A. (1995), The Wounded Storyteller; Body, Illness, and Ethics Chicago, University of Chicago Press.

 

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).