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).