Working Towards a Holistic Understanding of Self Harm

We are all in this together: working towards a holisticunderstanding of self-harmM . L O N G 1 b a h o n s m s c , R . M A N K T E L O W 2 b a m s c p h d &A . T R A C E Y 3 p h d h p c r e g i s t e r e d p r a c t i t i o n e r p s y c h o l o g i s t1Lecturer, School of Communication, University of Ulster, Jordanstown Campus, Newtownabbey,2Lecturer, School of Sociology and Applied Social Studies, and 3Lecturer, School of Psychology,University of Ulster, Magee Campus, Derry, UK

Keywords: language, religion,

self-harm, stigma, suicide

Correspondence:

M. Long

School of Communication

University of Ulster

Jordanstown Campus

Shore Road

Newtownabbey BT37 0QB

UK

E-mail: [email protected]

Accepted for publication: 4 February

2012

doi: 10.1111/j.1365-2850.2012.01893.x

Accessible summary

This paper has been informed through systematic literature searches of researchdatabases and core texts on the subject of self-harm.

Despite the increase of self-harm, stigma and misunderstanding surround the issue,which often compound the sense of emotional pain felt by those people who areaffected by self-harm.

Gaining an understanding of the cultural, historical and religious origins of self-harm can illuminate the ways in which self-harm has evolved with us as part of ourhumanity.

This paper aims to increase understanding of self-harm, and by doing so to questioncommonly held assumptions and foster more empathic responses to self-harmamong practitioners.

Abstract

Self-harm is a widespread and controversial issue in contemporary society. Statistics arebased on reported incidents and therefore do not accurately reveal prevalence, asself-harm is often a hidden behaviour. This highlights the essential need for practitio-ners and society to work towards reducing the stigma surrounding self-harm. Thispaper goes some way towards understanding the impact of self-harm on individualsand communities. It begins by exploring terminologies and definitions of self-harm anddiscusses the importance of sensitivity in language use relating to self-harm. It contin-ues by examining types of self-harm and subsequently presents life experiences thatmay contribute to the onset of self-harm. The paper elucidates the cultural, historicaland religious origins of self-harm, indicating the ways in which self-harm has evolvedwith us as part of our humanity. Moreover, literature relating to the significance ofstigma and attitudes is examined, followed by issues around psychiatric diagnosespertaining to self-harm. The paper concludes by synthesizing literature relevant to therelationship between self-harm and suicide.

Background

Evidence suggests that self-harm in the form of self-poisoning and self-injury is the reason for 170 000 hospitalpresentations in England and Wales each year (Hawton

et al. 2007). Moreover, there are around 11 000 presenta-tions of self-harm annually to hospitals in the Republic ofIreland (National Suicide Research Foundation Ireland2006). Self-harm is responsible for over 7000 hospitaladmissions per year in Northern Ireland and this figure

Journal of Psychiatric and Mental Health Nursing, 2013, 20, 105113

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increased by 9% between 2000 and 2006 [The Departmentof Health Social Services and Public Safety in NorthernIreland (DHSSPSNI) 2006]. As these figures are based onreported incidents they do not reveal the true scale of theproblem, as self-harming behaviour is typically hidden andtherefore difficult to measure accurately. It is evident thatself-harm is a significant public health issue throughout theUK and Republic of Ireland and that its occurrence may beescalating.

The social stigma that surrounds self-harm renders itmuch more complex in terms of identifying the scale of theproblem as well as understanding the true nature of theself-harming population and individual motivations forthe behaviour. A common myth surrounding self-harmimplies that it is attention-seeking behaviour, in the deroga-tory sense (Fox & Hawton 2004). The fact that manypeople who self-harm do so in secret and rarely disclose orask for help dispels the myth that it is used for secondarygain (Turp 2003, Fox & Hawton 2004, Mental HealthFoundation 2006). Self-harm is often understood to be anadolescent phenomenon; while the age of onset is typicallyreported as around 13 or 14 (Klonsky & Muehlenkamp2007), evidence suggests that self-harm reaches far beyondthe confines of adolescence (Chan et al. 2007).

The stigma, myths and lack of understanding that fosterburgeoning resentment among others can perpetuate thecycle of shame and guilt among people who self-harm,which subsequently increases their dependence on thebehaviour. Consequently, the majority of people who self-harm never present to formal health services (Ystegaardet al. 2008). In health services, patients who self-harm areoften perceived to be particularly difficult or demanding(Schoppmann et al. 2007). The negative and discrimina-tory notion that the behaviour is a waste of time andresources can exist among staff (Simpson 2006).

Search strategy

The paper analyses contemporary literature, which isinformed by ongoing systematic literature searches ofelectronic databases including PsychARTICLES, Psych-CRITIQUES, PsychINFO, MEDLINE and the CochraneLibrary as well as rigorous manual literature searches ofrelevant articles and core texts (see Appendix I). Searcheshave been ongoing from 2008 to the present time.

Terminology

Types of self-harm may present in various ways and holdmultiple meanings for each individual who enacts thebehaviour. Self-harm is a general term that refers to a rangeof more specific self-harming behaviours including: self-

poisoning (overdose with or without suicidal intent) andself-injury (self-cutting or self-burning). Some scholarsemploy the term deliberate self-harm or DSH. Otherwriters deem this to be insensitive and inappropriate ter-minology (Pembroke 1996, Allen 2007). Allen (2007,p. 174) suggests, . . . the use of deliberate as a prefix toself-harm is not only redundant but could also convey asomewhat pejorative belief that the person could refrainfrom doing this if he or she tried. Consequently, use of theterm deliberate self-harm will not be adopted in this paper.

Numerous terms are used to describe acts of self-harmincluding parasuicide, self-mutilation, self-laceration, self-injury or self-injurious behaviour. Kreitman (1977) coinedthe term parasuicide, to refer to non-fatal acts of deliberateself-harm. According to the Oxford English Dictionary,often in modern definitions the word para is understood tomean abnormal, hence implying that parasuicide is anabnormal suicide. The insensitive undercurrents of this ety-mology justify the decision to refrain from using the wordparasuicide to conceptualize self-harm in this paper.

Favazza (1996) uses the term self-mutilation to refer toacts that are now more widely conceptualized as self-injury.Mangnall & Yurkovich (2008) refer to the negative con-notations associated with the word mutilation. The wordmutilation perhaps evokes the sense of horror or disgustthat society should endeavour to move beyond when con-fronted with self-harm. Therefore the term self-mutilationwill not be employed in this paper. In a similar vein, theterm self-harmer will not be used, to describe people whoself-harm. This position is based on the belief that suchlabels reinforce stigma and effectively dehumanize peoplewho are much more complex and unique than the sum ofone facet of their behaviour (Allen 2007). For the purposeof this paper, the chosen terminology is that of self-harm.This decision is based on experience searching for literatureon the subject, communication with practitioners whowork within the field and personal understanding about thecrucial nature of communicating in a language that is bothappropriate to the action and non-oppressive for the actor.

Definition of self-harm

In this paper, Turps (2003) definition is used to conceptu-alize the activity of self-harm. Turp (2003) seeks to defineself-harm in a way that reflects the multifaceted naturethereof:

Self-harm is an umbrella term for behaviour:(1) that results, whether by commission or omission, inavoidable physical harm to self(2) that breaches the limits of acceptable behaviour, asthey apply at the place and time of enactment, and henceelicits a strong emotional response. (p. 36)

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This definition captures the various dimensions of self-harm for both individuals and society. It can be an action ora non-action, causing harm by deed or by neglect. Self-harm is not confined to a particular gender, age group,culture or type of behaviour.

Types of self-harming behaviour

There is a plethora of behaviours defined as self-harm. Thetwo most commonly reported types of self-harm have beenselected for review in this section: self-poisoning andself-cutting.

Self-poisoning

According to Hawton & Harriss (2008), Self-poisoning isdefined as the intentional self-administration of more thanthe prescribed dose of any drug, and includes poisoningwith noningestible substances, overdoses of recreationaldrugs, and severe alcohol intoxication where clinical staffconsider such cases to be acts of deliberate self-harm (p. 5).In Hawton & Harrisss (2008) study, analysis was carriedout of self-harm presentations to a general hospital inOxford over a 10-year period and 82.2% of self-harmpresentations were the result of self-poisoning. This com-pared with 13.5% resulting from self-injury. DHSSPSNI(2010) has identified drug overdose as the most commonmethod of self-harm in the Western Health and Social CareTrust (WHSCT) catchment area of Northern Ireland,accounting for 73.9% of accident & emergency (A&E)presentations for self-harm in 2009. Figures based on hos-pital presentations may not reflect the true nature of self-harm, in terms of both prevalence and demographics.Episodes of self-cutting are less likely to result in hospitalpresentation than self-poisoning (Hawton & Harriss2008), which may account for the increased incidence ofself-poisoning in figures based on hospital presentations.

There is literature which suggests that self-poisoningvaries from other forms of self-harm involving cutting orburning (Gallop 2002, Simpson 2006). Simpson (2006)articulates, . . . self-poisoning is more usually concernedwith ending consciousness, to end life, thus holding a sig-nificantly different meaning to self-harming (p. 429). Thusoverdose or self-poisoning appears to diverge from otherforms of self-harm which are often used to restore feelingand which communicate emotional distress through thevisible traces held on the body. Much of the literaturefocuses on hospital presentations which are often a resultof overdose; there is limited available research on thosepeople who self-harm and never present to hospital, amongwhom the most common method of self-harm is under-stood to be self-cutting or self-injury (Hawton & Harriss2008).

Self-cutting

DHSSPSNI (2010) has identified cutting as the second mostcommon method of self-harm in the WHSCT catchmentarea of Northern Ireland, accounting for 17.2% of allself-harm A&E presentations in 2009. The NationalInquiry into self-harm among young people suggests thatrates of self-cutting are between one in 12 and one in 15among young people in the UK (Mental Health Foundation2006). It is widely recognized that prevalence of cutting isdifficult to estimate as, those who cut themselves are lesslikely to attend accident and emergency departments(McLaughlin 2007, p. 72). Ystegaard et al. (2008) statethat self-cutting is the most commonly reported method ofself-harm in their study, accounting for 62.6% of self-harmamong young people. This indicates that among commu-nity populations, self-cutting may be the more prevalentmethod of self-harm (Hawton & Harriss 2008); however,the extent of this will not be recorded in statistics based onhospital presentations.

Cutting can incorporate a variety of behaviours, depen-dent on the severity and frequency of the injury, as well asthe location of the injury on the body and the instrumentused. Favazza (1996) distinguishes between repetitive mod-erate self-harm and episodic moderate self-harm. Repetitivemoderate self-harm is employed by people who become soengaged with their self-harm that they . . . may adopt anidentity as a cutter or burner and . . . describe them-selves as addicted to their self-harm (Favazza 1996,p. 251). Subsequently, repetitive moderate self-harm mayinvolve ritual about how, when and where people cut them-selves. People who hide their injuries may opt to cut lessvisible parts of the body, such as the stomach or legs.Episodic moderate self-harm includes random acts of self-cutting or burning, which are neither habitual nor ritualis-tic. It represents the means . . . to get rapid respite fromdistressing thoughts and emotions (Favazza 1996, p. 243).With episodic moderate self-harm, people may cut them-selves with any object immediately available to them, forexample a knife or broken glass.

Huband & Tantam (2004) differentiate betweenplanned and impulsive acts of self-cutting in their quali-tative study of women who repeatedly self-cut (n = 10).Huband & Tantam (2004) highlight two main pathwaysto cutting: the spring, which is characterized by abuild-up of emotion or tension; and the switch, whichinvolves a sudden impulse to cut. The spring pathway isdefined by an intolerable mounting of tension and therelief that the self-cutting provides is soon replaced by anegative emotion such as guilt. In the switch pathway,there is no plan or rumination, simply a desire to cut.The switch pathway indicates the potentially addictive

Working towards a holistic understanding of self-harm


nature of the behaviour. Huband & Tantam (2004)suggest that the effectiveness of therapeutic interventionswill depend on the pathway to cutting that the individualexperiences, for example participants who switch rankedcounselling and psychotherapy as less helpful than thosewho follow the spring pathway.

Self-injury is distinct from self-poisoning insofar asacts such as repetitive burning or cutting are often said torecover feeling rather than end it (Simpson 2006), totransfer psychological distress into a visible and physicalreality (Babiker & Arnold 1997) and to transform thebody into the site of communication for emotional dis-tress (Mangnall & Yurkovich 2008). Much of theresearch on self-harm is based around presentations tohospital following an episode of self-poisoning or over-dose. Huband & Tantams (2004) study captures anunder-researched area of self-harm, by qualitativelyexploring the experiences of people who self-cut. Subse-quently, more qualitative research on self-harm in theform of self-injury would be welcomed as an area offocus that has often been overlooked.

Life experiences that may contribute to theonset of self-harm

There are many life experiences which may increase thelikelihood of self-harm; the list presented in the discussionbelow is not exhaustive. Evidence relates the significance ofnegative early life experiences such as: sexual abuse; physi-cal abuse; neglect; separation and loss; and insecure attach-ment relationships, as risk factors contributing to thelikelihood of self-harm (Gratz 2003). The impact of suchexperiences on a persons capacity to meaningfully commu-nicate their feelings may lead to self-harm, which becomes ameans of communicating psychological distress through thebody (Babiker & Arnold 1997, Mangnall & Yurkovich2008). Negative early life experiences may result in a failureto achieve object love and subsequent inability to trustothers, which can impede a persons capacity to developsecure and trusting interpersonal relationships (Walsh &Rosen 1988), thus perpetuating the cycle of self-harm.

Turp (2007) presents process material from psycho-therapy practice, which transposes Bicks (1968) skincontainment theory for the comprehension of adult self-harming behaviour. The physical skin acts as a boundary toand a container for the internal functions of the body. It isboth tough and porous. Mother and child share their skinat initial development; the child then develops their ownskin while maintaining their connection with the mother.Similarly the psychic skin develops as a boundary to andcontainer for the psychic functioning of the mind. Wherepsychological development has been impeded in early

development, the individuals psychic skin may become tootough or too porous. If it is too tough, a second skin mayform whereby nothing or no one can permeate. The indi-vidual is overly self-reliant. If their psychic skin is tooporous, the individual is weakened and vulnerable by anintrinsic lack of discernment. Turp (2007) suggests issues ofskin containment predominate in clinical encounters withindividuals who self-harm.

It is not only childhood experiences that may lead aperson to self-harm, traumatic experiences in adulthoodsuch as rape, assault or political conflict can facilitate theenvironment wherein self-harm may flourish among indi-viduals. For some people negative and/or traumatic expe-riences may occur throughout the life cycle. Dorahy(2008) conducted a study on adults attending the TraumaResource Centre in Belfast, Northern Ireland (n = 81). Allof the participants in Dorahys (2008) study had experi-enced Troubles-related trauma, as a result of the politi-cal violence in Northern Ireland. For some participantsthis occurred during childhood, for others during adult-hood, and in addition all but four of the sample hadexperienced childhood abuse. Dorahy (2008) identifiedthat among participants, . . . two thirds of the samplereported a history of self-harm, with a quarter (27%) alsoreporting suicide attempts (p. 42). Dorahy (2008) con-cludes that self-harm has presented within this commu-nity as a less-than-helpful response to the trauma ofpolitical violence (p. 48).

Self-harm serves a number of functions for people whohave experienced negative life events. For example, self-harm may enable a person to communicate their distressthrough their body (Babiker & Arnold 1997, Mangnall &Yurkovich 2008); to transform overwhelming emotionalpain into tangible physical pain (Babiker & Arnold 1997);to punish the self for acts of abuse perpetrated against theself which become sources of shame, self-hatred and self-blame (Walsh & Rosen 1988, Tantam & Huband 2009) orto regain a sense of control when life feels inherentlychaotic (Pembroke 1996). It is crucial to remember thatreasons for and functions of self-harm are unique to eachindividual. Subsequently, if self-harm is to be understood inall its complexity it must be considered holistically in thecontext of a persons life.

The cultural, historical and religious originsof self-harm

In gaining a comprehensive understanding of self-harm, itis imperative to reflect upon the cultural, historical andreligious origins of the behaviour, which throughout timehas been used in many cultures to restore harmony andbalance at perceived moments of chaos. In a similar way

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the person who self-harms becomes a microcosm of theworld of mythology and religious symbolism, sacrificing,

. . . a body part or a portion of blood in order to achievea modicum of well-being. A partial sacrifice achievesonly partial peace (Favazza 1996, p. 25).

Armando Favazza (1996) is esteemed as the seminalauthor to provide a comprehensive understanding of self-harm in the context of culture and psychology. Favazza(1996) differentiates between culturally sanctioned prac-tices such as tattoos and pathological acts of self-mutilationsuch as self-cutting. Individuals who engage in self-harmingbehaviours often have been regarded as attention-seekersin the pejorative sense, who are perhaps merely followingsome new teenage fad (Fox & Hawton 2004, MentalHealth Foundation 2006). Favazza (1996) suggests thatbehaviours that cause harm to self have socio-historicalgravitas and are embedded in our cultural psyche.

In Christianity the path to martyrdom and sainthoodwas paved with self-sacrifice. The term mortification of theflesh, meaning literally putting the flesh to death hailsfrom St Pauls quotation,

For if you live according to the flesh you will die, but ifby the spirit you put to death the deeds of the body youwill live (Epistle to the Romans 8:13).

This belief has a long history in many religions: exem-plified in Christianity by Christ, who sacrificed his own lifethrough crucifixion to redeem humankind. The crucifix isperhaps the most widely recognized religious symbol in theWestern world, representing Christs self-sacrifice and suf-fering for the expiation of sins. Believers partake in Christsdivinity through the sacramental meal which involves theconsumption of His flesh and blood (Favazza 1996).

There are countless biblical stories about martyrdominvolving acts of self-destruction such as self-flagellation inorder to attain atonement. Saint Anthony (251356) wasunderstood to live in an isolated pit for 20 years: eatingonce every 6 months, refusing to wash and wearing acoarse garment that caused his skin discomfort and wound-ing (Favazza 1996). Saint Mary Magdelene dePazzi bornin 1566 devoted her life to self-sacrifice, At age 10 shemade a vow of perpetual chastity, secretly whipped herselfand wore a crown of thorns (Favazza 1996, p. 41). Similarpictures can be gleaned in indigenous tribal cultures,whereby the revered status of Shaman is achieved byenlightenment through great suffering (Favazza 1996). Actsof self-harm often evoke alarm, horror and disgust. Yet,these examples indicate that the notion of healing throughpain, pain as a means to enlightenment and the interchangebetween body and soul are concepts with socio-historicalresonance.

Favazza (1996) frames understanding of self-harm in thecontext of cultural determinism, whereby behaviours will be

interpreted differently within and between cultures. Cultur-ally sanctioned rituals in one culture may be deemed patho-logical behaviour in another. For example, the New Yearfestival of the Abidji Tribe from the Ivory Coast was pho-tographed by Micahel Kirtley & Aubine Kirtley (1982) andinvolved practices of trance-induced states where peopleplunged knives into their abdomens. When such acts aretransposed to Western culture, they are likely be deemedneedless acts of bodily mutilation. Tattooing may be aritualized practice among groups of people where it symbol-izes a sense of shared identity, but among other groups ofpeople the permanent alteration of ones body may evokedisdain or be entirely prohibited. Favazza (1996) suggeststhat acts which are harmful to the self have been an elemen-tal aspect of curing and preventing disease . . . from theearliest days of human existence (p. 227). For example, inthe Middle Ages, blood-letting was used as treatment formany diseases that were understood to be caused by anexcess of blood in the body. While self-harm may be consid-ered an abhorrent or incomprehensible behaviour by manypeople, locating it in its cultural and historical context canbring it from obscurity to enlighten understanding about theexistence of self-harm in every society.

Self-harm is a term that can encompass a wide range ofbehaviours conducted by individuals in all societies, agegroups, social classes, religions and races. Self-harmingbehaviours are dependent on cultural interpretations ofintent and acceptability. Turp (2003) coins the useful term. . . cashas an acronym for culturally acceptable self-harming acts or activities (p. 9). An activity such assmoking, for example, may cause more physical harm to anindividual than self-cutting. Yet the former is not generallymet with the same level of shock or disdain as the latter. Indistinguishing between cashas and other self-harmingbehaviours, Turp (2003) acknowledges the plethora ofactivities that can be defined as self-harm, such as tattoos,religious pilgrimages, alcohol consumption or overwork. Inthis paper, self-harm relates to the acts of self-harm that areoften interpreted as pathological, rather than cashas.Turps (2003) distinction between the behaviours affordsclarity and helps to avoid misinterpretation or dual inter-pretations of the term self-harm.

Stigma and attitudes

The term stigma originated with the Greeks, . . . to refer tobodily signs designed to expose something unusual and badabout the moral status of the signifier (Goffman 1963, p.11). In more recent conceptualizations, Goffman (1963)extrapolated three major types of stigma: the first is . . .abominations of the body, the second refers to . . . blem-ishes of individual character, and the third relates to . . .



the tribal stigma of race, nation and religion (p. 14).Stigma is thus of profound significance in relation to self-harm, in that people who self-harm may be stigmatized onaccount of both the physical marking of their body as wellas the inferred defamation of their individual character.Goffmans (1963) work is crucial in emphasizing the role ofstigma in discriminating and isolating people based onprejudicial assumptions. Subsequently, the impact ofstigma on people who self-harm may be powerfully detri-mental to their capacity for self-care at an emotional orphysical level.

For many people who self-harm, their behaviour ishidden, perhaps a powerful acknowledgement of theirawareness that the behaviour breaches social boundariesand the consequences of such breaches becoming commonknowledge, such as labelling, psychiatric diagnoses andimpact on personal and professional relationships. Withsocietys increased emphasis on appearance and the exte-rior self (Lemma 2010), there are many reasons for peoplechoosing to reject the situational status quo. These maybe part of societys dysfunctions when so many peoplerenounce them with their own hidden, private and ulti-mately self-destructive revolutions. Goffman (1963) states,A mental symptom, however, is a situational offense thatthe offender does not get away with (p. 240). For peoplewho self-harm and endure their distress in silence, theyendeavour to get away with their offense by concealing itat all costs. Those people who self-harm and want to seekand access help face an arduous task in overcoming inter-nal and external situational bias.

Professional attitudes to self-harm reflect wider societalattitudes and these both enhance and are enhanced byprevailing stigmatization of people who engage in self-harm. Walsh & Rosen (1988) articulate, . . . we inevitablyexperience discomfort when encountering fellow humanbeings so intensely distressed that they cause themselvesconcrete physical harm (p. 3). While those words werewritten more than 20 years ago, they seem to reflect a levelof discomfort shared by many people in society. Otherwriters in the field of self-harm relate that self-harm oftenevokes discomfort, confusion and even disgust among careproviders (Babiker & Arnold 1997, Shepperd & McAllister2003, Simpson 2006). Indeed, Shepperd & McAllister(2003) suggest that, . . . the whole experience of health-care can be another ordeal which the consumer finds trau-matic, invalidating and may even trigger further need toself-harm (p. 443). Professional attitudes to self-harm canimpact on responses to presentations of self-harm, subse-quently affecting individuals experiences of psychiatricand mainstream services.

Simpson (2006) questions the viability of therapeuticinterventions for people who self-harm in the National

Health Service. She maintains that despite efforts byNational Institute for Clinical Excellence to review theseservices, . . . it is difficult to see how this might beachieved inside organisations that, for the most part,appear to have become institutionally prejudiced towardspeople who self-harm (Simpson 2006, pp. 434435).Simpson (2006) suggests that in a climate of risk assess-ment, patient and health professional operate withindifferent realms of understanding. For patients their com-munication is limited in that words are not sufficient toexpress their pain, as such they resort to self-harm, . . .inscribing individual life stories on the body in the formof self-cutting (Simpson 2006, p. 433). Where a patientpresents who is unable to articulate their pain, . . . theprofessional helper may feel lost and deskilled (Simpson2006, p. 433). A lack of mutual understanding in a health-care environment may compound already existing prejudi-cial attitudes and further iterate the cycle of stigmatizationagainst people who self-harm.

Psychiatric diagnoses and self-harm

Borderline personality disorder (BPD)

There is a wealth of evidence which demonstrates thatthere is a link between self-harm and diagnosis of BPD.Klonsky & Muehlenkamp (2007) suggest this relationshipis, not surprising because both have negative emotionalityand emotion dysregulation as core features (p. 1048). Self-harm features as one of nine symptoms listed by Diagnosticand Statistical Manual of Mental Disorders (1994) in thediagnostic criteria for BPD. Five of the nine symptoms mustbe present for a diagnosis of BPD to be made; however,according to Proctor (2010), the diagnosis of BPD is oftenmade on the basis of self-injury alone (p. 19). Crowe &Bunclark (2000) suggest that diagnoses of BPD have beenmade about people who self-harm, irrespective of the pres-ence of other criteria. Diagnoses made on this basis mayindicate that the association between BPD and self-harmmay be not only erroneous but also detrimental to the livesof individuals who self-harm, who are further exposed tosystematic stigmatization as a result of the diagnosis ofBPD (Simpson 2006).

There is research evidence which seeks to move beyondthe stereotypic interpretations of self-harm as the symptomof disorders such as borderline personality. McAndrew &Warne (2005) present a case study on three UK-basedwomen with a history of self-harm, using feminist praxis toanalyse the womens discourse and understand the uniquemeanings for their self-harm. Each of the women partici-pating in the study has psychiatric diagnoses includingschizophrenia, or schizo-affective disorder, depression and

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BPD. They have also experienced traumatic life eventswhich pre-dated the onset of their self-harm, includingsexual abuse and rape. McAndrew & Warne (2005)employ a feminist praxis approach, to inform the studysmethodology in an attempt to redress the power dynamicinherent in the research process which mirrors that facedby women living in a patriarchal society. In this way theauthors are able to listen to and explore the individualvoices of their participants who have often felt voicelessand powerless in the system of psychiatric care.

McAndrew & Warne (2005) argue that it is imperativefor mental health practitioners to move beyond the con-fines of diagnostic labelling when working with self-harmas this may ignore traumatic life experiences and the socialcontext of a persons life (p. 172). McAndrew & Warne(2005) state explicitly that mental health services can onlyeffectively work with people who self-harm when theybegin to understand the complexities and variances of indi-vidual life experiences which often lead to self-harm. Theysuggest that disregarding the often traumatic history ofpeople who self-harm is akin to sticking a plaster on [the]wound to stop the bleeding while disregarding the bacteriathat lie beneath the surface (McAndrew & Warne 2005,p. 178). McAndrew & Warne (2005) also assert thatmental health nurses must foster their capacity for psycho-dynamic understanding, if they are to work sensitively andeffectively with people who self-harm.

Self-harm and suicide

The term parasuicide was developed by Kreitman (1977)to describe a range of non-fatal suicidal behaviours,including manipulative acts, less serious gestures andmore serious attempts. Yet the term parasuicide can becriticized for implying suicidal intention, when this maynot in fact be present (Fox & Hawton 2004, p. 14).Hawton et al. (2006) suggests that there is an associationbetween self-harm and suicide and cites that around 40%to 60% of people who take their own lives have a historyof deliberate self-harm. Yet Cutliffe et al. (2008) articulatethat while links do exist, there is a wealth of empiricalevidence that shows that 95% and over of people whoself-harm do not go on to take their own lives (p. 154).The figures may capture an element of suicidal ideationamong certain individuals who self-harm; however, it isalso evident that for many people who self-harm, there isno intention to die.

Menninger (1938) suggests that the self-destructive ten-dencies within individuals who substitute part of themselvesfor their whole selves represent a triumph of the life force inthe Eros/Thanatos conflict. Menningers (1938) ideas wereground-breaking in the implication that self-harm can be

life-giving. Walsh & Rosen (1988) refute the conflation ofself-harm and suicide by claiming that the objective ofsuicide is to end life, whereas self-harming behaviours, . . .however limited as coping mechanisms, are nonethelessultimately adaptive to sustaining life (p. 51). Cutliffe et al.(2008) articulate succinctly that suicide is death-orientedwhereas self-harm is life-oriented (p. 155). In the SANE(2008) report on self-harm, 20.1% of respondents (n =111/553) state that the main function of their self-harm is toprevent suicide. Other writers in the field including Favazza(1996), Freeman (2010) and Pembroke (1996) concur withthe idea that there is not necessarily a continuum fromself-harm to suicide; in fact they can be two very differentbehaviours with divergent functions.

Self-harm and suicide behaviours are often categorizedas analogous, particularly within service provision, forexample the Protect Life Strategy is the Suicide and Self-Harm Strategy for Northern Ireland commissioned by theDHSSPSNI. The extent to which this understanding mayimpact on professional attitudes towards or treatment out-comes for individuals who self-harm, if or when they doseek help, is unclear. In order to facilitate a comprehensiveanalysis of either self-harm or suicide, it is vital to under-stand that self-harm serves unique functions and holdsindividual meanings, which are often distinct from thosepertaining to suicidal behaviour.

Conclusion: implications for practiceand research

Self-harm is pervasive in society, a behaviour which hasevolved with us throughout history, cutting across socialand cultural divides, affecting people in clinical and com-munity populations. By providing an all-encompassingdefinition of self-harm, examining the cultural, historicaland religious origins of self-harm and considering issuesaround psychiatric diagnoses pertaining to self-harm, thispaper challenges practitioners to consider the potentiallyuniversal nature of self-harm. The discussion around sen-sitivity in language use offers one fundamental meansthrough which practitioners can lead the way in recon-structing myths and reducing the stigmatization of peoplewho self-harm. Further qualitative research from the per-spectives of people who self-harm would deepen under-standing of the issue, enabling people to share theirexperiences, advancing practice in a meaningful way.

This paper has sought to increase dialogue among prac-titioners, illuminate the issue of self-harm and engendergreater willingness to look beyond the behaviour in orderto understand the person. It is well documented that pro-fessional responses based on negative attitudes can com-pound an existent sense of shame among people who



self-harm. Is it time now to rewrite the script? Workingtowards a holistic understanding of self-harm, which rec-ognizes this as a shared piece of human experience, couldfoster more empathic responses to people who self-harm,ultimately enhancing their capacity for self-care.

Acknowledgments

The authors would like to thank Professor ChristopherLewis of Glyndwr University, for his contributions duringthe seminal stages of this research process.

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Appendix I: Search formulae and results

Search formulae

PsychARTICLES

MEDLINEPsychCRITIQUESPsychINFO

(self-harm OR self-mutilation OR self-injur* OR self injury OR self-cutting ORself-laceration OR self harm OR DSH OR SIB) AND (help-seek* OR help seekOR seek help)

151 161

(self-harm OR self-mutilation OR self-injur* OR self injury OR self-cutting ORself-laceration OR self harm OR DSH OR SIB) AND (stigma OR attitudes ORprejud*)

746 1021

(self-harm OR self-mutilation OR self-injur* OR self injury OR self-cutting ORself-laceration OR self harm OR DSH OR SIB) AND (help-seek* OR help seekOR seek help) AND (stigma OR attitudes OR prejud*)

64 80

(self-harm OR self-mutilation OR self-injur* OR self injury OR self-cutting ORself-laceration OR self harm OR DSH OR SIB) AND (counselling OR counsellingOR psychotherapy)

899 1059

(self-harm OR self-mutilation OR self-injur* OR self injury OR self-cutting ORself-laceration OR self harm OR DSH OR SIB) AND (counselling OR counsellingOR psychotherapy) AND (help-seek* OR help seek OR seek help)

55 61

(self-harm OR self-mutilation OR self-injur* OR self injury OR self-cutting ORself-laceration OR self harm OR DSH OR SIB) AND (counselling OR counsellingOR psychotherapy) AND (stigma OR attitudes OR prejud*)

203 306

(self-harm OR self-mutilation OR self-injur* OR self injury OR self-cutting ORself-laceration OR self harm OR DSH OR SIB) AND (counselling OR counselling ORpsychotherapy) AND (stigma OR attitudes OR prejud*) AND (help-seek* OR helpseek OR seek help)

34 46



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