of self harm
be smoking or cutting oneself, self harm can be an imaginative way
to cope with trauma. To avoid shaming people who self harm clinical
psychologists should not assume that self harm is wrong, argues
a teenager I was anti-smoking. I knew it was bad. It smelt and I
did not want it around me. I smoked two cigarettes once because
I was miserable. It didn't really help, and I didn't rush out and
it wasn't until I was in my 20s, and at university that I started
smoking seriously. I've never really stopped.
I wish I never started. I still know how bad it is for me and for
those around me. And one day I'd like to give up.
smoking will inevitably be banned in (enclosed) public places I
accept. However, I'm not sure that such actions will stop the nation
smoking. It may help 'social' smokers, but what about us hardened,
me widen this debate a little bit more. I know cigarettes may be
unique in the sense that they are always physically bad for us,
but there are other drugs, that whilst not universally bad, are
deemed to be bad enough that they are illegal (heroine, cocaine,
this ban, many people use such drugs. Indeed, we take more illegal
drugs in this country than anywhere else in Europe. A policy of
prohibition does not stop habitual drug users. It criminalises those
most in need, shames them and ultimately restricts the ways in which
we can support people to manage their (illegal) drug use.
we don't adopt a policy of prohibition we think the answer is to
give people information about the (self) harm caused by the effects
of smoking, using alcohol or cutting, for example. Yet, I smoke
cigarettes knowing that they are bad for me. People use illegal
drugs and other forms of self-harm knowing the damage such actions
we need to check that people have basic information about the things
they do. However, most habitual self-harmers have detailed knowledge
about the negative effects of their actions. When we tell people
what they already know we perpetuate a culture of shame. And when
we invite people to feel shame about their behaviour we may be complicit
in reproducing some of the feelings that underlie the behaviour
in the first place. For example, when people tell me that smoking
is bad for me it makes me feel stupid, angry and ashamed, and ultimately
makes me want to reach for another cigarette.
clinical psychologists we have a significant role to play in supporting
and helping people who self-harm. If we are to be more helpful than
harmful we need to reflect on how our attempts to intervene can
sometimes exacerbate our clients' felt sense of shame, stupidity
and powerlessness: feelings that may underlie self-harm in the first
example, when we suggest our clients have misunderstood their actions
(as some cognitive approaches might suggest) or are going to change
if we simply stop rewarding them with attention (as some behavioural
theories imply) we infer that our clients self-harm because they
lack information or imagination. The assumption is that self-harm
is an essentially a destructive act that should be stopped.
make the behaviour the main focus of our concern and sometimes fail
to ask, in our fervour to stop it, why people act in the way they
do. We fail to integrate different services such that we treat 'symptoms',
but never address root causes. For example, women sometimes use
alcohol to dissociate from their everyday experiences of domestic
abuse. Yet few drug and alcohol services have formalised links with
local refuge provision (services in Knowsley, Merseyside, are one
exception to this) or routinely concern themselves with matters
self-harm for many reasons: not because they lack information about
its negative effects but because they have the imagination to find
ways of coping when they feel powerless or trapped. Most people
self-harm not because they have a desire to die, but because it
helps them stay alive.
smoking, using drugs and cutting oneself didn't 'work', we wouldn't
do it. Self-harm is a trade-off between damage and preservation
(cigarettes work like this for me). Sometimes, this trade off stops
working when people feel out of control of the things they do. If
we are to help people through such times I think we need to stop
adding to their felt sense of shame about their actions.
shame people when we label them as alcoholics or addicts, or when
we assume self-harm is a symptom of borderline personality disorder
(people get this diagnosis when they cut themselves, which, it can
be argued, may be a safer alternative to smoking cigarettes).
we transform what people do into who we think people are we imply
they can never change. Alcoholics may be permanently in recovery,
but they can never recover.
reason people self-harm is because they feel powerless, yet we respond
to self-harm with increasingly controlling behaviour. We lock people
up when we consider them to be a danger to themselves, and then
fail to provide comprehensive mental health services.
National Service Framework for mental health states that we should
adopt a more social, holistic and recovery based approach and move
away from a more restricted medical model of distress. Yet, without
a diagnosis, in a tier-based system, people cannot get treatment.
sometimes getting a diagnosis (of personality disorder) can mean
people are refused services (they are hopelessly untreatable). And,
treatment often means legal psychiatric drugs, not talking therapies
or social support.
we are to support people who self-harm we need to accept that self-harm
(including smoking) is often about self-preservation. If we assume
such behaviour is always wrong we can fail to fully explore the
underlying issues that bring meaning to such actions and be too
quick to restrict our clients' choices.
of us self-harm in one form or another (as noted, I smoke). We might
not share the same behaviours but we certainly cope with similar
feelings sometimes (upset, hurt, shame, anger, boredom, frustration
etc). If we are mindful that the feelings are quite ordinary we
might not get so worried about behaviour that seems extraordinary.
And when we recognise that self-harm can be useful we may then find
ways of working that validate rather than undermine our clients.
Recovery doesn't always mean changing our coping strategies (although
I might, one day).
* Sam Warner
is a consultant clinical psychologist working for Liverpool and
Warrington social services, children and families division, and
research fellow at Manchester Metropolitan University. She is a
member of the Forensic
Research Group and the Discourse
government's national service framework for mental health
26, 2004: Psychiatrists rebuke colleagues over remarks on self harming
patients - concern after people who self harm described as "wilfully
29, 2004: Treat people who self harm with respect, new guideline
urges professionals - A&E staff should also receive specialist
training, NICE recommends
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to the converted?
El-Leithy, clinical psychologist,
Traumatic Stress Service, St. Georges Hospital, London
December 13, 2004
much as I agree with the sentiments of this piece I can't help but
feel it is just preaching to the converted. There is nothing new
in formulating self-harm as a coping behaviour.
No doubt in presenting it as one option amongst many, and weighing
up the relative costs and benefits, clients can be helped in a way
that neither minimalises the power of self-harm, nor denies their
right to use such methods to cope.
However I am unsure who this piece is trying to convince, as most
people reading it would, I think, find it less than challenging
to their already held view of the world. Can I suggest that this
section [clinical psychology comment] instead be used for considering
issues that are contentious, rather than rehashing old ideas."
No, not everyone
Reid (not real name), mental health service user, Birmingham
December 14, 2004
cut when I feel abused by my local mental health service providers.
Sometimes when I feel hurt by them, the only person I can lash out
at is myself. When people try to stop me, it makes me feel more
abused. When they locked me in a psychiatric ward it was the only
feeling of control I had over my own body or my own destiny. It
was the only little bit of freedom I had.
don't think that it is a waste of time to write about this because
there are still mental health professionals who stick labels on
you if you get to the stage of self-harming, and who see you as
an attention-seeker instead of understanding that it is a big scream
of 'go away, get out of my life'.
have only ever self-harmed in response to what mental health professionals
have done to me. Nothing else in my life has ever driven me to do
between 'drive' to self harm and smoking
Barker, professor of health science, Trinity College, Dublin, Ireland.
15 , 2004
typically engaging piece from Sam Warner who is someone who knows
a lot about self harm and has the capacity to express it intelligently
but also in an interesting fashion.
said, 'Susanna's' reply puts the whole self-harming scenario into
a different context. She noted that: 'I have only ever self-harmed
in response to what mental health professionals have done to me.
Nothing else in my life has ever driven me to do this.' This seems
to be something of a skeleton key.
experience of people who self harm confirms this 'driving' hypothesis,
although what actually does the driving differs from one person
to the next.
as a former smoker and a fairly active drinker, I think it is fairly
uncontentious to say that few people are 'driven' to smoke or drink,
whatever they say.
of us - like Sam - have to apply ourselves, fairly diligently, to
getting over the revulsion and acquiring the taste. Seems quite
unlike the lived-experience of self harm in the psychiatric context.
the NICE (National Institute for Clinical Excellence) side of things,
it could ultimately be a blessing in disguise that 'self harming'
people find it so difficult to access 'treatment'. What they need
is understanding, human support and a bit of acceptance. They are
most unlikely to find this in A&E and certainly not in the psychiatric
us remember that it is the 21st century. Time to do something radically
different to help our fellow women and men.
did smoking keep people alive?
Cullen, Bellenden Road, London SE15
December 15, 2004
comparison between smoking and self-harm does a disservice to both
communities. Nobody has died from passive self-harming, but thousands
die every year from passive smoking.
crucial difference between smoking and self-harm is a smokers
willingness to risk inflicting physical harm on others.
the author is asking us to accept smoking as a legitimate form of
self-preservation, are we also expected to tolerate
people who cut others as well as themselves?
simply isnt true that regarding self-destructive behaviour
as 'wrong' precludes a full exploration of the underlying issues.
If smoking didnt work, we wouldnt do it
the author, '
self-harm is about self-preservation.'
100,000 people die each year in the UK as a result of smoking. Globally,
the figure is nearly six million. Is this annual holocaust really
a sign that smoking helps people to stay alive?
for a cigarette is not an act of imagination. In the era of the
suffragettes, advertisements showed attractive young women smoking
cigarettes which were promoted as Flames of Freedom.
companies have always used their immense wealth to impose insidious
marketing strategies on young and vulnerable consumers. Smoking
has very little to do with individual choice and a great deal to
do with corporate power.
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