Clinical psychology comment

The usefulness of self harm

December 13, 2004

Whether it 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 Sam Warner

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As 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 buy more.

No, it wasn't until I was in my 20s, and at university that I started smoking seriously. I've never really stopped.

Yes, 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.

That 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, dedicated smokers?

Let 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, ecstasy, etc).

Despite 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.

When 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 cause.

Clearly, 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.

As 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 place.

For 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.

We 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 of abuse.

People 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.

If 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.

We 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).

When 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.

One 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.

The 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.

Perversely, 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.

If 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.

Most 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 Unit

See:
* The government's national service framework for mental health

See also:
August 26, 2004: Psychiatrists rebuke colleagues over remarks on self harming patients - concern after people who self harm described as "wilfully immature"
July 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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Preaching to the converted?

Comment from: Sharif El-Leithy, clinical psychologist,
Traumatic Stress Service, St. Georges Hospital, London
Date: December 13, 2004

As 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."

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No, not everyone is converted...

Comment from: Susanna Reid (not real name), mental health service user, Birmingham
Date: December 14, 2004

I 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.

I 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'.

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.

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Difference between 'drive' to self harm and smoking

Comment from: Phil Barker, professor of health science, Trinity College, Dublin, Ireland.
Date: December 15 , 2004

A 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.

That 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.

My experience of people who self harm confirms this 'driving' hypothesis, although what actually does the driving differs from one person to the next.

However, 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.

Most 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.

On 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 services.

Let us remember that it is the 21st century. Time to do something radically different to help our fellow women and men.

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Since when did smoking keep people alive?

Comment from: Andy Cullen, Bellenden Road, London SE15
Date: December 15, 2004

The 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.

A crucial difference between smoking and self-harm is a smoker’s willingness to risk inflicting physical harm on others.

If 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?

It simply isn’t true that regarding self-destructive behaviour as 'wrong' precludes a full exploration of the underlying issues.

' If smoking didn’t work, we wouldn’t do it…' claims the author, '…self-harm is about self-preservation.'

But 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”?

Reaching 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”.

Cigarette 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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