Understanding and Responding to Self-Harm: The One Stop Guide: Practical Advice for Anybody Affected by Self-Harm

part one

What is self-harm?

chapter 1

What do we mean by ‘self-harm’?

If you are trying to find out about self-harm (especially by looking online) you can end up muddled by what seem to be contradictory statements. Or you may read something about self-harm and think ‘that’s all very well but it doesn’t apply to me’ even though you yourself self-harm or know somebody who does. Of course, self-harm is an emotive topic and that is partly why the way in which people talk about it gets muddled. Another reason is that the expression ‘self-harm’ isn’t used at all consistently. So, to avoid confusion, let’s start by examining what self-harm is, and exploring how different terms are used by different people. On the way, we will also debunk some of the myths that surround the topic.

Defining ‘self-harm’: keep it broad and keep it simple

WHO, the World Health Organization, issues definitions of illnesses and conditions. The WHO defines self-harm as

an act with non-fatal outcome, in which an individual deliberately initiates a non-habitual behaviour that, without intervention from others, will cause self-harm, or deliberately ingests a substance in excess of the prescribed or generally recognised therapeutic dosage, and which is aimed at realising changes which the subject desired via the actual or expected physical consequences.

That definition means that self-harm is intentional, is done by somebody to themselves, and is done by someone who wants to make something change. By saying it is ‘non-habitual’ it means that it is done as a conscious act, separate from normal day-to-day life.

The WHO definition might seem a bit mind-boggling and rather legalistic-sounding, so here’s a simpler one, adopted by the UK’s National Institute for Health and Clinical Excellence (usually called NICE): ‘self-poisoning or self-injury, irrespective of the apparent purpose of the act’.

That is the definition of self-harm used in this book. Let’s look in a bit of detail about what it means in practice.

First and foremost, self-harm is an action by a person. It’s something that somebody does to themselves. It is not a description of who somebody is and not a name for a mental disorder. You sometimes hear people described as ‘cutters’ or ‘self-harmers’. That’s undesirable language and it’s offensive. It is dismissive to label someone because of something they do. Even if they do it quite often it doesn’t define them as a person. And as a description of their actions it’s misleading because it is oversimplified. Even if we do something over and over, it does not mean that our actions are unchanging and fixed.

You will notice that neither of these definitions says anything about the reasons that the person has for their act of self-harm. You have to remember that the definitions include acts of attempted suicide but also acts where there is no apparent desire to die. The definitions also include those times when the person actively rejects any notion that they wanted or intended to die. This is an important point. Ever since the 1950s, when self-harm started to be seen as a common problem in developed countries, it has been clear that every act of self-harm is not a failed attempt at suicide.

As will be discussed later when I review explanations for self-harm, some people are quite clear that they don’t want to die at the time they harm themselves. They may in fact be using non-fatal self-harm as a way of defending themselves against more threatening thoughts about suicide. On the other hand, self-harm is definitely not the opposite of attempted suicide. Some non-fatal acts are indeed failed suicide attempts. And research studies that have followed large groups of people who had already harmed themselves find that they have a suicide rate many times higher than the rest of the population.

To summarise, whatever definition is used, the reasons for self-harm are complicated and in truth many people find it difficult to put into words exactly why they have harmed themselves. They may or may not intend to die. Some may eventually die through self-harm. Nevertheless, the person you know who has self-harmed may actually have reduced the likelihood of their suicide by resorting to a harmful but not fatal act. The most important point to make is this: when someone has self-harmed, you can’t make any assumption about whether or not they intended to kill themselves. It isn’t wise to make blanket assumptions.

Before we move on, here are a few other terms that you may come across. Self-harm and deliberate self-harm are used to mean the same thing. They can be regarded as identical, although self-harm is now more commonly used. Parasuicide is an expression that isn’t used so much now, but you might find it in older writings. It’s a word that was made up in the 1960s to mean ‘behaviour that’s like suicidal behaviour’. It has (not surprisingly) fallen out of fashion. Attempted suicide sounds as if it refers only to acts where death was desired, but in fact it was quite widely used from the 1970s onwards to refer to all acts of self-harm. Self-mutilation is really the same as self-injury, and has been dropped as a term in most settings. This is because ‘mutilation’ means disfigurement or maiming, and a lot of self-injury isn’t deliberately intended to cause that sort of injury, or permanent scars. Sometimes, even if there is such an intention, there is in fact no permanent effect.

When self-damaging actions aren’t called self-harm

There are lots of harmful things people do to their bodies that don’t usually get counted as ‘self-harm’ in the sense I am talking about. Here are some of the common ones:

Piercing the body for fashionable (cosmetic) reasons

Cutting patterns on the body for social or symbolic reasons (scarification)

Taking dietary modification to extremes – undertaking prolonged fasts or excluding all but an extremely limited number of foods from the diet

Using recreational drugs or alcohol in a wild or reckless manner.

Why aren’t these activities usually included in the category of self-harm? One reason is that their primary purpose isn’t to damage the body. For example, several of the actions in this list are designed to change the body’s physical appearance for social or cultural reasons that are seen as desirable rather than damaging – even when taken to extremes as in prolonged starvation such as anorexia nervosa. Bodily damage, including serious illness, can arise from drinking too much or taking recreational drugs, but the primary purpose of using these substances is to experience their psychological effects rather than to cause damage. So, these are sometimes called indirectly harmful behaviours to distinguish them from the intentionally harmful actions that are labelled as self-harm.

The other reason that these activities are talked about differently is that they are thought of as being socially approved – that is, shared and supported within a social group – whereas self-harm is thought of as having individual and abnormal psychological causes.

As with all simple distinctions, it isn’t that straightforward. There is in reality a rather unclear boundary between actions where damage to yourself is an unintended consequence and acts of self-harm where damage is intended. For example, studies into how young people respond to stress have shown that self-harm, drinking too much and eating disorders may often go together. It is also possible that someone who regularly uses substances in a way that their social group tolerates may push themselves beyond the ‘normal’ range for that group.

Acts that are definitely in the category of self-harm – cutting your arms to produce scars – can sometimes be so common as to seem normal in certain social groups that aim for a rebellious image. This particular example shows that apparently simple distinctions can be less clear than they seem initially.

Do people who engage in indirectly harmful behaviours for unhealthy reasons, or who self-harm for reasons accepted by a group to which they belong, need protection against doing harm to themselves? There is no simple answer to these questions, especially when talking about young people. It is an active debate in public health. For now, these issues have been raised in order to clarify that in this book self-harm is referring only to intentionally harmful actions.

So far this chapter has outlined what professionals mean when they use the expression ‘self-harm’. It isn’t how everybody uses the expression, but it is a helpful and simple way – it doesn’t make the idea too broad by including too many different behaviours, and yet it doesn’t narrow it down too much by (for example) limiting it to only one method of self-harm or one presumed motive.

It can be difficult to know what definitions mean without clear examples, so the next section will look at what self-harm is by going into more detail about what people actually do. Not every possibility is described, but it will cover all the common methods of self-harm.

Describing self-harm – what people do

The definition of self-harm by the World Health Organization refers to ‘a non-habitual behaviour’ or acts in which somebody ‘deliberately ingests a substance in excess of the prescribed or generally recognised therapeutic dosage’. The NICE definition more concisely describes the two main types of self-harm as ‘self-poisoning or self-injury’.

One of the confusions you come across in the use of language is that some people use the term self-harm to refer only to self-injury. For example if you put ‘self-harm’ into an internet search engine you get lots of material (especially if you search for images) about people who cut themselves. It is almost as if people who poison themselves aren’t thought of as self-harming, or as if they are completely different from people who self-injure. Commonly, an act of self-poisoning is likely to be seen as attempted suicide while self-cutting is seen as non-suicidal. Indeed the label ‘non-suicidal self-injury’, which is widely used especially in the US, suggests exactly this distinction. It’s true that people who self-harm a lot, perhaps dozens of times a year, are likely to use self-cutting most of the time but we shouldn’t think of these two acts (cutting and poisoning) as being completely different. There is plenty of evidence that this way of thinking – about self-harm being exclusively the same as self-injury while self-poisoning is something different – is wrong. Self-poisoning and self-injury have pretty much the same causes, both can be associated with thoughts of wanting to die or can take place with no wish to die at the time, and people who repeatedly self-harm will often switch between self-injury and self-poisoning as their chosen method.

There are a couple of reasons why self-injury attracts so much attention. First, we live in a very ‘visual’ world and it’s easier to show pictures of somebody with scars or holding a razor blade than it is of somebody taking an overdose of tablets. Second, some of the interest in self-injury comes from a sort of horrified fascination with it – ‘How could anybody do that to themselves?’

A balanced view of self-harm requires us to consider all its aspects. So, let’s start by reviewing both self-poisoning and self-injury.

Self-poisoning

If you work in a hospital, the commonest type of self-harm you see is self-poisoning – often called an overdose because what people typically do is to swallow too much of readily available prescribed or over-the-counter medications. The common ones that people take are physical painkillers (paracetamol, aspirin, ibuprofen) or medications for emotional pain, such as tranquillisers or antidepressants.

I felt so awful, I just wanted it to stop, to switch off for a while. I went into the bathroom cupboard and found some tablets of my mum’s – painkillers her doctor gave her when she injured her back. There was 10 left in the pack, it said the adult dose was two so I took them all and lay down in my bedroom.

Laura, 19

Less commonly, poisoning can be with substances that have no value as medication – for example bleach or household products that are poisonous. The choice of poison may depend upon its availability. In agricultural communities weed killer is more widely used. Powerful painkillers that are like morphine (called opioids) are usually only available on prescription and are more often used in urban areas. You may have read that this problem of opioid prescribing and the risk in overdose is a public health concern now in the US, where they are facing a sharp rise in both non-fatal overdose and of suicides with these drugs. It is less of a problem in the UK, where doctors are increasingly discouraged from prescribing strong painkillers for people unless they have a life-limiting physical illness like cancer.

Self-injury

Most acts of self-harm do not lead to hospital attendance, and in these cases it is self-injury that is the more frequent method used. Here are some of the ways in which people injure themselves:

Cutting with razors, broken glass, knives – anything sharp enough

Self-cutting is such a pervasive act now that nearly everybody will have heard of it or will know