Let’s stop the stigmatisation of self-harm

“Yes, but people shouldn’t have to talk about it…”

“…and do you really think everyone is like you, that they’ll want people coming up to them and asking about it?”

These were some good points.

This conversation took place minutes before I found out my article on self-injury had been published without my consent. It had started raining, so the discussion came to an end and my friend and I parted ways. It reminded me to send off a request, the third of that week, to ask if the edited version was ready, so I could approve any changes or not before it went to print. “It’s out!” the reply returned quickly. Up popped a grainy photo of a newspaper page: a large silhouette with cogwheels for a brain loomed beneath a small patch of text. What? It was already in print? I had been told the week before that the editors were concerned my original piece glamourised self-harm, something I disagreed with, but was patiently waiting to discuss once the sub-editing was finished. I zoomed in and began to read the familiar intro… It only took until the second paragraph to realise an article largely different from my own had been signed off with my name.

A key focus of my original article was about an experience I’d had at an Orthopaedics conference a couple of months before, because it framed the points I wanted to make about non-suicidal self-injury (NSSI) perfectly. One of the registrars, while fiddling with my arm, noticed the dulled scars on my shoulder and stopped in her tracks, remaining silent for roughly five seconds. Having moderate depression co-morbid with anxiety, I tend to be hyper attentive to body language and overthink things, so what may have been mild discomfort on her behalf appeared to me as disgust and embarrassment. For the rest of the day, I was quiet, mulling over that short scene until I was miserable.

Firstly, this highlighted the sometimes irrational thought processes common to mental illnesses such as anxiety and depression. Secondly, although I had blown it out of proportion, her response was clearly not helpful. But this article read differently. In this version, the registrar was a ‘horrible person’ who had said ‘something nasty to make me feel upset’. Albeit, my original text was ambiguous: “However, it only took one [of the registrars] for me to feel upset.” But my article emphasised that I was looking at their body language, and it is just common sense that doctors don’t whimsically say ‘horrible’ things that would jeopardise their whole career. Damn. The bit in about scars not causing long-term damage to my physical health, just as the ones picked up on the playground don’t affect non-self-harmers, was kept, but the context was lost.

They’re just scars. We all have them, whether from sports, accidents or as an expression of mental illness. Some look ‘cool’ and some don’t. Mine don’t, but they’re there to stay. My point is that superficially, the act itself is not a major problem (except for risk of infection, of course). The psychiatric condition from which it manifests is. Therefore, when someone reacts with discomfort to the obvious patterns of self-injury, I struggle to believe it is based purely on aesthetics. If someone has a series of disfiguringly large scars from a serious accident, I concede that aesthetics may come into play; however, without knowing the context in which those injuries were obtained, it is ludicrous to judge a person by them. In my case, where the context was evident, the non-verbal reproach to an outcome of my condition is therefore demonstrative of subtle but unmistakable stigma. As the aforementioned scenario was obfuscated in the published article, I shall turn to science, which is harder to obscure.

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In 2007, researchers at Columbia critically assessed all previous literature looking into the epidemiology of NSSI in an attempt to come up with an exact figure for how many people have performed NSSI in their lifetime. The figures they derived ranged from 13 per cent to 23.2 per cent, depending on what level of severity or method (cuts, burns, high impact injury such as punching walls etc) of self-harm was assessed. Many studies over the last few years indicate that NSSI is on the increase, especially amongst adolescents, so it is likely that this number is now higher. So, at the lowest estimates, one in ten people reading this article will have had or are yet to have a personal encounter with NSSI.

In 2010, a questionnaire study of 73 psychiatric patients at a hospital in Derby found a significant correlation between self-harm and self-criticism, shame and self-persecution. Although a relatively small study, it illustrates the psyche of someone who self-harms. That is, it is the consequence of moral distortions emerging from a psychiatric illness.

This quotation is taken from a small, intense study of self-injurious adolescents in Ireland, and it sums up my concern perfectly about the stigma around NSSI. “A person might internalize the external stigma, subsequently leading to a sense of confusion and self-doubt… For many of the participants, this experience ultimately compounded a sense of emotional reticence, rejecting the idea that they would want help or indeed that they would want to break out of the spiral of self-injury” (Long et al, 2014).

What about those who swear such stigma does not exist? Unfortunately, there is little current evidence about NSSI stigma in the UK with which to argue my point. Instead, I present you with evidence from 2008, obtained from 157 finalists at universities in the West Midlands studying for careers in healthcare. Participants were given one of two vignettes: a young woman who self-harms because of drug misuse, and the other because of drug abuse. The former is deemed to be within the woman’s control, and the latter out of their control (analogous to self-injury as a result of psychiatric illness). When asked a series of questions gauging attitudes towards the vignettes, a significant proportion responded with a set pattern of beliefs: that self-harm was a manipulative act, worthy of anger, and something that we should be reluctant to assist with. This was least common amongst nurses, who reported the most familiarity with self-harm, but shockingly was the most common amongst medical students who would become the first point of call for self-injury cases. This pattern occurred only slightly more for the drug misuse vignette.

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While a major criticism of this study is that self-reported attitudes and behavioural intentions may not translate to actual behaviour, it is clear that a significant number of healthcare students our age had very negative attitudes towards self-harm based on preconceptions about its purpose only seven years ago. I highly doubt such aversive opinions have disappeared in such a short time. The most important finding of this study, in my opinion, is that familiarity with self-injury leads to the best behavioural intentions.

Therefore, self-injury is common and a result of moral distortions. Stigma regarding self-injury is likely to exist even among those who are responsible for care-giving due to preconceptions, and can lead to emotional reticence, preventing someone with a psychiatric illness from seeking necessary help. Familiarity is the most beneficial factor in responding appropriately to self-injury. As such, I still believe that in my orthopedic scenario, the best thing the registrar could have done would be to ask about the scars. Become familiar with NSSI by asking about it, just as you would someone with scars from an accident; rid yourself of preconceptions and destroy this ridiculous stigma that can be so harmful to those with mental illness.

Before I conclude, NSSI does have an association with suicide and therefore the act itself may be indicative of a person at high risk. However, this is in the minority of cases. In 2011, after the Columbia report, 2,000 adolescents in China were asked about personal self-injury and suicide attempts; lifetime prevalence of self-injury was 23.2 per cent, while that of suicide attempts (SA) was 3.2 per cent. Self-injury and SA co-occurrence was 2.3 per cent – typically, those that reported SA came from significantly less functional families than those reporting NSSI, indicating the origin of such behaviours is dissimilar. This is supported by another report from Oxford and Bristol scientists published last year, who argue that vulnerability and motivational factors need to be better assessed if we wish to prevent such behaviours. In light of this evidence, we should be concerned about self-harm, given the links to suicide attempts. However, we should not assume that self-injury is predictive of suicide attempts, and therefore any approach to NSSI should not be of aggressive concern, but a gentle inquiry showing understanding and support.