‘Most acts of self-harm that result in a young person going to hospital involve overdoses rather than self-injuries.’

‘Self-injury is a neglected area of self-harm research and we know little about its epidemiology, hospital care, and outcome.’

‘The UK is now the self-harm capital of Europe,’ claims Anabel Unity Sale in Community Care Magazine (2004). ‘It leads to 150,000 attendances at accident and emergency units a year,’ states Alexandra Frean (Times Online, March, 2005). It’s reaching epidemic proportions – more like 170,000 end up in casualty because of it. It’s said that 25,000 youngsters are referred to hospital because of it, more young men are doing, it, more young girls are doing it, ‘seemingly ordinary, adult women’ are increasingly doing it (Mills, Times Online, May, 2005) – even kids as ‘young as eight’ are doing it. (Revill, The Observer, June 2005). Celebrities are glamourising it, and encouraging kids to do it . . . so the speculation goes on, and confusion reigns.

Self-harm (self-poisoning and self-injury) are sensitive issues, and presenting accurate information about the behaviour is vital.

The media in particular, play a crucial role in educating the public and shaping and influencing public opinion. As such, they have a responsibility not to mislead or misinform. Indeed, flawed reporting can lead to prejudice, stigma, and misunderstanding.

In this chapter, media assertions and attitudes about self-harm and self-injury go under the microscope, the magnitude of self-injury is discussed, and two controversial issues are addressed. Also examined is the relevance of a change of term recently implemented in the professional arena, and whether researchers and practitioners’ use of different terms is responsible for sparking confusion.

Media hype

Self-harm – in particular self-injury – has recently grabbed the attention of all strands of the media, with articles, once rare, now in abundance in teen magazines, national newspapers, professional journals, and health magazines. Books on the subject have flourished; countless websites have sprung up – many authored by individuals with personal experience of self-injury; the topic has featured in television documentaries, dramas, and soaps; films have entered the arena, and the music industry is no exception. Some (yet by no means all) examples are now given.

Television documentaries, dramas, and soaps

• Jailbirds (BBC1, April 12, 1999), a fly-on-the-wall documentary showing what life is like for women behind bars, filmed at New Hall Prison, Yorkshire.
• East: Suffering in Silence (BBC2, July 17, 2000), which highlighted the growing problem of self-injury among young Asian women in Britain.
• Hollyoaks (Channel 4), wherein Lisa, one of the characters (played by Gemma Atkinson), is seen struggling with the problem.
• Life Isn’t All Ha Ha Hee Hee (BBC 1, May 2005), a compelling drama, in which Sunita, a depressed Asian wife turns to self-injury. (Based on the novel Life Isn’t All Ha Ha Hee Hee by Meera Syal).

The film industry

• Girl, Interrupted (Columbia Pictures, 1999).
• Secretary (Lion’s Gate, 2002).
• In My Skin (Rezo Films [French], 2002).
• Thirteen (Fox Searchlight Pictures, 2003).

The music industry: songs referencing self-injury

• Manic Street Preachers’ ‘Yes’, ‘Roses in the Hospital’, ‘Die in the Summertime’ and ‘Born to End’.
• The Used’s ‘I’m a Fake’, ‘A Box Full of Sharp Objects’, and ‘Let It Bleed’.
• Papa Roach’s ‘Scars’ and ‘Last Resort’ (American).
• Linkin Park’s ‘Part of Me’ and ‘Crawling’ (their ‘Numb’ video also shows a girl with scars on her arm) (American).

Books and Internet sites displaying images of self-injury

Internet sites displaying graphic images of wounds and scars have come under hefty criticism because people (including many that self-injure) consider the images are potentially ‘triggering’, or give encouragement to vulnerable youngsters to experiment with the behaviour. Yet it’s not just websites that display pictures – they appear in books, newspapers and magazines – they can even be found on professional websites. Here are some examples:

• Morgan’s book, Death Wishes? (1979:118–121) contains four pages of pictures of self-injury (mainly limbs), which albeit in black and white, could be classified as ‘detailed’, and Favazza’s book, Bodies Under Siege (1996: 159–160) displays a couple of similar pictures.
• An article entitled The First Cut. . . (Carroll, H. The Daily Mirror Mhealth, April 15, 2004, p.33) showed a woman displaying badly scarred arms (full colour picture).
• The British Association for Counselling and Psychotherapy (BACP), on the front cover of CPJ (Counselling and Psychotherapy Journal) (2003) displayed a picture of a woman with her face turned sideways, showing two badly scarred arms (black and white picture).
• While searching the British Medical Journal website for information, I came across two provocative images. Both displayed a pair of arms, with a razor blade in the right hand being held against the left wrist about to be cut. (BMJ 2002; 2005).

Celebrities that self-injure

Numerous celebrities have admitted publicly their struggles with self-injury, or reports have suggested they self-injured. A recent casualty, Dame Kelly Holmes, the thirty five year old track star, publicly disclosed in May 2005, that a year prior to her double gold victory at the Olympic Games in Athens, she had injured herself repeatedly for a period of two-months. Others include actresses Angelina Jolie and Christina Ricci, actor Johnny Depp, ‘shock rocker’ Marilyn Manson, and Richey Edwards, a former member of the Manic Street Preachers group, who disappeared without trace on 1 February 1995 (Gabrielle, 1999–2007), actress and comedienne Roseanne (Arnold, 1994), and deceased pop diva Dusty Springfield (Valentine & Wickham, 2000).

Young people and self-harm: A National Inquiry

Prompted by concerns over the reported increase in self-harm among young people in the UK, the government launched the first ever inquiry into self-harm among 11–25 year olds at the House of Commons on 30 March 2004. The Mental Health Foundation and Camelot Foundation jointly spearheaded the inquiry.

Aims of the inquiry (2004) included education and awareness raising about self-harm; gaining more understanding about self-harm; making policy recommendations, and initiating practice guidelines and information for individuals and organisations working with young people that self-harm.

The Inquiry definition (2004a) of self-harm included cutting, burning, banging, hair pulling and self-poisoning. It excluded eating disorders, drug and alcohol misuse, and risk taking behaviours such as unsafe sex and dangerous driving.

The two-year inquiry, listened to evidence from over 350 individuals and organisations, paying particular attention to the voices of young people with experience of self-harm. Chair of the Inquiry, Catherine McLoughlin CBE, in the final report entitled The Truth Hurts: Report of the National Inquiry into Self-harm among Young People (2006) says this in the foreword:

This report sets out an agenda for change. There is no shortage of things that need to be done. We need to know more about the prevalence of self-harm, across the UK as well as in particular population groups; we need to commission services where young people feel listened to, and respected; we need much better evidence of what works, both in relation to preventing self-harm and in intervening once the behaviour is underway; we need to build a better understanding of why young people self-harm, and provide high-quality information for young people, their families, and a whole range of agencies and professionals in contact with young people. Above all, perhaps, we need to develop the confidence of those closest to young people, so that they can hear disclosures of self-harm without panic, revulsion or condemnation. (p.3)

The Truth Hurts report can be downloaded for free from the Inquiry website: www.selfharmUK.org (accessed June 12, 2007).

Among other topics, the Inquiry’s first interim report (2004b) focused on the prevalence of self-harm in the UK. Citing as its source the National Institute for Clinical Excellence (NICE), Self-harm scope document (2002) it states, ‘Rates of self-harm in the UK have increased over the past decade and are reported to be among the highest in Europe’.

Horrocks and House report similarly, ‘Rates of self-harm in the UK are among the highest in Europe at 400 per 100,000 per year’ they report in a paper entitled Self-poisoning and self-injury in adults. (2002:509).

Is the UK the self-harm capital of Europe?

Among the highest rates of self-harm in Europe seems to be closer to the truth – not the highest, as explicitly claimed by Anabel Unity Sale. Worth keeping in mind too is that significantly more research on self-harm appears to have taken place in the UK compared to other countries, which could have a bearing on the situation. Furthermore, recent media reports suggest that self-injury is a global problem.

The magnitude of the problem

If you want to inspire confidence, give plenty of statistics. It does not matter that they should be accurate, or even intelligible, as long as there are enough of them.
—Lewis Carroll

Self-injury tends to be a secretive activity carried out behind closed doors and many people attend to their own wounds, so countless episodes go unreported. Hence, an attempt to determine precisely how many people self-injure is beset with difficulties.

Further, many episodes go undetected. For example, those who do seek treatment for their wounds may hoodwink accident and emergency staff into believing their injuries have been inflicted by others or have been caused by an accident.

In the absence of official statistics on self-harm in the UK, evidence of the incidence of self-harm comes mainly from hospital-based studies, psychiatric samples, small community based studies, and school-based studies.

Hospital attendances for self-harm

Alexandra Frean’s contention that self-harm ‘leads to 150,000 attendances at accident and emergency units a year’ is consistent with figures quoted in the National Institute for Clinical Excellence (NICE), Self-harm scope document mentioned above. The same figure appears in Self-harm: The short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care (2004), the final version of the NICE guidelines. However, as evidenced by the statistics shown in Figure 4.1 (Prevalence estimates for self-harm [self-poisoning and self-injury]), there are considerable inconsistencies in estimates of how many people self-harm.

Aside from the discrepancies, the figures suggest that the backdrop of self-harm has altered enormously over the past eleven years. In fact, comparing the lowest rate (1996, 87,000) with the highest rate (2005, 170,000) implies an increase of 93%. What remains uncertain though is how many people from the approximated statistics self-poison and

how many self-injure. Hospital statistics specifically focused on self-injury are hard come by due to much of the research focusing on self-poisoning. However, according to Williams (1997) self-cutters:

. . . are in the minority, accounting for about 10 per cent of parasuicide episodes. Even so, this means that in the United Kingdom 10,000 episodes of self-cutting come to the attention of accident and emergency departments of hospitals each year. (p. 98)

In a study by Horrocks, Price, House, and Owens (2003), one of the aims of which was to establish prevalence rates of self-injury, the researchers examined statistics on attendances for self-harm at general hospitals in Leeds over an eighteen month period. They discovered that ‘about one-fifth of all attendances at A&E departments for self-harm were for self-injury’ (21% for self-injury, 82.5% for self-poisoning).

NHS guideline to standardise care for people who self-harm

In 2004, The National Institute for Health and Clinical Excellence (NICE) and the National Collaborating Centre for Mental Health (NCCMH) published a guideline for the NHS in England and Wales, making recommendations on the care of people who self-harm in the first 48 hours after the self-harming incident. The guideline, entitled Self-harm: the short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care (National Collaborating Centre for Mental Health, 2004) recommends an extensive list of ‘priorities for implementation’ (pp. 48–50). These include:

• People who have self-harmed should be treated with the same care, respect, and privacy as any patient. In addition, healthcare professionals should take full account of the likely distress associated with self-harm.
• If a person who has self-harmed has to wait for treatment, he or she should be offered an environment that is safe, supportive and minimises any distress.
• People who have self-harmed should be offered treatment for the physical consequences of self-harm, regardless of their willingness to accept psychosocial assessment or psychiatric treatment.
• Adequate anaesthesia and/or analgesia should be offered to people who have self-injured throughout the process of suturing or other painful treatments.
• When assessing people who self-harm, healthcare professionals should ask service users to explain their feelings and understanding of their own self-harm in their own words.
• Healthcare professionals should involve people who self-harm in all discussions and decision-making about their treatment and subsequent care. To do this, staff should provide people who self-harm with full information about the different treatment options available.
• When physical treatment of self-injury is likely to evoke distressing memories of any previous sexual abuse, for example when repairing harm to the genital area, sedation should be offered in advance.
• Clinical and non-clinical staff who have contact with people who self-harm in any setting should be provided with appropriate training to equip them to understand and care for people who have self-harmed.
• Providing treatment and care for people who have self-harmed is emotionally demanding and requires a high level of communication skills and support. All staff undertaking this work should have regular clinical supervision in which the emotional impact upon staff members can be discussed and understood.

A question of attitude

In the research undertaken for Healing the Hurt Within, 1st edition (Sutton, 1999), many respondents reported receiving mixed attitudes when attending A&E for help with their injuries – here are just a few of the testimonies received:

Bearing in mind the respondents’ experiences, I asked Richard Pacitti, Chief Executive of Mind, Croydon, and member of the Self-Harm Guideline Development Group, if he considered that the new guideline would bring about a change of staff attitudes in A&E to people that self-injure. He replied:

I believe that one of the reasons that people who self-harm sometimes get poor treatment is that some front line staff have misconceptions about self-harm. For this reason, the guidelines make very strong recommendations about the need for training for staff to overcome myths and misunderstandings. My experience is, as someone who provides training about self-harm, that once people have a better understanding of the reasons why people self-harm and the functions it serves for them, their attitudes change. For this reason, I remain positive that the guidelines should lead to people who self-harm being treated with the care, sensitivity, and the respect they need and deserve.

Unhelpful Media Attitudes to the NICE guidelines

Richard Pacitti also drew my attention to several newspaper articles that appeared following the launch of the guideline. Among them included an article entitled: This ‘epidemic’ is all selfishness (Telegraph.co.uk, August 01, 2004) in which the author Leo McKinstry makes an insensitive, unkind and slanted attack on people who self-harm, asserting that a great deal of self-harming behaviour is ‘ruthlessly manipulative’. To further fan the flames he writes:

[People who self-harm] are so self-important that they think they have the right to clog up the NHS with their undeserving cases . . .. The nurses’ attitude is understandable, given that they have to deal with genuine emergencies rather than the antics of a self-centred attention seeker.

Another article entitled: Cut it out, please (SocietyGuardian.co.uk, August 03, 2004) written by an NHS doctor (authored under the pseudonym Rachel James) was also scathing – the author writes:

It is hard not to get frustrated: people who self-harm do have a choice, although it may not seem like it at the time. They could not do it, or they could do it and stay at home to deal with the consequences. Just please don’t lacerate yourself, come to hospital and then complain about it. A&E is an emergency service.

Publication of the ‘James’ article sparked a heated online exchange of views between psychiatrists, doctors, and other professionals – one consultant psychiatrist went so far as suggesting that ‘self harming patients be charged £50 for attendance at an A&E ward.’ (2004, August 26, James, A.)

With dispassionate attitudes such as these it’s hardly surprising that many people who self-injure fear seeking help for their injuries, or steer well clear of A&E. Further, to the unenlightened and uninformed reader the articles present a misinformed and stigmatising portrayal of people that self-injure, destined to fertilise the myths rather than dispel them.

The expected review date for the NICE guidelines is July 2008: it will be interesting to see whether a change for the better in attitudes towards patients that self-injure is reported. From the foregoing, sadly, it looks as if there is still much work to be done in raising awareness and understanding about self-injury.

Note: An unsupported version of the NHS guidelines, a condensed version, a quick reference guide, and a booklet for the public can be downloaded free from The National Institute for Health and Clinical Excellence (NICE) website: http://www.nice.org.uk/

A striking increase in self-harm

If self-harm is on the rise in the UK as the statistics in figure 4.1 suggest, could part of the reason be due to a substantial increase in the number of young men self-harming? For example, the Samaritans (2000) theorise that ‘Between 1980 and 1998 rates of self-harm among men aged 15 – 24 almost doubled.’ Could another possible explanation be that increased awareness of self-injury has encouraged more people to seek help? Over a decade ago, Favazza (1996) suggested this was already happening – he states:

The propulsion of self-mutilation into the consciousness of both the general public and the mental health establishment has created a sense of optimism. Patients are now more willing to seek help, and they feel less ashamed of their behaviour. (p. 233)

If Favazza’s premise is correct, are we perhaps looking at an ‘explosion of admission’ in contrast to an ‘outbreak of action’? To establish other experts’ views on the situation, I invited two American practitioners, both renowned in the field of self-injury, to comment.

Tracy Alderman, author of, The Scarred Soul (1997) (personal communication, May 24, 2004) had this to say:

While I believe that self-injury is on the rise among young people, I also believe that the epidemic numbers of self-injury we’re now seeing are due to more and more people admitting to performing self-injurious behaviours. Ten years ago it was difficult to find any information regarding self-injury. Now, information on self-injury is present in books, magazines, movies, television shows and music. People are talking about self-injury more and more. While it is still a secretive behaviour, the vast increase of media attention, and identification of idols who have self-injured, such as Princess Diana, have decreased the stigma attached to the behaviour and allowed young people to be much more willing to admit to others that they too self-injure.

Barent Walsh, co-author with Paul M. Rosen, of Self-mutilation: Theory, Research and Treatment (1988), and author of Treating Self-Injury: A Practical Guide (2006) (personal communication, June 02, 2004) remarked that:

I believe we are currently seeing an epidemic of action. I am very busy these days training staff and parents regarding self-injury in middle schools, high schools, and colleges. These settings would have known if children and adolescents were previously self-injuring. There is clearly an explosion of the behaviour in these settings that goes way beyond an increase in more accurate reporting. I wish I had specific statistics to back this up, but I do not.

Recap

Both authors speculate that self-injury is definitely on the increase, especially among young people. Barent Walsh strongly believes that there is an eruption of the behaviour in schools and colleges. Tracy Alderman considers that media spotlight on the issue, a growth of literature on the subject, and high-profile celebrities’ public disclosures of self-injury has reduced the stigma, generated more openness, and encouraged more people to admit they have a problem with it, which partially reflects the views of Favazza. Overall, the consensus seems to be that not only are we looking at an ‘explosion of admission’, we are also looking an ‘outbreak of action’? However, as Barent Walsh rightly points out, to support claims that the behaviour is on the increase, concrete statistics are necessary,

Self-injury upstaging self-poisoning

An issue of deep concern is the strong possibility that the public – albeit perhaps not intentionally – are being misled about how many people self-injure in contrast to self-poisoning. For instance, if people read the widely reported statistics that 150,000/170,000 people are receiving hospital treatment for self-harm annually, does it register that the large majority of those cases are due to self-poisoning? Space does not permit inclusion of the many comments received on this issue, but the consensus is that mention the word ‘self-harm’ and it immediately conjures up images of people cutting themselves. Moreover, because self-injury is ‘not the norm’, it tends to arouse curiosity – not least from the media, strands of whom sensationalise the issue to the expense of downplaying the extent of overdosing. In some articles featuring ‘self-harm’, overdoses hardly receive a mention – in some cases no mention whatsoever.

One clear example of self-injury upstaging self-poisoning is evident in a report about Dame Kelly Holmes, which appeared in the Daily Telegraph carrying the headline ‘Holmes’s self-harm confession highlights “hidden epidemic.”’ (Nicole Martin, The Daily Telegraph, Monday, May 30, 2005). It quotes the well-publicised assertion that approximately 170,000 people are treated in hospital each year after deliberate self-harm, yet fails to make a single reference to overdosing. Another, carrying the headline ‘On a knife edge’ in the TimesOnline (Simon Mills, 2005, May 08), citing the Samaritans as its source of information, claims ‘that 25,000 people a year, mainly women, are admitted to hospital with self-inflicted injuries’. [Emphasis added] What sort of image does that conjure up? Overdosing? I doubt it. Cutting? Highly probable. And similar to the previous article, no reference is made to overdosing.

Media misinterpretations of self-harm

The question that urgently needs addressing concerning media interpretations of self-harm is whether journalists, like many lay people, are confused about what exactly is and is not self-harm, which sets the stage for our next topic.

The terminology controversy

Did you notice the various terms used in Figure 4.1 (Prevalence estimates for self-harm)? Now ponder Figure 4.2 (The wide variety of terms used to describe the act of hurting oneself), as this forms the basis for our ensuing discussion on problems with terminology and definitions.

Misunderstandings about what is and is not self-harm arise from different researchers attaching different definitions to the term ‘self-harm’. For example, as you read earlier, the Young People and Self-harm National Inquiry included ‘self-poisoning’ in its definition. Hawton and Rodham in their recent book, By Their Own Young Hand: Deliberate Self-Harm and Suicidal Ideas in Adolescents (2006:11) do likewise, defining DSH thus: ‘Deliberate self-harm includes any intentional act of self-injury or self-poisoning (overdose), irrespective of the apparent motivation or intention’. Hawton, K. et al. (2002) and De Leo, D. & Heller T.S (2004) include the use of ‘recreational’ or illegal drugs in their study definitions. The Royal College of Psychiatrists (2004)

stretches their definition of self-harm even further by encompassing ‘excessive amounts of alcohol’.

Deliberate self-harm and parasuicide: their historical roots

Employing the term deliberate self-harm to describe self-harm and self-poisoning is standard practice in the UK medical profession, whereas in the Republic of Ireland, the term parasuicide is more common. Where do these terms originate? Their roots go back over a quarter of a century. In Death Wishes? (1979) Morgan coined the term deliberate self-harm to embrace a wide range of non-fatal self-harming behaviours, defining DSH thus: ‘Non-fatal episodes of self-harm may be referred to collectively as problems of self-poisoning and self-injury’. (p.88) Parasuicide is defined by Kreitman et al. (1977) as ‘a non-fatal act in which an individual deliberately causes self-injury or ingests a substance in excess of any prescribed or generally recognized therapeutic dosage’. (p.3)

Attempted suicide and suicide

To complicate the issue further, the term attempted suicide (regardless of the intention behind the act) is also used to describe non-fatal acts of self-harm – in other words acts of self-poisoning and self-injury. To muddy the waters even more, the term ‘deliberate act of self-harm or injury’ is being considered as a substitute verdict to ‘suicide’ in the coroner’s court in cases where there is doubt about an individual’s intention. (2004, Calthorpe, B., and Choong, S.) This perhaps explains a statement on the University of Oxford Centre for Suicide Research website (1998–2007) asserting that; ‘suicide and attempted suicide’ are now usually termed ‘deliberate-self harm’ or ‘self-harm’ in the UK’.

Looking at Figure 4.2 you will note that I have placed deliberate self-harm, parasuicide and attempted suicide on the left hand side, as essentially they all refer to the same behaviour, and are sometimes used interchangeably.

Focusing on self-injury

Researchers who focus specifically on self-injury are more consistent with their definitions, yet when it comes to terms, there is considerable inconsistency. You will see from the four definitions below that they all emphasise the point that the act is ‘without suicidal intent’ and all four refer to the behaviour as ‘deliberate’ or ‘intentional’. Many people who self-injure find the modifiers ‘deliberate’ or ‘intentional’ objectionable or deem them incorrect. This thorny issue is addressed later on. You may be wondering why I have included so many definitions – the answer is because they put the spotlight on several different terms used to describe the same act, as shown on the right-hand side of Figure 4.2.

Self-mutilation (SM)

‘I define self-mutilation as the deliberate destruction or alteration of one’s body tissue without suicidal intent’. (Favazza, 1996: xviii-xix)

Self-injury (SI)

‘We understand self-injury as an act which involves deliberately inflicting pain and/or injury to one’s own body, but without suicidal intent’. (Babiker and Arnold, 1997: 2–3)

Self-inflicted violence (SIV)

‘The term self-inflicted violence is best defined as the intentional harm of one’s own body without conscious suicidal intent. In simpler terms, self-inflicted violence (SIV) is the act of physically hurting yourself on purpose’. (Alderman, 1997: 7)

Self-injurious behaviours (SIBs)

‘We define SIBs as all behaviours involving deliberate infliction of direct physical harm to one’s own body without any intent to die as a consequence of the behaviour’. (Simeon and Favazza, 2001:1)

Self-injury as defined in this book

You will note from the above definitions that the intention behind self-injury is excluded. Embracing this aspect was considered important by the Internet respondents (see Chapter 1). For purposes of clarification and comparison the definition is reproduced again here:

Self-injury is a compulsion or impulse to inflict physical wounds on one’s own body, motivated by a need to cope with unbearable psychological distress or regain a sense of emotional balance. The act is usually carried out without suicidal, sexual or decorative intent.
—Sutton, et al. (2000)

Classification of self-injury

Favazza (1996) separates self-injury into two groups: culturally sanctioned self-injury (further divided into cultural rituals and practices) and deviant-pathological self-injury (further divided into major, stereotypic, and moderate/superficial), the latter additionally separated into three subtypes: compulsive, episodic, and repetitive self-injury. More recently, Favazza and Simeon (2001) proposed four main categories of self-injurious behaviours, stereotypic, major, compulsive and impulsive. Figure 4.3 (Classifying self-injurious behaviours) provides an overview of the classifications as proposed by Favazza, and Simeon and Favazza.

Compounding the issue

The situation regarding classifying self-injury is not eased by the fact that neither DSM-IV-TR (APA, 2000) nor ICD-10 (WHO, 1992), the two major classification systems for diagnosing mental disorders, recognise self-injury as a separate disorder or syndrome. However, hopefully this situation will change when DSM-V is published, which is anticipated to be in 2010 or later. For proposed terms, see:

• 1.Favazza (1996: 253–254). Favazza argues a case for repetitive self-mutilation (RSM) to be listed in the DSM ‘on Axis 1 among the “impulse control disorders not elsewhere classified.”’
• 2.Deliberate self-harm syndrome (1983, Pattison, E. & Kahan, J.) For an adapted version of the classification schema as proposed by Pattison and Kahan, see Walsh and Rosen (1988: 30, Figure 2.1.)
• 3.Repetitive superficial or moderate self-mutilation syndrome (1993, Favazza, A.R. & Rosenthal, R.) The authors recommend classification of the syndrome as an Axis I Impulse Disorder.
• 4.Self-injurious Behaviour Syndrome (2002, Turner, V.J.) Turner proposes classifying the syndrome in DSM as an Impulse-Control Disorder Not Elsewhere Classified. (pp. 58–59)

Why don’t researchers agree on a single term?

The answer seems to be because UK researchers have found that self-harm is often synonymous with suicide. For example, in a systematic review of studies from UK and non-UK countries to approximate rates of fatal and non-fatal repetition of self-harm (UK and Ireland [36%]; Scandinavia and Finland [26%]; North America [11%]; Australia and New Zealand [8%] and the rest of Europe [19%]), Owens, Horrocks and House (2002), found that:

• There is a strong association between self-harm and suicide.
• Later suicide arises somewhere in the region of 1 in 200, and 1 in 40 patients that self-harm in the first year of follow up.
• After nine or above years, the figure is approximately 1 in 15 people.

They draw the conclusion that ‘Suicide risk among self-harm patients is hundreds of times higher than in the general population’.

Overdosing vs. self-injury

It may be the case that a small number of people attend hospital for both self-injury and self-poisoning. Nevertheless, bearing in mind that those who self-injure are very much in the minority of hospital attendees for self-harm, it would seem a reasonable assumption to make that the large majority of those who later commit suicide come from the group that repeatedly self-poison.

Whilst recognising that self-poisoning and self-injury sometimes serve similar functions (to escape from mental pain, an unspoken plea for help), many people that self-injure make a distinction between the two behaviours – here are two such cases submitted by respondents:

Recap

To clarify, what the respondents are saying is that:

• Overdosing is about giving up the will to carry on, about loss of hope, about going beyond coping.
• Cutting is an insurance policy for survival; it’s about coping, about going on living, about stepping back from suicide. In essence, it is not about wanting to kill oneself or a suicide attempt gone wrong.

It is prudent to remember, however, that self-injury is invariably a sign of acute distress and sadly, occasionally people do kill themselves – at times accidentally by taking things too far – or sometimes because a person’s situation becomes so intolerable no other way out can be seen. Any mention of suicidal thoughts therefore needs to be taken seriously and not dismissed as attention seeking, manipulation, or ‘crying wolf’.

Is the terminology controversy much ado about nothing?

The controversy over terms is no trivial matter. The terms deliberate self-harm, self-harm, and parasuicide, muddy the waters, causing bewilderment and misunderstandings in their wake. For researchers scouring the academic literature for statistics and information specifically on self-injury it can lead down many blind alleys and waste an inordinate amount of time. For busy journalists it can lead to misreporting the facts. For the public it can lead to believing misrepresented facts presented by the media, and for those in need of help it may lead to the wrong form of treatment. Another respondent also labours the point that self-poisoning and self-injury are two different behaviours – she writes:

Furthermore, as Walsh and Rosen (1988) emphasised almost twenty years ago: ‘This debate over terminology is, of course, no mere quibbling over words. At stake is how SMB [self-mutilative behaviour] should be understood, described, diagnosed, and treated’. (p. 21)

Is self-injury always deliberate?

Whilst some who self-injure agree that the act is ‘deliberate’ or ‘intentional’, others find the prefixes offensive. Louise Pembroke, editor of Self-Harm: Perspectives from Personal Experience (1996) is one such case – she explains why:

The term “Deliberate Self-Harm” is objectionable. “Deliberate” can imply premeditation and wilfulness. Self-harm is always atypical. Sometimes it can be spontaneous and sudden with little awareness or conscious thought. Conversely, the drive to self-harm maybe powerfully constant and unrelenting with a conscious battle raging. How self-harm occurs and the levels of awareness vary considerably. Self-harm or self-injury does not require qualifying with “Deliberate.” (pp. 2–3).

NHS self-harm guidelines

With my SIARI website hat on (a registered stakeholder for the NICE self-harm guidelines), I had an opportunity to respond to the Draft for first Consultation of the NICE guidelines, mentioned earlier. One of the issues I raised, alongside several other stakeholders, was the significant role of dissociation in the process of self-injury for some people. Another issue, raised by stakeholders and service users, was the Guideline Development Group’s choice of term, that being ‘Intentional’ self-harm. It was rewarding to see in the full guideline published November 2004, that they had dropped the prefix ‘intentional’; also to read the following statement:

Many service users object to these terms, especially those who harm themselves during dissociative states, afterwards being unaware of any conscious intent to have harmed themselves. Also, it can be argued that prefixing the term ‘self-harm’ with ‘intentional’ would suggest that there may be accidental and non-intentional forms of self-harm. Clearly, the non-intentional forms, such as those carried out during dissociative states, are covered by the term ‘self-harm’ alone. (p.18)

(For further information on dissociation and self-injury see Chapter 8

Although these changes may seem inconsequential, a ripple effect appears to be happening. Just recently, I stumbled across a report from The Royal College of Psychiatrists, entitled Assessment following self-harm in adults (2004) stating that:

The use of the adjective “deliberate” has not been acceptable to all and some services users fear it might be of itself stigmatising. For this reason we have dropped the term ‘deliberate’ from the title of this report. (p.7)