Self-harm strategy development: qualitative evidence

Executive Summary

Understanding the prevalence of self-harm, as well as demographic patterns and trends is important. However, equally important is understanding the range of meanings and functions that self-harm plays in the lives of people who self-harm, and how it is explained and understood by them.

Using a meta-ethnographic approach to better understand diverse liveRed experiences of self-harm, this review addresses gaps in current understanding of self-harm, offers a nuanced exploration of the experiences of those who self-harm, and aims to situate lived experience of self-harm within intersecting socio-economic and cultural contexts.

This review addresses the following research questions:

1. How do people who self-harm make sense of self-harm; what functions and meanings does it have?

2. How is self-harm related to other social factors in qualitative literature?

3. What experiences do people who self-harm report with services?

4. What messages do answers to the above questions pose for the new self-harm strategy in Scotland?

The methodology for this review was informed by Sattar et al.’s (2021) guidance on the principles of meta-ethnography. The purpose of a meta-ethnography is to synthesise qualitative research to generate new insights by interpreting beyond the findings reported in the studies included in the synthesis. This was identified as the most appropriate framework to use to as it facilitates the exploration of how the included studies relate to each other, while also allowing the development of new insights derived from considering the full range of studies together.

This review examined qualitative or mixed methods studies with a qualitative element (inclusive of peer reviewed articles, PhD and DClinPsy theses) that explored experiences of self-harm, of any kind and intent, as self-defined by study participants (including experiences of suicide attempts where referred to as self-harm). The research had to have been written in English, conducted in the UK and published between 2012 and 2022.

Careful consideration was given to whether the search should include papers that explored experiences of suicide attempts or self-harm with (either possible or confirmed) suicidal intent. As large numbers of eligible papers were anticipated, search terms relating to suicide were not used. However, papers where self-harm was understood or reported as suicidal were not screened-out. Papers that described accounts of behaviours or experiences that could be considered injurious to the self (e.g. extreme sports, drug use) were only included if participants themselves considered them a form of self-harm.

Searches were conducted on several databases and, following a screening exercise, 65 papers were included. A further 4 were identified via hand-searching, bringing the total number of papers included to 69. The quality of the included studies were appraised using the CASP checklist for qualitative research. The overall quality of the studies was good.

The following observations can be made about the studies included in this review:

• Only a minority of studies looked specifically at self-harm in the context of suicidal or non-suicidal intent.
• Most studies did not specify a particular definition of self-harm, instead allowing participants to self-define.
• Where this information was reported, approximately two thirds of participants were female.
• Most studies were conducted in England – 8 Scottish studies were included, along with 2 from Wales and 1 from Northern Ireland.
• Ages, where reported, ranged from 9 to 86 years.
• 8 studies focused on the experiences of young people under the age of 24.
• 7 studies looked specifically at the experiences of men.
• 3 studies specifically addressed the experiences of LGBTQ+ people.
• Most studies were carried out in the community.
• 5 studies were conducted in prison settings, 3 in inpatient mental health wards and 1 in a residential children’s units.
• Where race and ethnicity were reported, most participants were white.
• None of the studies looked specifically at the experiences of people from Black backgrounds and 1 explicitly looked at the experiences of Asian women.

Qualitative meta-analysis was conducted following the meta-ethnography. Key stages of this process include determining how the studies are related, translating the studies into one another, synthesising and then presenting these translations.

Findings

The review describes 3 overarching themes: (1) Context and culture; (2) Narrating the unspeakable and (3) Navigating changed landscapes. Four concepts were identified within each overarching theme. While themes and concepts discussed reflect the overall experiences of the study participants as presented by study authors, they will not be representative of every person who self-harms, or even of all study participants.

Theme 1: Context and culture

Many of the studies included in the review present self-harm as heavily contextual, supporting an understanding of self-harm as situated in the context of rather than in relation to isolated reasons/triggers. Through this theme, ideas of intersectionality are discussed along with an exploration of what social factors are understood to affect people who self-harm. Concept 1A - Not just teenage girls - underlines some of the problems with common assumptions about self-harm among young people. Concept 1B – Influence and information - builds on this, specifically examining the impact of social media and suicide clusters. Concept 1C - Something is very wrong with me - explores feelings of shame - or experiences of being shamed through abuse or bullying - as a precursor, background, and trigger to self-harm. Finally, concept 1D - Self-harm and the State - addresses self-harm in the context of institutions and closed settings.

Theme 2: Narrating the unspeakable

Many of the studies included accounts of the physical act of self-harm, including methods, emotions and physical sensations. These were intensely personal and varied widely – not only between and within studies, but within individual narratives. The 4 concepts identified within this theme – compulsion and control, the work of staying alive, drama versus mundanity, and pleasure and pain - present the functions and experiences of self-harm as complex, fluid, and deeply contextual.

Theme 3: Changed landscapes

This theme was developed to represent narratives of what it means to have self-harmed, how this impacts on ones’ navigation through life, and how one is perceived by others. Many study participants talked about the impact their self-harm had on their relationships, functioning, careers, and how they saw the world and themselves. Each concept within this theme – scars, stigma and shame; navigating the world; I (don’t) need to stop; and finding help that doesn’t hurt - reflects a sense of a changed self, and a world that needs to be newly negotiated.

In addition to the 3 themes, this review also identified 3 related ‘opportunity areas’ relating to self-harm. These were constructed via close examination of the themes, and exploration of areas of agreement and contradiction. The opportunity areas represent spaces for potential action, progress and further research.

Opportunity area 1: Towards safer social environments

The testimony of those with lived experience tells us that causes, reasons and motivations are often personal, changeable and difficult to define – even (perhaps especially) for the individual themselves.

Across a wide range of studies within varied settings, participants consistently spoke of their self-harm occurring within the context of what might be understood as psychologically unsafe environments (e.g. prison, inpatient settings, residential children’s units) due to abuse, bullying, discrimination and stigma, or living under state protection/control. This has implications for professionals and policy makers seeking to address self-harm in these settings as well as schools and other closed’ or ‘bounded’ settings, and points to the need for greater understanding of how these environments might be made safer.

While the concept of ‘safe environments’ is perhaps easier to quantify and measure within defined settings such as schools or prisons, we suggest this also applies to the broader social, cultural and economic contexts that self-harm occurs within.

While some of the studies identified within our review explore the impact of poverty, queerphobia, discrimination, racism and abuse, we have identified a need for more nuanced examination of these harms as they relate to self-harm. This is particularly the case for self-harm among those from minority ethnic groups, who remain under-represented in qualitative studies of self-harm. Further research would enable greater understanding about the experiences of self-harm practice among more diverse groups.

Opportunity area 2: Understanding the practice of self-harm as complex and individual

This review supports an understanding of self-harm as complex and individual. It is suggested that attempts to understand ‘reasons for’ or ‘functions of’ self-harm may be counterproductive, and indeed many narratives from study participants reflect a sense of frustration at attempts to understand ‘why’ someone is self-harming.

The diversity of experience and meaning related to self-harm covered in this review poses challenges for healthcare professionals and policy makers wishing to better understand and support those who self-harm. Nonetheless, we suggest that an understanding of self-harm as complex, individual and impossible to generalise must be placed at the heart of policy and practice, and highlighted through public health campaigns and communications.

Opportunity area 3: Enhancing quality of life through improved responses

Our review identified accounts of stigmatising, dehumanising and ineffective responses to self-harm from healthcare professionals. These not only represent missed opportunities to help, but lived experience testimony tells us they cause tangible harm, including reluctance to seek medical assistance in future, loss of hope, health repercussions and escalating self-harm and/or suicidality.

Participants spoke, also, of what constituted good care, especially in the A+E department. They shared the importance of time and space to talk and be listened to, open-ended questions that allow for nuance, and self-harm being treated compassionately but in a ‘business as usual’ manner. When asked what helps, participants’ responses generally point to simple measures that are not costly to implement. This offers an opportunity for healthcare professionals and challenges perceptions of patients presenting with self-harm as difficult or impossible to help.

Outside of acute hospital settings, participants also reported problematic responses to self-harm. Many participants were troubled by expectations that they should aim towards reducing or stopping their self-harm. For a great many, this was not desirable. This has implications for professionals who support those who self-harm and policymakers. It raises questions regarding what measurements and targets are possible. The findings of this review support a move away from a focus on prevalence, rates and preventing self-harm from occurring – and towards enhanced understanding and improved responses where it does.

There is still much that is not known about self-harm. In particular, a significant paucity of qualitative studies which engage with Black and minority ethnic people was identified. While there are understandable concerns about self-harm among young women, it is vital that self-harm is understood as a practice that many different social groups – and age groups – engage in.

Our review was particularly concerned with identifying the relationship between self-harm and social or contextual features. Moreover, the review demonstrated the importance of immediate and more distal social factors – from relationships, bullying, institutions, to queerphobia and poverty – in making sense of self-harm.

Many studies had less focus on such social factors, such as the relationship between gender and self-harm. Studies which engage more deeply with social factors – proximal and distal – in how self-harm is understood and experienced would be welcome, and may offer fruitful ways forward in making recommendations for policy and practice.

Limitations

This review was conducted with specific keywords, date restrictions, and a focus on the UK. While this approach was developed to ensure the number of papers to be screened and included was manageable, some studies will have been omitted. With only some exceptions, the review focuses on peer-reviewed articles, meaning that some sources will also have been omitted (e.g. book chapters). Finally, studies with those who have self-harmed have tended to focus on relatively similar samples, with the studies in this review primarily draw on samples that are more often female, more often younger, and more often involving relatively educated participants.