Self-harm strategy development: qualitative evidence

Findings

Study characteristics

A total of sixty-nine studies were included in the review, with a total sample size of 1846 participants. Among studies where this information was reported, approximately two thirds of participants were female. As noted previously, these are not precise figures as many studies did not report on gender or other demographic information. All studies were conducted in the United Kingdom, with the majority being in England. Two were in Wales and eight were in Scotland. One study was carried out in Northern Ireland. Ages, where reported, ranged from 9 to 86 years. Eight studies focused on the experiences of young people under the age of 24 and seven studies looked specifically at the experiences of men. Few of the studies reported on sexuality or gender identity. Three of the studies included in our review specifically addressed the experiences of LGBTQ+ people.

Settings varied among the studies, with the majority carried out in the community. Five were conducted in prison setting, three inpatient mental health wards and one in a residential children’s units (with three more carried out with participants who were care experienced but not currently in care). Where race and ethnicity were reported, the vast majority of participants were white. One of the studies explicitly looked at the experiences of Asian women. None of the studies we identified specifically looked at the experiences of people from Black backgrounds.

While a minority of studies looked specifically at self-harm in the context of suicidal intent (n=7) or non-suicidal intent (n=8), the large majority of studies did not specify a particular definition of self-harm, instead allowing participants to self-define.

Table 2 : Seven stages of meta-ethnography applied to the review (Sattar et al., 2021)

1. Getting started

The focus of interest was lived experiences of self-harm

2. Deciding what is relevant

Inclusion/exclusion criteria were considered and decided upon (Table 1)

3. Reading the studies

69 studies were identified. These were closely read and re-read to identify themes and concepts relating to the aims of this review. Study characteristics and data were extracted. Themes were highlighted by hand.

4. Determining how the studies are related

Studies were listed on a spreadsheet in chronological order. Concepts were entered alongside their corresponding studies. Concepts compared and contrasted, with similarities, connections and resulting questions highlighted. Concepts were then clustered into meaningful categories which were given an appropriate thematic label.

5. Translating the studies into one another

Studies were considered in chronological order for each theme, looking at where each subsequent study added to or challenged thematic ideas. First order constructs (participant quotes) were considered alongside second order construct (study author conclusions).

6. Synthesising the translations

A ‘line of argument’ synthesis was developed, using newly identified themes to suggest three distinct ‘Opportunity areas’ to improve understanding of, and support for, those who self-harm.

7. Expressing the synthesis

Here we present our review following eMERGE guidelines for meta-ethnography (France et al., 2019) alongside PRISMA framework for reporting on systematic reviews.

Quality assessment

Studies were generally of good quality, with some limitations as indicated in Appendix 2 particularly with regard to (a) consideration of ethical issues and (b) consideration of the participant-researcher relationship. Notable exceptions to this were the doctoral and DClinPsy theses included in this review, where the extended format naturally allowed for more in-depth reflection on reflexivity and positionality, along with a fuller account of ethical considerations. One further observation is that detailed data on participant demographics were frequently unavailable in the studies we considered (see Appendix 1). As a meta ethnographic approach seeks to situate lived experience within social contexts – which would include age, gender, sexuality, socioeconomic background – this would have been beneficial. It is possible that study authors opted not to include detailed demographic data in order to preserve participant anonymity, particularly in small-scale qualitative studies carried out within a close-knit community.

The qualitative metasynthesis

The metasynthesis resulted in three overarching themes: (1) Context and culture; (2) Narrating the unspeakable and (3) Navigating changed landscapes. Within each overarching theme, four concepts have been identified, as illustrated in the table below. While themes and concepts discussed in this section reflect the overall experiences of the study participants as presented by study authors, it is recognised that they will not be representative of every person who self-harms, or even of all study participants. Themes and concepts are discussed individually in this section, but can be better understood as “interconnected to each other […] distinguishable parts of a whole” (Ljungberg et al., 2015, p. 483).

Table 3: Themes and concepts

1. Context and culture

A) Not just teenage girls

B) Information and influence

C) Something is very wrong with me

D) Self-harm and the State

2. Narrating the unspeakable

A) Compulsion and control

B) The work of staying alive

C) Drama vs. mundanity

D) Pleasure and pain

3. Changed landscapes

A) Scars, stigma and shame

B) Navigating the world

C) I (don’t) need to stop

D) Finding help that doesn’t hurt

Theme 1: Context and culture

Many of the studies included in the review present self-harm as heavily contextual, supporting an understanding situated in the context of rather than in relation to isolated reasons/triggers for. 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 (mental health inpatient units, prisons, residential care).

Concept A: Not just teenage girls

While narratives of self-harm often focus on young girls (Chandler and Simopoulou, 2021), many of the qualitative studies we identified explored the lived experience of other groups, such as men, prisoners, and older adults. Participants from these more diverse groups frequently reflected on not ‘fitting’ society’s expectations of a person who would self-harm, and the implications this had for them in terms of being understood, accessing support, and navigating mental health services. In studies which included adults, many spoke of their frustration at self-harm being seen as a ‘coping mechanism’ for teenagers, that they ought to have moved on from in adulthood. Boyce’s (2021) study included narratives from adult women who shared the impact of these assumptions.

“It doesn’t stop when you get to 18, but that is how it’s portrayed. People have said to me ‘Haven’t you grown out of that by now?’. I wish people were better informed. I sometimes feel embarrassed because I am 33, which just makes it all worse. I hate that.” Female, 33 years (Boyce et al., 2021)

In addition to feelings of embarrassment and shame brought about by this judgement and lack of understanding, there are implications for treatment. Many participants spoke of an absence of self-harm support services after the age of 18 or 25, with resources often aimed at younger people and focussing on issues that would be more relevant for teens such as bullying, school stress and exams.

“I very recently had an assessment with IAPT^[1] who wanted to refer me to a self-harm support group, but it’s not available to those over the age of 25, which is upsetting. Many resources online seem to be aimed at those under 25 too, so they don’t always feel as applicable or helpful to me because they focus on issues typically faced by teens.” Participant (unclear gender/age) (Boyce et al., 2021)

While the majority of studies focussed on straight girls and women, a number included the narratives of men, non-binary and LGBT people. In their study on experiences of self-harm in marginalised sexualities and genders, McDermott et al. (2015) found that although some participants felt that their self-harm was connected to struggles with gender identity many felt strongly that the two were unconnected.

“Year X is stressful and self-harm is my coping mechanism…I’m tired of everyone thinking I am depressed over being a lesbian…I love being a lesbian.” Female, 16 years, lesbian (McDermott et al., 2015)

Other participants, both in this study and others carried out with participants with marginalised gender or sexual identities (Marzetti, 2022), extended this argument. Participants underlined that self-harm and emotional distress wasn’t related to their own feelings about their gender or sexuality, but to the abuse and discrimination they suffered.

“It’s not being gay…it’s being tormented and belittled.” Female, 15 years, lesbian (McDermott et al., 2015)

Few of the studies we identified looked at the experiences of Black and minority ethnic people who self-harm. Of those that did, all were with Asian participants. We did not identify any studies specifically exploring the experiences of participants from Black backgrounds. We did not identify any study participants from a traveller background. Brown et al.’s (2022) small qualitative study included two Asian participants, and noted that both had self-harmed as a response to feelings of shame at not living up to cultural expectations.

“In our religion we’re not meant to be like in a relationship before marriage and stuff…so I’ve always, erm, known…I probably deserve to be struggling, as a punishment.” Yasmin, 19 years, female, Asian British (Pakistani), (Brown et al. 2022)

Although this account provides some insight, it should be stressed that accounts from ethnic and culturally diverse voices were notably lacking among the studies we reviewed. This poses a challenge for those who seek to better understand and support people from multi-cultural backgrounds who self-harm, and points to an urgent need for more research with diverse participants, so that we might better understand how far their experiences and needs may vary.

Concept B: Information and influence

Several of the studies sought to better understand the role the media plays in influencing and informing self-harm, particularly for young people (Jacob et al., 2017; Lavis and Winter, 2020; Sutherland et al., 2014). This was a complex issue, with many young people acknowledging the dual role of the internet – as a place of safety and support but also somewhere it was easy to find information that could promote or trigger self-harm. Several young people who had used pro self-harm websites – like this teenager – reported initially going onto the internet in search of support.

“I would just look at tips; how to hide it, you know, how to make it, make it hurt more and things like that, and yeah just kind of, I don’t know, I don’t know. I did go on there for a positive reason in the beginning, but after that I was just looking at negatives so like pro self-harm sites and that was it then.” Female, 13 years (Jacob et al., 2015)

Among both adult and teenage participants, several reported using the internet to look up suicide methods, with many reporting accessing information intended for a medical audience – for example, to look up lethal doses of medication.

While present, narratives which speak to the potential harms of the internet do not reflect the full picture. These must be considered alongside the accounts of those for whom the internet was described as a safe haven, a place to seek support, and as a tool for recovery and/or safety. Lavis and Winter’s (2020) study presented a nuanced exploration of the harms and benefits of the internet in relation to self-harm, drawing on an analysis of data from Reddit (a largely unmoderated online discussion forum) posts alongside data from semi-structured interviews with people who self-harmed. Participants in this study spoke at length about the value of online peer support – with several reflecting that giving support to others had helped them as much as receiving it. Participants reported that their online interactions around self-harm generally did not focus on the self-harm itself, but the emotions and contexts surrounding it. One participant stated this explicitly:

“It’s not so much talking about what you are doing, but talking about the context that you are doing it in.” Female interview participant (Lavis and Winter, 2020)

For many, online peer support provided a community lacking in their offline lives, a way to share experiences with people who understood them, and a protection against feelings of loneliness and isolation.

“I think a lot of people…the reason they go to these groups is because they want to know that they’re not alone and that it matters what happens to them. And having someone else acknowledge what you’re going though and to say that they care about you and to show that they see you, it helps a lot to feel like you’re, like you matter, and you’re not just drifting through the world disconnected.” Interview participant (Lavis and Winter, 2020)

Young people across studies within our review were often highly skeptical of suggestions that self-harm or suicide among their peers created a ‘contagion’ effect (where self-harm was viewed as potentially ‘spreading’ among peer-groups), with many describing these narratives as harmful and distressing, particularly to those who had been bereaved by suicide.

“It seemed like the press were trying to find a link between all of them and I think obviously some of them were linked but [M] had nothing to do with any of the others. So that was upsetting for people reading it because it was like they were just saying how they were killing, killing themselves because their friend had done it or their family had done it and that wasn’t the case, for [M] it wasn’t anyway cause I knew him, I spoke to him that day.” Female, 24 years, lost two close friends to suicide in the space of two weeks (John et al., 2022)

John et al.’s (2022) study had an innovative design, which involved interviewing people who had been treated for self-harm at the same time as a ‘suicide cluster’ had occurred in the same area. This facilitated explicit exploration of understandings of ‘contagion’ and ‘clustering’. Participants in this study and others provided accounts which emphasised that knowing other young people who self-harmed had not influenced or caused them to self-harm themselves. This provides an interesting and important contrast with prevailing understandings of risk factors in suicide prevention, which indicate that knowing someone who has died by suicide is a major risk factor for suicide. These qualitative accounts unsettle and challenge this narrative. However, such accounts are also likely to be shaped by wider discourse about ‘authenticity’ in relation to self-harm. Chandler (2016, 2018) found that people who self-harmed struggled to discuss self-harm in ways which both acknowledged the potential influence of others, whilst simultaneously denying such influence. Chandler argued that there were likely moral and cultural influences on how these stories about self-harm were shaped – and particularly a need to provide an account which showed that an individual was not influenced by, and was not ‘copying’ others.

In some studies, participants reported shared experiences between friends who were both self-harming as protective, reducing feelings of being alone. There were several descriptions of the benefits of having someone holding them ‘accountable’ in their efforts to stop self-harming. However, there were also some accounts of this placing a strain on friendships, and self-harm getting ‘worse’ after a friendship breakdown (Coronel, 2021)

Both adults and young people reported the first incidence of self-harm as extremely significant, both in its own right and as a precursor to continued self-harm. Donskoy and Stevens (2013) refer to this as the ‘ah-ha effect’ – described as a surprised realisation that injuring oneself has felt good.

“It was great. It was great. It was a sense of – I suppose it must be like for a drug addict for its first fix. You know, phyorr! You know, your serotonins and everything straight up the roof, great!” Peter, 18+ male (Donskoy and Stevens 2012)

Such was the significance of the first episode, that several participants suggested that the best way to reduce self-harm was to stop people ever ‘finding out’ how effective it could be in the first place. Others reported returning to imagery from the first time they self-harmed and being influenced primarily by their own personal ‘practice’ of self-injury, rather than any external factors (Dargan et al., 2016). Again, it is possible that these accounts are shaped by wider cultural understandings of self-harm as an individual practice, with Dargan et al (2016) observing that participants frequently chose language to highlight the personal and individual nature of their self-harm.

Concept C: Something is very wrong with me.

A common theme among the papers was a reported feeling of ‘wrongness’ or self-disgust as a precursor to, or part of self-harm. For some, the feeling and the behaviour were explicitly connected, with self-harm taking the form of behaviours such as skin-picking to remove perceived imperfections (Anderson and Clarke, 2019). Anderson and Clarke (2019) note that any damage to skin was not the intent, but appeared to be viewed as ‘collateral damage’ in the quest to remove any bumps or imperfection. Participants frequently used language of addiction, obsession and compulsion to describe the skin-picking – the study authors note this is unsurprising, given the shared clinical features between self-harm and obsessive-compulsive disorder.

“…a bad part of me says that I must get anything dirty out of my body so I pick and pick!” Female, 18+ (Anderson and Clarke, 2019)

In other studies, participants spoke of an overwhelming sense of self-loathing and disgust, with many connecting their self-harm to feelings of low self-esteem. While some participants could give no underlying cause or explanation for these feelings, there were many narratives of bullying – the impact of which often lasted long into adulthood and contributed to longstanding feelings of shame and self-disgust.

“Some of the things they said on a regular basis was like, ‘you are the ugliest person in the world, like no-one will ever love you’, and things like that. It’s like, although after I finished secondary school, although I didn’t hear from them again for a long time, it was like they left but I kind of created this bully that was inside me and like even after losing my contact with them I realised I had the same pressure on me, myself now, like ‘why are you like this? You are so ugly. You’re never enough!’ and things like that.” Ayla, 18 years, she/her (Marzetti et al., 2022)

A number of participants reported having been abused in childhood, and reflected on how this contributed to feelings of ‘wrongness’ and shame, as well as self-harm and suicidal thoughts. Mason et al. (2022) specifically explored the role of disgust in the experiences of men who had attempted suicide. They identified a history of abuse as a key contributor to shameful feelings.

“Weak. Disgusting…I never feel clean…what happened to me shouldn’t happen to anybody. And it just makes me feel worthless, shit, I shouldn’t be here.” Luke, 54 years, male, attempted suicide by jumping (Mason et al. 2022)

These strong feelings of wrong-ness, disgust, and shame, hold special relevance when it comes to considering the importance of responses to and support for those who self-harm, which we pick up in Theme 3: Changed landscapes, and in our Discussion.

Concept D: Self-harm and the State

Several of the studies explored the way participants experienced their interactions with the State, and how this was reflected in their self-harm practice. This theme was particularly prominent in studies carried out within closed institutions – prisons, residential homes and inpatient mental health units.

For some, self-harm was viewed as an almost inevitable response to an intolerable environment, where mistreatment was common, as described by this participant from Marzano et al.’s (2016) study of experiences of non-suicidal self-harm, carried out within a men’s prison.

“Because it’s disgusting the way they treat people on the mental health side of things. It’s a joke, it really is a joke. No wonder there is so much suicide and self-harming in these places – not just this place, in all of them. Do you know what I mean? You can’t believe the way that they treat you.” Male prisoner (Marzano et al. 2016)

This sense of self-harm as an inevitability is mirrored by participants from studies carried out in other closed institutions. This young woman in a residential children’s unit described a similar sense of despair and injustice when asked about her reasons for self-harming, connecting this to her experiences of being in the care system (Johnson et al. 2017).

“If you were sixteen years old and you were in care, you had all your stuff in your room taken out how would you like it?” Female, 16 years (Johnson et al., 2017)

In these responses – and in contrast to other accounts which framed self-harm as a more ‘individual’ practice – self-harm in these contexts was often presented a product of the environment. We identified different ways in which the environment was drawn on – in some cases, participants, such as the young woman above, described the environment almost in a causal way; whereas others incorporated the environment into a discussion of the functions that self-harm provided in these settings. For instance, several respondents described their self-harm as – at least in part – having a conscious function within that setting: as communication, as activism, as ‘two fingers up’ to authority.

“I think also it was two fingers to the system because I was supposed to be on 15 minute observations […] I managed to do that whilst sat on my bed, with, in full view of the door, just dismantle a razor blade, and nobody actually noticed me doing it, so I supposed I was partly trying to show a weakness in the system, that I could take control, and if I wanted to harm myself I could do.” Jim, attempted suicide while on 15-minute observations in a mental health unit (Donskoy and Stevens, 2012)

Outside of prisons and other closed settings, some participants spoke of a fear of state involvement as a repercussion of self-harm, for example police being called following a suicide attempt, being arrested while unwell, or social services becoming involved.

While this was generally viewed as unhelpful, some cited fear of state involvement as a paradoxically protective factor against self-harm, as seems to be the case for this woman in Polling’s (2017) study with individuals living in a highly deprived area of London.

“I went to school with some really nice middle-class girls. And a few of them took overdoses and their parents then sent them to the south of France to rehab, and stuff like that. Whereas we’d get none of that. We’d get our children taken away from us, would have to go through social services craziness, we’d probably have to go and do some parenting courses, we’d have to go to court, we’d probably lose our flats. There is so much more for us to lose if we were to kill ourselves.” Female participant (Pollings, 2017)

Those accounts which we reviewed to develop Concept D underlined the importance of institutional and social contexts in shaping practices of and responses to self-harm. These should not be taken to imply that self-harm is only shaped by such contexts in instances where people are in ‘closed’ settings such as prison or in-patient care, or in cases where participants are living with socioeconomic disadvantage. Indeed, the participant in Polling’s (2017) study indicates how conditions of affluence also shape self-harm, albeit in different ways. More broadly, while more ‘extreme’ cases such as those we discuss here highlight this more starkly, a consideration of social context should be relevant to all self-harm.

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. Participants were often deeply aware of the apparent contradictions within their experiences – for example the experience of self-harming as a way to practice self-care. Many spoke of their attempts to navigate and reconcile these tensions, both privately and in their interactions with others (loved ones, professionals) who often sought a less ‘messy’ narrative. The concepts identified within this theme present the functions and experiences of self-harm as complex, fluid, and deeply contextual.

Concept A: Compulsion and control

Control was a common topic in participants’ accounts, with variations in whether they viewed self-harm as something they could control. For some, as in Miller’s (2021) study with young people aged 13-17, self-harm was described as a compulsion, something participants had little control over. Language of addiction was common:

“They [urges] just take over; you feel that you have no control left…It’s physical and mental, you feel that you have no control…progressively over the years it has got worse and completely out of control.” Zoe, Female, aged 13-17 (Miller, 2021)

There were several accounts of having very little control over whether to self-harm, yet still feeling able to retain some control over how. For some, as in Woodley at al. (2021), this was connected to a wish to ‘do it sensibly’ – that is, in a way that did not attract outside intervention or scrutiny.

“I don’t do it a deep as I’d like to sometimes because I think, no, because that’s going on your medical record…if you are going to do it, do it sensibly.” Gemma, Female, aged 18+ (Woodley et al., 2021)

Others described self-harm as a way of regaining the agency and control absent in other areas of their lives, including, sometimes, as a way to reassert control in relationships with others. Wadman et al. (2018) found that this was a prominent feature of self-harm in their study participants, aged 13-18.

“I just didn’t have no control in my life. And everyone was making choices for me and that was my only way of controlling anything. That was my choice to do or not, and that was the only thing I could control, everything else was controlled by people.” Young person (Wadman et al. 2018)

Participants were often painfully aware of stigmatising narratives around self-harm as a manipulative, or attention seeking act, and generally rejected this explanation for their own self-harm (Chandler 2018, Quinlivan 2021). However, there were many accounts of self-harm as a way to communicate feelings of distress which had either been difficult to articulate verbally – or had not been listened to by others. Self-harm as communication was particularly observed in settings where there was an imbalance of power, for example in prisons (Marzano 2016).

“I try to explain, I do tell them, but it’s still they don’t wanna know. Until you do something […] what do I have to do? Right, I’ll cut myself. They might listen to me then.” Male prisoner (Marzano 2016)

Steggals et al. (2020) explore how the private practice of self-harm can take on communicative meaning in community settings, as well as in the closed environments previously described. Through their case study analysis of women who self-harm, they frame self-harm as a form of social communication frequently drawn upon when ordinary language ceases to be enough. Importantly, these understandings of self-harm as a social communication do not necessarily contradict accounts of self-harm as a personal and private practice – rather, they add a further dimension to our understanding of these accounts. This tension between what is personal and private, and what is communicative, is reflected throughout study participants’ stories. Such accounts emphasise the limitations of either/or explanations for self-harm (as either individual/private or social/communicative) and supports an understanding that it can be ‘both’.

Concept B: The work of staying alive

While some studies looked specifically at suicide attempts, the majority defined self-harm in a broader sense, with participants exploring the meaning and motivations within their own self-harm. A small minority of participants in the reviewed studies were clear that self-harm, for them, had always been in the form of a suicide attempt (Walker et al., 2021); however most narratives presented the function and meaning of self-harm as fluid, shifting, and difficult to define – both at the time of the self-harm, and later. Thus, although many accounts reported thoughts about suicide or dying, and did appear to connect self-harm to more abstract concepts of suicide, this connection did not generally extend so far as conscious intent. Several participants reported ongoing reflection as to their degree of suicidal intent, with this quote from Donskoy and Stevens (2013) underlining some of the complexity people might face when trying to ‘define’ intent.

“I was quizzing in my head whether it was suicide or was it a cry for help. It’s just like you know I’ve got all the respect for people who commit suicide, sort of fair enough, fair enough. You know. Get out of it basically, you know […] I dunno, whether or not for me it was a cry for help or whether it was actually like I really wanted to do it. I still don’t know, to be honest.” Jack, 18+ Male (Donskoy and Stevens, 2013)

For some participants self-harm was described as deeply distressing. However, self-harm was much more often described as a way of coping with life, and in some cases even more positively framed, as a means of self-care. This was often explicitly described as a way of staying alive, with self-harm described as actively protective against suicide, providing a further challenge to the frequent characterisation of self-harm as a risk factor for suicide. This was the case among adults as well as young people, as in Miller et al. (2021).

“I think it’s a way of taking care of yourself, because I feel in a way like self-harm stops you thinking about suicide as well.” Sophie, Female aged 13-17 (Miller et al., 2021)

For many participants, it seems self-harm was sometimes about suicide, and sometimes not. When exploring the difference between suicidal and non-suicidal self-harm, participants frequently described using different methods depending on intent. Reasons for this varied, but were generally related to perceived lethality of particular methods. While there were some exceptions, hanging was most commonly associated with suicide attempts, with participants generally describing cutting as non-suicidal, ambiguous or mixed intent. Accounts of self-poisoning and overdoses were less clearly defined in the narratives, although those who attended hospital after overdose were generally treated as having attempted suicide, regardless of stated intent. This element of choice applied even in prison settings (Chamberlen, 2016; Walker et al., 2021) perhaps further highlighting the role control plays.

“Hanging – wanted to die and expected to die. Cutting – wanted to let frustrations out and expected a release.” Male prisoner (Walker et al., 2021)

These accounts underline the importance of acknowledging the variety of methods and means that self-harm can involve, and the potential for these to have different meanings to different individuals.

Concept C: Drama vs mundanity

Across studies, participants consistently described their self-harm as a way of dealing with big, overwhelming and distressing feelings – with anger the most frequent example given. This depiction of self-harm as a way of regulating emotion, providing release and restoring calm was repeated across and within studies.

While this presentation of self-harm was common, a significant minority of participants described self-harm as being a quiet, routine, comforting – almost mundane – practice, seemingly unconnected with the overwhelming feelings of anger and distress described elsewhere. This depiction was more common among participants who self-defined their self-harm as a form of self-care or something that gave feelings of pleasure or satisfaction (Chandler, 2013; Donskoy and Stevens, 2013; Wadman et al., 2017). Many participants reflected that self-harm would be difficult to stop, because it had become an automatic response to distressing feelings – and one that could be relied upon to work.

Lockwood et al.’s (2020) study looked at the role impulsivity plays in the self-harm of young people. While impulsivity did play a role for some people, some of the time – many young people in contrast described self-harm as a detached, almost formulaic, inbuilt response to bad feelings.

“It’s sort of like an inbuilt thing now. It’s like…I’m feeling like that, so then, I’ll do this [self-harm]. It’s like Maths – you add ‘this’ and then ‘that’ and it’s equal to self-harm.” Jen, 17, Female (Lockwood et al., 2020)

Participants in the study reflected widely on their practices of self-harm and its relationship to impulsivity and emotions. We want to draw attention here to the subtly different ways that study participants described self-harm, and the way these can be drawn into and obscured by more clinical concepts such as ‘impulsivity’. Lockwood et al (2020) note that the design of their study likely shaped the way that young people sought to make sense of their self-harm. Indeed, while offering a novel exploration of psychological traits, that drew on a qualitative design, Lockwood et al.’s study notably did not engage with the contexts in which impulsivity or related emotions may take place.

Concept D: Pleasure and pain

The role of pain in self-harm varied across studies, with many participants reporting that they did not think they felt pain at the point of self-harm. In contrast, for some, feeling pain was a fundamental part of their self-harm practice, either as a form of punishment of the self or, in some cases, as a reminder of being alive.

“I am doing it to feel pain to remind myself that I can still feel pain, because at the moment I feel nothing. I feel numb and it’s my only way that I am reminding myself that I am still here, that I am still alive…by seeing the blood.” Isla, 13-17, Female (Miller et al. 2021)

Feelings of pleasure during self-harm were also commonly reported, with participants often saying that this was something they felt ashamed of or unable to talk about. It was not unusual for self-harm to be associated with feelings of calm, ‘a buzz’ or a ‘high’ which was sometimes spoken about like an addiction or compulsion. Several participants reflected that it was these feelings of pleasure that made it hard to stop self-harming, particularly as this was something that was often kept hidden.

“A lot of people don’t talk about that, about how good it [self-injury] feels. And, also that, erm, people that haven’t experienced how that feels, and think that, people that self-harm are masochists or something. But, mostly you don’t actually feel the pain. And, I know a lot of people have gone on about, it’s endorphins and stuff. And I guess it is, I don’t know […] but, em, it feels good…but a lot of people don’t really want to talk about that.” Rease, 28, Female (Chandler, 2013)

Here, we would draw attention to the challenge that these accounts may pose for policy makers and practitioners seeking to draw on and recognise perspectives of those with lived experience of self-harm. As we discuss further in the next section (Theme 3: Changed landscapes) – self-harm is frequently stigmatised, framed as a practice that is shameful and should be hidden. Approaches which ‘listen to’ and ‘include’ lived experience are often seen as a way of tackling such stigma. However, accounts such as those here, which describe self-harm as effective or pleasurable, may be seen as worrying or dangerous in a context where self-harm is both stigmatised, and seen as a worrying concern (especially among young people) – something that should be stopped or prevented. We return to this tension later.

Theme 3: Changed landscapes

The theme of ‘changed landscapes’ 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. Several reflected on a complex relationship with their self-harm scars, with differing views on whether these gave rise to feelings of shame or pride (or a mix of both). Conversations around ‘stopping’ were central to this theme, as were accounts of receiving support and treatment for self-harm. Each concept within this theme reflects a sense of a changed self, and a world that needs to be newly negotiated.

Concept A: Scars, stigma and shame

Participants often spoke of a sense of shame at having self-harmed. This was often, but not always, connected to having visible self-harm scars and how these would be perceived by others.

“The worst part for me is the shame and self-hatred. Knowing intellectually that I am harming myself and not being able to stop. Consumed with thoughts about how weak I am, how pathetic, and people must think I’m really sick.” Adult participant (Anderson and Clarke, 2019)

Within the studies, several participants discussed how they made decisions on whether to cover up their scars, indicating that this could vary depending on context and environment. Many accounts emphasised a preference for keeping scars covered, for reasons that were wide-ranging and included shame and fear – or previous experiences – of stigma. Several reflected on their scars – and, by association, themselves – being a ‘trigger’ for others, and often felt responsibility to protect others from the reality of their uncovered selves. This often exacerbated feelings of shame and low self-esteem, made worse by stigmatising comments from others. This participant from Brown et al.’s (2022) study on the role of shame in self-harm recalled several occasions where they had been chastised for wearing short sleeves:

“Put a jacket on, you’re triggering people.” Emily, 23 years, non-binary (Browne et al. 2022)

Where participants had chosen to stop hiding their scars, this was a carefully considered decision, often remembered as a significant moment. For some, this was transformative and freeing. Firstly in a physical sense, for example no longer having to wear long sleeves in warm weather, but also in terms of no longer feeling like they were hiding their ‘true self’ or being ‘deceptive’.

“I am now a university student, and my scars are now visible. I made the decision not to spend another hot day in extreme discomfort, not to let my fashion sense be dictated by anything other than desire and not to obsess over every action with the anxiety of being exposed. The transition was easy. I was meeting new people and if I didn’t mention my scars, neither would they. On the flip side, if I did choose to mention self-harm to close friends, they then weren’t shocked. I can have intimate relationships without the fear that I am being deceptive – something that held me back before.” Lynda, 18+, Female (Sutherland et al., 2014)

Scars were not universally viewed as shameful or something to be hidden. Many spoke of coming to accept their scars as a conscious act of self-compassion. For some, they were beautiful in the way they told a story and allowed one’s inner experience to be seen on the outside. Some referred to scars as visible evidence that they had fought a battle or overcome a tough time, and were able to find pride in this.

“It is about adornment and celebration […] And in a way my scars are as well, actually, ‘cos I do think they’re really beautiful, and they’re like a part of my, my experience, my history. And I very much believe about, em, your experience – written on the body and the body telling a story.” Rease, 28, Female (Chandler, 2014)

While most narratives around self-harm scars discussed feelings about whether or not to hide them, there were a few accounts exploring experiences of actively showing (as opposed to no longer hiding) self-harm scars to others. This was generally described as a significant moment which had to be carefully considered. For some, this resulted in strengthening relationships, becoming closer with friends or feeling known and ‘seen’ on a deeper level. For others the decision to show their scars was a way of communicating distress, and quietly hoping to invite connection and support.

“There may be times where I might deliberately want to show someone my scars because I really want to connect with them and I can’t work out how to do it. Umm particularly if I’m... if I am really low umm and ... because I’ve become very withdrawn and... and I lock myself away and stuff, and if I do it, if I cut umm I might sort of accidentally on purpose, accidentally let someone see it so they can see that something’s not right.” Urania, 18+, Female (Givissi, 2016)

The studies we have identified suggest that those with more social capital (educational status, age, financial situation), may be more able to ‘own’ their scars, and this may play into decisions about whether to show or conceal them. Although this was not universal, participants from higher socioeconomic backgrounds (Givissi, 2016; Sutherland et al., 2014) were generally more likely to share stories of showing – or finding pride in – their scars. In contrast, accounts from more marginalised groups (Chandler, 2013; Marzano et al., 2016; Walker et al., 2021) – particularly men and prisoners – tended more towards language of shame and concealment.

Concept B: Navigating the world

Several studies and participant narratives explored the impact that self-harm had on their functioning and ability to thrive across multiple areas of life, with work, study, relationships, hobbies and parenting the most frequently discussed. For some, the self-harm itself (along with associated rituals including covering up injuries) had become a disruptive force in their life that had resulted in significant, tangible loss. This participant describes the impact of self-harm related to obsessive-compulsive disorder:

“I have spent thousands on makeup and skincare. Worn long sleeves, jeans and boots in the middle of summer. Worn more makeup than a circus performer. Been hours late for engagements because I was picking then had to jump through all the hoops to cover it up. I have even not gone out when my apartment building had a real fire alarm because I was picking and didn’t have enough time to slap on enough makeup and cover up my marks.” 18+, Female (Anderson and Clarke, 2019)

Importantly, it was not often the self-harm itself that posed the most significant barriers, but rather external responses and stigma from others.. Many older participants reported workplace discrimination and stigma from colleagues and superiors following disclosure (or accidental ‘outing’). Among those who had not disclosed their self-harm at work, participants were unanimous that this would be met with shaming, ridicule, lack of understanding, and potentially the loss of their job. This was feeling particularly prominent in participants who worked with vulnerable people, and often founded on previous, negative, experiences of disclosure. This participant who works in the care industry described her experience of disclosing a suicide attempt to her manager:

“He [manager] didn’t say the word ‘self-harm’ but he said, about being a danger, he said do you feel like you’re safe to be at work and I said what do you mean, and he ignored me and said do you think you’re dangerous to be at work. That’s how he put it, he meant, he said both: like to me or people I were looking after... that made me not tell anyone else for ages.” Hannah, 18+, Female (Higgins, 2020)

There were often occasions where – either explicitly or implicitly – the line between ‘harm to self’ and ‘potential for harm to others’ seemed to become blurred, not only in the views of colleagues and line managers, but often in the individual themselves. Charlotte, a childcare assistant, reported that she felt she must always wear long sleeves when working with children:

“It’s not fair on them, erm, and they don’t know what they’re looking at, and it’s not fair to introduce them to it, ‘cos they’re suggestible…I’ve got to be really careful…I can’t put myself in a position where I could be that influence on a child.” Charlotte, 23 years, Female (Brown et al. 2022)

This sense of ‘doing harm’ by self-harming was also seen in narratives of mothers (there were no accounts we found relating specifically to fatherhood), who often felt that they were potentially damaging their children. One mother, suffering from skin picking disorder, spoke of her fear of being an unfit mother:

“My children have seen my bloodied face and back. There are days I want to call child protective services on myself.” 18+, Female (Anderson and Clarke, 2018)

Others were concerned about ‘passing on’ their self-harm to their children, although in many cases – such as this participant – it was unclear whether the fears related to a genetic predisposition or passing on learned behaviour.

“I’ve just had my first child, and I want to be free of this – don’t want to pass it on to her.” 18+, Female (Anderson and Clarke, 2019)

Parent-child relationships were also explored through the narratives of young people who self-harmed. While there were examples of parents responding helpfully and supportively to disclosure/discovery of self-harm, accounts of parental responses perceived as unhelpful were far more common. There were multiple accounts of self-harm being the focus of arguments and anger, with parents described as often making assumptions regarding the reasons for self-harm. Accounts such as this, from a young person in Wadman et al.’s (2018) investigation into self-harm in young people, were frequent. The young person shares her mother’s response to finding out about her self-harm, having read her private text messages:

“My mum was like ‘well why are you doing it?’ She got dead angry with me, she wouldn’t give me eye contact or talk to me. The next day… we had this huge argument and I was crying and she was shouting at me and she was like ‘is it something that you and your friends do?’ And I was just ‘no’.” Female, aged 13-17 (Wadman et al., 2018)

Young people often reported avoiding discussing self-harm with their parents as they felt it would inevitably lead to confrontation, arguments, upset, or – the most frequently used term – ‘drama’. Another participant from Wadman et al.’s study reflected on this, concluding they were better off not discussing their experiences.

“I think they’re more frustrated at the fact that I don’t go to them and talk to them first, and then I end up in hospital again. If my mum and dad found out again then it’d just be a whole lot of drama again and I just, I think I’d rather not deal with the drama.” Female, aged 13-17 (Wadman et al., 2018)

Young people who reported positive reactions from their parents generally described calm, loving, no-blame responses, although these were often accompanied with a great deal of sadness. It was not uncommon for parents to cry during discussions about self-harm – these tears were often described as troubling, shocking, or guilt-inducing by young people.

“She just broke down into tears. She wasn’t angry or anything, she broke into tears and she just gave me a massive hug and told me that we’d get it sorted and everything.” Female, aged 13-17 (Wadman et al., 2018)

Across the studies, it was clear that self-harm could have far-reaching impacts on people’s relationships – whether close family members, students or teachers at school, friends, or colleagues at work. While much is often made in clinical literature about the ‘management’ of self-harm, these accounts underlined how those who self-harm also have to ‘manage’ the relationships they have with those around them. As in Concept A (Scars, stigma and shame), one way of managing this is through concealing self-harm or, on occasion, showing it. In this section, we have shown how participants across the studies were faced with also managing changing and challenging personal relationships once self-harm did become known.

Concept C: I (don’t) need to stop

Many of the studies explored participants’ views about whether stopping self-harm was a reasonable or desired goal. Views varied here. For some, self-harm was directly associated with a bad time in their life, feelings of distress and pain. For these participants, it made sense that no longer self-harming was a goal. This was usually not because of the self-harm itself being something they felt needed to end, but because of its significance as an indicator of things being generally bad. Their logic was that if they were no longer self-harming, it would be a clear indicator that things were starting to generally improve for them.

Others were clear that they wanted to stop, but felt unable to. This is summed up clearly by a participant in Rouski et al.’s (2021) study with young people in residential care – and echoed in narratives across studies in all settings.

“I’d love to stop. But I can’t.” Lilli, 16 years, Female (Rouski et al. 2021)

This type of account was often seen among participants who also described their self-harm as an addiction or compulsion. Again, the wish to stop was rarely about the self-harm itself, but in this case about a desire to be free from the compulsion, or able to break a habit or addiction. Several authors (Anderson and Clarke, 2019; Boyce, 2021; Rouski et al., 2021; Sutherland et al., 2014) observed that these participants were often distressed more by the fact they could not stop, rather than wanting to stop, suggesting that control plays a role here.

Much more frequently, participants were unequivocal that stopping was not only undesirable for them, but could potentially be dangerous (i.e. in participants who self-harmed to distract from suicidal thoughts). When directly asked about this, Wadman et al. (2020) observed that frequency of self-harm was not a reliable indicator of recovery or improvement.

“It could be that you’re doing it less often but it’s more severe, and is that really an improvement?... Like, if it’s less frequent and less severe, then that’s an improvement.” Young person (Wadman et al., 2020)

Both adults and young people across the reviewed studies spoke of their frustration and sadness at being urged to stop by well-meaning parents, professionals and loved ones, while feeling strongly that this was not the best thing for themselves, or a goal they wished to work towards. For these participants, self-harm was viewed as a valuable tool to help them cope with life. For many, they had tried a great deal of other strategies (often suggested by healthcare professionals), and these had all come up short in terms of managing distress quickly and effectively. Many participants had – initially – kept an open mind and tried other strategies, but had returned to self-harm as one that worked for them. These two participants from Woodley et al.’s (2021) exploration of how young people who self-harm manage risk were seemingly resigned to self-harm as the most effective option.

“It’s the quickest, easiest way out and there’s nothing second. Nothing is going to be more effective than self-harm really, and it isn’t. Unfortunately.” Chloe, young person, Female (Woodley et al. 2021)

“I’ve worked my way through the coping skills list. I think I’ve literally tried everything.” Anna, young person, Female (Woodley et al. 2021)

Many accounts suggested a fear of life without self-harm. Although some participants clearly stated that stopping self-harm would increase their risk of dying by suicide, it was more common to see more ambiguous language here: removal of a ‘safety net’, ‘nowhere else to turn’, ‘taking away the only thing I’ve got that helps’, or ‘what I do to keep living’ (Long, 2018; Wadman et al., 2018; Wadman et al., 2017; Woodley et al., 2021). While these do not explicitly refer to an increased risk of suicide, they do speak to participants’ clear views that removing self-harm as an option would have harmful, and potentially high-stakes repercussions.

Concept D: Finding help that doesn’t hurt

Many of the studies explored the experience of seeking and receiving (or not receiving) professional help for self-harm, both for young people and adults. Young people had clear views about what was helpful – and what was unhelpful. Views about Child and Adolescent Mental Health Services (CAMHS) varied, with frequent reports of being offered ‘strategies’ that they did not find helpful or effective. Wadman et al. (2020) explored young people’s experiences of receiving support for self-harm, this participant’s frustration reflecting a common theme among participants.

“[CAMHS] just giving me the same solutions over and over again, it didn’t feel like there was anything new. It was just ‘have you tried this, have you tried that’ and I’d just be like ‘no, it doesn’t work’, and she’d just be like ‘well try it again’.” Young person (Wadman et al., 2020)

Older teens, in particular, often spoke of CAMHS treatment as infantilising and geared towards younger children, although there were also narratives, such as this one (Wadman et al. 2020), from young adults who had found the transition to adult services challenging.

“I used to go to CAMHS but I always thought they treated you like a little kid. Yeah, like obviously I’m 16, and they always like show you a piece of paper saying ‘look at this blob, what do you feel today?’ I’m, like, that’s summat what you would do with younger people.” Young person (Wadman et al. 2020)

Several studies looked at experiences of using harm minimisation strategies commonly recommended by healthcare professionals – these included snapping elastic bands around wrists, holding ice cubes, or drawing on skin with a red marker. Although some participants found these useful, young people were generally critical of their effectiveness. This was usually because these methods failed to meet some fundamental element of the sensation (pain, pleasure), emotional response (release, calming) or effect (blood, harm to self) that was being sought through their personal practice of self-harm. Young people’s experiences of harm minimisation strategies was the explicit focus of one paper (Wadman et al., 2020).

“They give you leaflets about 105 ways to stop harming and things, but it’s like I’ve tried the laggy [rubber] band, I’ve tried drawing on myself. I’ve tried the ice. And it’s like, these things don’t work.” Young person (Wadman et al.,2020)

“I think the one where you draw on yourself with red pen, I think that’s completely ridiculous…they were saying some people who self-harm do it because they like to see the blood…but also they need the pain as well, so that one was quite pointless.” Young person (Wadman et al., 2020)

Among the accounts of receiving care or support for self-harm, the majority of these were narratives of A+E attendance. While some did receive compassionate care and/or referrals for further support, experiences were overwhelmingly poor, with incidences of stigma, discrimination and poor treatment not only commonly reported, but frequently described by participants as a well-known ‘norm’ they were resigned to. For some, poor treatment felt like something they deserved. The following quotes are from three separate study participants talking about experiences of accessing help for self-harm in hospital A+E departments (Owens et al., 2016). They reflect derogatory and demeaning attitudes from some healthcare professionals, and the impact this can have on self-esteem and self-worth (including beliefs about being deserving of care).

“Some nurses…just look at you with utter disgust like you’re some monster.” No participant details (Owens et al., 2016)

“I was treated from start to finish as if I was pathetic and not worthy of treatment.” No participant details (Owens et al., 2016)

“When you’re that low, you think you deserve bad treatment and are not able to complain.” No participant details (Owens et al., 2016)

Participants often reported that poor experiences in A+E put them off seeking help in the future, often with serious consequences in the form of untreated injuries and infections which caused ongoing, long-term health implications for some. Poor treatment in A+E also contributed to ongoing feelings of shame and low self-esteem, creating what some referred to as a vicious cycle: feeling shame, self-harming, seeking help, being made to feel more ashamed and then self-harming again.

“I will not go up there anymore, mainly because I feel like such a time waster, and I hate all the questions they ask you…I just want to get back home, hide under the duvet and die of shame…I’ve ended up with numerous infections however from not getting wounds treated.” No participant details (Owens et al., 2016)

Some participants reported outright refusal from A+E staff to treat – or sometimes even see – them following self-harm. This was perceived as reflecting practitioner views around time wasting, inefficient use of resources, or a belief that withholding care and attention would cause patients to stop their self-harm. Participants were unequivocal that this was not the case, and had in fact often been a clear trigger for further episodes self-harm and/or suicidality. Several participants in Quinlivan et al. (2021, 2022) reported attending A+E following a suicide attempt, only to have their motivation, methods and intent questioned.

“I was refused treatment for self-harm and to see a psych by an ED doctor because ‘you’re just going to do it again anyway’ so I left the ED department in distress (only a day out of being discharged from an acute ward very suddenly) and with a wound on my leg that was muscle-deep and eventually required internal suturing.” Female, 50-54 years (Quinlivan et al. 2022)

“The most unhelpful things are to be told that I didn’t really mean to kill myself because I’m not dead and that it is up to me if I kill myself.” Female, 35-39 years (Quinlivan et al. 2021)

Several of the studies (Owens et al., 2016; Quinlivan et al., 2022, 2021) specifically explored experiences of receiving psychosocial assessment following A+E treatment. Where this was received, participants often found it a helpful, affirming experience, particularly where they were given space to fully explore their feelings. Many participants shared the view that a single, positive experience with the liaison team in A+E could be transformative in terms of restoring both hope for recovery, and faith in the mental health system. Interesting here is the word ‘human’ in stark contrast with a participant narrative discussed above, where the word ‘monster’ was used to convey how they felt had been treated (see p. 36).

“The last two occasions I have had an assessment with a psychiatric-liaison practitioner, they have been really positive. I was made to feel as a human and felt as though how I was feeling was validated…They temporarily restored my faith in the MH system.” Female, 20-24 years (Quinlivan et al., 2022)

Several of the studies explicitly asked participants for their views or advice on what would be helpful in terms healthcare responses to self-harm. Interestingly, even in the studies where this was not explicitly asked, many participants instinctively seemed to reflect on ‘if I could give some advice to healthcare professionals’ or ‘if I could give advice to someone who self-harms’. As well as highlighting the fundamental importance of actually being seen, and being treated with dignity, there was agreement that receiving a prompt, thorough assessment was important. There was overall consensus that open questions with space – and, importantly, time – to reflect were much more helpful than a ‘checklist’ type set of questions. Control and agency remained important, with participants valuing being given input – and asked for agreement – about plans for their care. These views are reflected in the quotes below, from three separate participants in Quinlivan et al.’s study (2021) which explicitly looks at experiences of psychosocial assessment following self-harm.

“In any situation, what works well is when I feel listened to and like I had some input and agreement into the decision and follow and most importantly that I understood the situation and why it was happening.” Female, 30-34 years (Quinlivan et al., 2021)

“I was given a very quick psychiatric assessment in A&E. I was appreciative of being given some attention at the time as it was the first time I’d spoken about my mental health and self-harm/suicidal ideation…Ideally it would be beneficial to be given some time and space to explore issues rather than feeling that they want you processed and out of the department as soon as possible.” Male, 40-44 years (Quinlivan et al., 2021)

“What didn’t work well was being told I would be okay, the nature of a checklist-like set of questions to evaluate someone’s mental health, left no room for me to really talk about how I was actually feeling.” Non-binary, 18-23 years (Quinlivan et al., 2021)

Reflecting on how they would advise others who self-harm, participants in these studies generally still recommended help-seeking, despite their own poor experiences. However, they were often critical of mental health campaigns suggesting help was easily accessed by anyone who took the step of asking. Instead, reflecting on their own experiences led them to suggest a more nuanced, pragmatic approach to guidance around help-seeking for self-harm.

“Rather than saying, like ‘if you ask for help, the help is out there’, that’s not entirely true so instead, we should say, ‘if you ask for help, the help may be difficult to get’ but that’s not a reflection on how much you need it, it’s a reflection of how tight the services are at the moment, and how resources are being diverted to other areas, it’s not your fault and it’s not something that you should have to tackle on your own.” No participant details (Lavis and Winter, 2020)

While lived experiences of accessing help for self-harm clearly point towards a need for change in healthcare responses, this quote is interesting. It reflects a feeling shared among many participants that this kind of frank expectation management – rather than painting a depressing and off-putting picture of help-seeking – may be helpful for individuals, and protective against feelings of shame or self-blame when help proves difficult to find.