Self-harm strategy development: qualitative evidence

Discussion

The three themes established by this review reflect the way the studies – and their participants – talk about self-harm. Close examination of the themes, areas of agreement and contradiction in accordance with Sattar et al.’s (2021) guidelines has allowed us to develop a ‘line of argument’ synthesis. This synthesis supports an understanding of the study themes as being broadly distinguished by relating to before, during or after the self-harm, as indicated below.

Figure 3: Line of argument synthesis

Theme 1: Context and culture

Before: Social contexts, harmful environments, triggers and influences

Theme 2: Narrating the unspeakable

During: The act itself, what self-harm is and isn't

Theme 3: Changed landscapes

After: Support, stigma and quality of life

Considering the literature and its themes in this way has allowed us to propose three related ‘Opportunity areas’. These represent areas of potential action, progress and further research, as identified through insights and lived experiences of people who self-harm. Each of these offer opportunities which national (and local) strategies designed to support and respond well to those who self-harm, might consider.

Opportunity area 1: Towards safer social environments

Firm conclusions about the causes of, and reasons for self-harm are outside the aims and scope of a qualitative review. 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. While qualitative evidence cannot definitively tell us that self-harm happens because of particular social environments, it supports an understanding of self-harm occurring in the context of those social landscapes. 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, be that because of abuse, bullying, discrimination and stigma, or living under state protection/control (prison, inpatient settings, residential children’s units). Testimony from those living within social environments that are perceived and experienced as unsafe often put forward that their self-harm was – if not actively caused by their environment, could be understandable when considered within it. This has implications for professionals and policy makers seeking to address self-harm in schools, prisons, in-patient hospitals and other relatively ‘closed’ or ‘bounded’ settings, and points to the need for greater understanding of how – or indeed whether – 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. While accounts point to the role cultural expectations, discrimination and ‘othering’ may play, the voices of Black and minority ethnic individuals are notably absent within the studies we were able to identify. While our review was able to identify some diverse explanations, understandings and experiences of self-harm practice, these must now be supported by research with participants from more diverse groups.

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

Our review supports an understanding of self-harm as complex and individual. We suggest 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 repeated attempts (by professionals, by parents, by themselves) to understand ‘why’ someone is self-harming. While some explanations and understandings featured more heavily in the studies included, caution must be applied in making generalisations. This, of course, applies also to our own identification of themes within this review. For every study participant who shared a more ‘typical’ experience of self-harm – as a coping mechanism, as a way to deal with tough emotions, as a response to anger – there were many others for whom these characterisations not only did not apply, but contributed to feelings of isolation, ‘otherness’ and shame. Participants were often deeply and painfully aware of stigmatising discourses around self-harm and many referred to – and rejected – these when making sense of their own self-harm practice. Our review identified common narratives around ‘attention seeking’, the role of social media influences, and ‘genuineness’ of suicide attempts as causing particular distress to participants. We noted that while many participants were unable to define or explain what their self-harm was, they were clear on the stigmatising assumptions and tropes that did not apply to them, and so often drew upon these in their accounts.

This diversity of experience and meaning poses challenges for healthcare professionals and policy makers wishing to better understand and support those who self-harm. Nonetheless, we suggest this 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. Several studies identified these poor responses – particularly within A+E departments – as forming part of a cycle of shame and low self-worth, contributing to repeated self-harm. Several participants were clear that it was not the self-harm that posed a risk to their quality of life, but the stigmatising responses they received. 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. Of particular note is that 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, necessary or advisable in the context of a self-harm policy, and how impact might be measured, particularly given challenges around measuring and defining self-harm. 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.