Self-harm strategy development: qualitative evidence

Appendix 1: Characteristics of qualitative studies included in qualitative synthesis

Marzano et al. (2012)

Study aims

To understand how health and prison staff response to self-harm influenced prisoners

Setting (Country)

A male prison (England)

Participants

Adult male prisoners (n=22)

Methods

• Person-centred, qualitative Semi-structured interviews.
• Analysis informed by principles of thematic and discourse analysis.

Definition/understanding of self-harm used within study

Repetitive, non-suicidal.

Summary of findings, themes, and concepts

85% reported officers’ reactions to self-harm in negative terms.

Recurrent themes:

(a) Officers did not care, understand, or care to understand.

(b) Being treated ‘like a kid’

(c) Failure to take seriously

(d) Medical staff ‘worse than officers’

(e) Preferred reaction: care, compassion, respect

Quality assessment: CASP Score (Max = 10)

9

Baker et al. (2013)

Study aims

Explore what women hope to achieve by self-harm

Setting (Country)

Medium secure forensic unit (England)

Participants

Female patients (n=25)

Methods

• Semi-structured interviews.
• Thematic analysis.

Definition/understanding of self-harm used within study

Intentional injuring of body without apparent suicidal intent.

Summary of findings, themes, and concepts

Identified themes:

(a) The traumatised individual

(b) Interrupted maturation process

(c) The hidden experience

(d) Crossing the line: Individual and systemic repercussions

Quality assessment: CASP Score (Max = 10)

9

Chandler, A (2013)

Study aims

Exploratory- broad aims.

Setting (Country)

Non clinical setting (Scotland)

Participants

N=12 Gender: Female (n=7), Male (n=5)

Methods

• Life-story interviews.
• Narrative analysis.

Definition/understanding of self-harm used within study

Range of interpretations and experiences. Cutting.

Summary of findings, themes, and concepts

Identified themes:

(a) The absence of pain

(b) Pain or pleasure?

(c) Physical pain as central

Quality assessment: CASP Score (Max = 10)

9

Donskoy and Stevens (2013)

Study aims

Explore pathways to first episode of self-harm

Setting (Country)

Nonclinical setting (England)

Participants

N=11 Gender: Male (n=6), female (n=5). All participants were White British

Methods

• Semi-structured interviews.
• Thematic and narrative analysis.

Definition/understanding of self-harm used within study

First episode of self-wounding, without suicidal intent.

Summary of findings, themes, and concepts

Three participants were aware of suicidal feelings prior to self-harming (but not intent). Self-harming ‘swept’ away thoughts of suicide.

The first episode as unique

Quality assessment: CASP Score (Max = 10)

9

Hunter et al. (2013)

Study aims

Explore experiences of assessment and examine meanings of assessment for service users.

Setting (Country)

Specialist self-harm team (England)

Participants

Adults who had attended the local emergency department following self-harm and had received an assessment (n=13) Gender: male (n=7), female (n=9)

Methods

• Semi-structured interviews.
• Interpretative phenomenological analysis.

Definition/understanding of self-harm used within study

Intentional self-poisoning or injury, irrespective of motivation.

Summary of findings, themes, and concepts

(a) Function of psychosocial assessment unclear

(b) Assessment legitimises distress, alleviates loneliness, and aids recovery.

(c) Feeling shamed or judged.

(d) Cycle of referral to same/similar services increases hopelessness. (

e) Struggling to be heard/believed.

(f) Unclear follow-up procedures.

Quality assessment: CASP Score (Max = 10)

10

Klineberg et al. (2013)

Study aims

Increase understanding of how adolescents speak about self-harm

Setting (Country)

Schools in London (England)

Participants

N=30 ethnically diverse school pupils of which most (n=20) had self-harmed. Gender: Male (n=6) female (n=24)

Methods

• Semi structured interview.
• Framework approach for analysis.

Definition/understanding of self-harm used within study

Forms included cutting, overdoses, self-burning.

Summary of findings, themes, and concepts

Self-harm as varied and complex. None of the participants directly reported clear suicide attempts.

(a) Disclosure and secrecy

(b) Barriers to help seeking.

(c) Responses to disclosure

Quality assessment: CASP Score (Max = 10)

9

Chandler, A (2014)

Study aims

Explore accounts of self-injured bodies

Setting (Country)

Non-clinical setting (Scotland)

Participants

N=12 adults who had self-injured (7F, 5M).

Methods

• Semi-structured interviews.
• Phenomenological analysis.

Definition/understanding of self-harm used within study

Self-injury. Particular focus on the ‘bodily aftermath’, rather than the act itself.

Summary of findings, themes, and concepts

Self-harm narratives can be understood by Frank’s narratives of illness (chaos, restitution, and quest).

(a) Restitution – returning to a pre self-injured state.

(b) Transforming the self – revisioning scars; scars as communication

(c) Reading and listening to the self-injured body

Quality assessment: CASP Score (Max = 10)

9

Inckle, K (2014)

Study aims

Explore in depth experiences of self-injury. To challenge dominant commentaries about gender and self-injury.

Setting (Country)

Non clinical setting (England)

Participants

Three men who had self-injured

Methods

• In depth interviews.
• Thematic analysis.

Definition/understanding of self-harm used within study

Self-harm as a coping mechanism, expression of control, way to gain relief from feelings.

Summary of findings, themes, and concepts

Exploration of gender norms.

(a) Gendering distress

(b) Strong and silent

(c) Injured bodies and masculinity

Quality assessment: CASP Score (Max = 10)

9

McAndrew and Warne (2014)

Study aims

Explore narratives of adolescents engaging in self-harm.

Setting (Country)

Non-clinical setting (England)

Participants

Young people (13-17 years) who had experienced severe self-harm or suicidal behaviour (n=7).

Methods

• Narrative interviews.
• IPA.

Definition/understanding of self-harm used within study

Self-harm and suicidal behaviour.

Summary of findings, themes, and concepts

Three main themes identified:

(a) Cutting out the stress

(b) Stepping into the path of help

(c) Prioritising self-harm on public health agenda

Quality assessment: CASP Score (Max = 10)

8

Sutherland et al. (2014)

Study aims

To explore self-compassion among individuals who self-harm

Setting (Country)

Online accounts

Participants

Online accounts from 27 websites. Demographics unknown approx. n=170

Methods

• Semi-structured interviews.
• IPA.

Definition/understanding of self-harm used within study

Non suicidal self-injury (NSSI)

Summary of findings, themes, and concepts

Three main themes identified:

(a) Self-kindness

(b) Common humanity

(c) Mindfulness

Quality assessment: CASP Score (Max = 10)

8

McDermott et al. (2015)

Study aims

To explore LGBT people’s cybertalk about self-harming

Setting (Country)

Online forums (Various, including England)

Participants

Unknown. Approx. n=290.

Methods

• Thematic analysis of online comments and chats.

Definition/understanding of self-harm used within study

Broad meaning – self defined.

Summary of findings, themes, and concepts

(a) Self-harm as a result of transphobia and homophobia

(b) Self-harm due to self-hatred

(c) Self-harm rejected as being related to sexuality of gender

Quality assessment: CASP Score (Max = 10)

6

Morris et al. (2015)

Study aims

To explore emotion across the lifespan in individuals who self-cut

Setting (Country)

Personality disorder service (England)

Participants

N=8 Gender: Female (n=7), male (n=1)

Methods

• Semi-structured interviews.
• Narrative analysis.

Definition/understanding of self-harm used within study

Cutting

Summary of findings, themes, and concepts

(a) Seen and not heard.

(b) A release- to get rid of the pain and hurt.

(c) A Vicious circle

(d) A different world – detachment

(e) ‘Trying to turn my life around’

Quality assessment: CASP Score (Max = 10)

9

Chamberlen (2016)

Study aims

To explore the meanings and motivations of self-injury practices as disclosed by female former prisoners.

Setting (Country)

Non clinical setting (England)

Participants

Female former prisoners (n=24) aged between 19 and 42.

Methods

• Semi-structured interviews.
• Thematic analysis.

Definition/understanding of self-harm used within study

Self-injury of any kind

Summary of findings, themes, and concepts

Pain of imprisonment ‘inscribed and experienced’ on the body.

Quality assessment: CASP Score (Max = 10)

10

Dargan et al. (2016)

Study aims

To further understanding of the role imagery plays in the experience of self-injury.

Setting (Country)

University campus (England)

Participants

Students (n=10) from three universities across north-west England. Gender: Female (n=7), male (n=3)

Methods

• Semi structured interviews.
• IPA.

Definition/understanding of self-harm used within study

Self-injury; suicidal or non-suicidal.

Summary of findings, themes, and concepts

Themes identified:

(a) Origins and precipitants of self-injurious imagery

(b) What it is like to experience self-injurious imagery

(c) Meaning and interpretation of self-injurious imagery

Quality assessment: CASP Score (Max = 10)

10

Givissi (2016)

Study aims

To explore experience of having marks and scars on the body as the result of self-harm

Setting (Country)

Community setting (England)

Participants

Female participants (n=6)

Methods

• Semi structured interviews.
• IPA.

Definition/understanding of self-harm used within study

Self-harm resulting in physical marks or scars

Summary of findings, themes, and concepts

Four superordinate themes identified:

(a) From depth to surface

(b) Bargaining

(c) Connecting the dots

(d) Drawing butterflies

Quality assessment: CASP Score (Max = 10)

10

Long et al. (2016)

Study aims

To understand clients’ experiences of counselling for self-injury

Setting (Country)

Non-clinical setting (Northern Ireland)

Participants

N=10. Gender: Female (n=8), male (n=2)

Methods

• Semi-structured interviews.
• Grounded theory.

Definition/understanding of self-harm used within study

Broad meaning – self defined

Summary of findings, themes, and concepts

Key themes identified:

(a) Building up trust

(b) Seeing beyond the cutting

(c) Human contact

(d) Integrating experiences Central category of ‘Developing a healing reconnection with self and others’

Quality assessment: CASP Score (Max = 10)

9

Marzano et al. (2016)

Study aims

To understand the needs and motivation of incarcerated men who self-harm without apparent suicidal intent.

Setting (Country)

Male prison (England)

Participants

Male prisoners (n=20)

Methods

• Semi-structured interviews.
• Thematic analysis.

Definition/understanding of self-harm used within study

Non suicidal

Summary of findings, themes, and concepts

Three main themes identified:

(a) Contextualising self-harm: troubled lives and troubling environments

(b) Confusing and confused: not always making sense of self-harm

(c) (De)constructing self-harm and “self-harmers”

Quality assessment: CASP Score (Max = 10)

9

Owens et al. (2016)

Study aims

To examine young people’s perceptions of A+E treatment following self-harm and their views on what constitutes a positive encounter.

Setting (Country)

Online forum

Participants

Young people (n=31) aged 16 to 25 years with experience of self-harm. Mean age 19.5 years. Gender: Female (n=30)

Methods

• Secondary analysis of qualitative data from an online discussion forum.

Definition/understanding of self-harm used within study

Any method of self-harm. 100% of participants had self-harmed by cutting.

Summary of findings, themes, and concepts

Authors identified a cycle of self-harm, shame and avoidance. This was exacerbated by poor responses by medical professions in A+E. Participants avoided attending A+E wherever possible due to these poor responses. Positive encounters were those where they received non-discriminatory care, delivered with kindness.

Quality assessment: CASP Score (Max = 10)

9

Rayner and Warne (2016)

Study aims

To explore the role of interpersonal processes in the development and maintenance of self-injury

Setting (Country)

Secondary mental health services (England)

Participants

Three pairs of clients and staff.

Methods

• Interviews in pairs.
• Thematic analysis.

Definition/understanding of self-harm used within study

Non-suicidal self-harm

Summary of findings, themes, and concepts

Interpersonal trigger followed by anger and shame resulted in self-injury to ‘numb’ experiences.

Quality assessment: CASP Score (Max = 10)

10

Sambath (2016)

Study aims

To explore the subjective experiences and meaning of self-harm for South Asian women

Setting (Country)

Community setting (England)

Participants

South Asian women (n=5)

Methods

• Semi-structured interviews.
• IPA.

Definition/understanding of self-harm used within study

Self-harm as emotional regulation

Summary of findings, themes, and concepts

Four master themes identified:

(a) The overwhelming struggle

(b) Self-harm as an emotional response to cope with the struggles

(c) Self-harm as a double-edged sword

(d) Experiences of support services

Quality assessment: CASP Score (Max = 10)

10

Whalen (2016)

Study aims

To understand the role impulsivity plays in self-harm.

Setting (Country)

Low secure forensic hospital (England)

Participants

Women detained in low secure forensic hospital (n=6)

Methods

• Semi-structured interviews.
• IPA.

Definition/understanding of self-harm used within study

Self-harm as an impulsive act.

Summary of findings, themes, and concepts

Themes identified:

(a) I need you for safety, but I fear you

(b) I need someone to hold and make sense of things.

(c) Mistrust: a need to withdraw

(d) Nothing is in the middle.

(e) I’m going round in circles and keep making the same mistakes

(f) I can’t believe the abuse.

(g) A need to escape from the pressure of being stuck: the only choice.

(h) Living in a hostile world

(i) Escaping or avoiding the dread

(j) Betrayed: you’re not on my side

(k) It won’t happen again.

(l) A sense of losing and finding myself

(m) A move away from intolerable feelings: alive or obliterated.

(n) Lost: where do I belong?

Quality assessment: CASP Score (Max = 10)

10

Jacob et al. (2017)

Study aims

To explore how young people understand and use online images of self-harm.

Setting (Country)

Community setting (Wales)

Participants

Young people aged 16-24 with a previous history of self-harm. (n=unknown)

Methods

• Semi-structured interviews.
• Thematic analysis.

Definition/understanding of self-harm used within study

Self-harm. Definition determined by participant.

Summary of findings, themes, and concepts

Viewing images serves a vital role in many young peoples’ self-harm, as part of ritualistic practice. Many invoked a physical reaction.

Quality assessment: CASP Score (Max = 10)

8

Johnson et al. (2017)

Study aims

To seek service users reviews on what staff supports were effective and which were counterproductive.

Setting (Country)

Residential care centre (Scotland)

Participants

Young people (n=7) aged 14-16 years. Gender: Female (n=4). All had been in a care setting for over six months. Ethnicity: White British (n=7)

Methods

• Semi-structured interviews.
• Thematic analysis.

Definition/understanding of self-harm used within study

Any deliberate self-harm, any intent.

Summary of findings, themes, and concepts

Global themes of safety and care. Suggestions for care included:

(a) Collaborative planning for support can be successful.

(b) If items are removed, these should be returned as quickly as possible. Removing all objects was often harmful.

(c) When providing emotional support, it was effective to first focus on calming the young person and then exploring triggers.

(d) Peer support as helpful.

Quality assessment: CASP Score (Max = 10)

8

Wadman et al. (2017)

Study aims

To explore young adults’ personal accounts of self-harm in order to identify ways to improve support

Setting (Country)

Community setting (England)

Participants

Young adults (age range 19-21) with repeat self-harm (n=6). All had self-harmed within the last 6 months. Gender: Male (n=1)

Methods

• Semi-structured interviews.
• IPA.

Definition/understanding of self-harm used within study

Repeated self-harm, primarily cutting.

Summary of findings, themes, and concepts

Six themes identified:

(a) Keeping self-harm private and hidden

(b) Self-harm as self-punishment

(c) Self-harm provides relief and comfort.

(d) Habituation and escalation of self-harm

(e) Emotional gains and practical costs

(f) Not believing they will stop completely.

Quality assessment: CASP Score (Max = 10)

9

Biddle et al. (2018)

Study aims

To explore suicide-related internet use and its impact on suicidal behaviour.

Setting (Country)

Two contrasting samples:

(a) Community setting

(b) Patients presenting to hospital emergency departments

Participants

Community based young people (n=13) Patients presenting to hospital emergency departments (n=20) Gender: Female (n=19)

Methods

• In-depth interviews.
• Thematic analysis.

Definition/understanding of self-harm used within study

Suicidal behaviour

Summary of findings, themes, and concepts

Purposes of suicide-related internet use identified:

(a) Researching known methods

(b) Researching everyday items

(c) Seeking new/recommended methods

(d) Seeking details of effective implementation

(e) Seek evaluation of methods

(f) Help-related internet use

Quality assessment: CASP Score (Max = 10)

9

Boyce et al. (2018)

Study aims

To explore the role of self-harm groups from the perspective of group members.

Setting (Country)

Community self-harm group (England)

Participants

Participant data not provided.

Methods

• Qualitative case study approach.
• Thematic analysis.

Definition/understanding of self-harm used within study

Self-harm

Summary of findings, themes, and concepts

Self-harm self-help groups can provide a safe and non-judgemental space. Four themes were identified:

(a) A safe space

(b) A different approach

(c) Alleviation of isolation

(d) Learning from others

Quality assessment: CASP Score (Max = 10)

8

Edmonson et al. (2018)

Study aims

To explore acceptability of photo-elicitation approach in research on self-harm.

Setting (Country)

Community setting. (England)

Participants

Female participants (n=6)

Methods

• Participants asked to take photo to describe their experiences of self-harm, then interviewed.
• Interviews and photos allocated thematic codes.

Definition/understanding of self-harm used within study

Not specified

Summary of findings, themes, and concepts

Participants responded positively to using images to support discussion about self-harm. Four main themes identified to represent negative, positive and adaptive purposes of self-harm:

(a) Self-harm as a response to distress

(b) Self-harm to achieve mastery.

(c) Self-harm asp protective

(d) Self-harm as language or communication

Quality assessment: CASP Score (Max = 10)

7

Long (2018)

Study aims

To provide insight on experiences of stigmatisation for people who engage in hidden self-injury.

Setting (Country)

Community settings (Northern Ireland)

Participants

Counselling clients with a history of self-injury but no longer engaging in self-injury. (n=10.) Counsellors (n=10)

Methods

• Semi structured interviews.
• Grounded theory analysis.

Definition/understanding of self-harm used within study

Self-injury.

Summary of findings, themes, and concepts

Three categories identified:

(a) Stigma and rejection

(b) Fear and the need to rescue. (

c) Secret, shame and self-stigma

Quality assessment: CASP Score (Max = 10)

9

Mackenzie et al. (2018)

Study aims

To understand support needs of probation clients by exploring experiences of near-lethal suicide attempts

Setting (Country)

Participants recruited from London probation areas (England)

Participants

Probation clients (n=7)

Methods

• Semi structured interviews.
• IPA.

Definition/understanding of self-harm used within study

Near-lethal suicide attempt

Summary of findings, themes, and concepts

Themes identified:

(a) Experiences of loss

(b) Difficulties with trust

(c) Control: loss and regain

(d) Struggles to find a purpose

Quality assessment: CASP Score (Max = 10)

9

Wadman et al. (2018)

Study aims

To explore how looked-after young people make sense of the experience of self-harm and resulting supports.

Setting (Country)

Community setting

Participants

Young people with experience of public care system (n=24). Age ranges between 14 and 21 years. Gender: Female (n=20).

Methods

• Semi structured interviews.
• IPA.

Definition/understanding of self-harm used within study

Self-defined by participants.

Summary of findings, themes, and concepts

Prevalent themes:

(a) Changes in care placement

(b) Feelings of anger

(c) Not wanting/feeling able to talk

(d) Developing coping strategies

(e) Clinical services: A relational mixed bag (patronised, not listened to, nothing being done, comfortable/able to talk).

Quality assessment: CASP Score (Max = 10)

10

Wadman et al. (2018a)

Study aims

To explore young women’s experience of self-harm in the context of interpersonal stressors and support

Setting (Country)

Non clinical setting

Participants

Adolescent females aged 13-18 years (n=14).

Methods

• Semi structured interviews.
• IPA.

Definition/understanding of self-harm used within study

Self-injury or self-poisoning, regardless of intent

Summary of findings, themes, and concepts

Themes identified:

(a) Arguments and worries about family breakdown.

(b) Unhelpful parental response when self-harm discovered and impact on seeking support.

(c) Ongoing parental support

(d) Long-term peer victimisation/bullying as a backdrop to self-harm

(e) Mutual support and reactive support from friends (and instances of lack of support)

(f) Emotions shaped by others (shame, regret and feeling ‘stupid to self-harm’).

(g) ‘Empty promises’ – feeling personally let down by clinical services

Quality assessment: CASP Score (Max = 10)

9

Anderson and Clarke (2019)

Study aims

To better understand experiences of those who problematically pick at their skin.

Setting (Country)

Online discussion forum

Participants

Approx. n=100. Demographic information not collected.

Methods

• Thematic analysis.

Definition/understanding of self-harm used within study

Problematic skin-picking

Summary of findings, themes, and concepts

Themes identified:

(a) I get out of my skin.

(b) I am shameful. (c)

No one must ever see

Quality assessment: CASP Score (Max = 10)

9

Bailey et al. (2019)

Study aims

To gain insight to how adults who self-harm make sense of the behaviour, and implications for help seeking.

Setting (Country)

Online setting

Participants

Adults aged 25-60 years (n=19). Mean age = 32 years.

Methods

• Thematic analysis of comments in online self-harm forum.

Definition/understanding of self-harm used within study

Self-defined. Any form of self-harm

Summary of findings, themes, and concepts

Comments online forum contained themes of:

(a) Role of self-harm

(b) Experience of sharing self-harm with others

(c) Stigma and shame

(d) Managing and lessening of self-harm

Quality assessment: CASP Score (Max = 10)

8

Camm-Crosbie et al. (2010)

Study aims

To explore autistic individuals’ experience of treatment and support for self-harm and suicidality.

Setting (Country)

Community setting (England)

Participants

Autistic adults (n=200). Age range 18-6S7 (mean =38.9). Gender: Male (n=77).

Methods

• Survey.
• Thematic analysis of open ended questions.

Definition/understanding of self-harm used within study

Self-defined. Self-harm and suicidality.

Summary of findings, themes, and concepts

Three themes identified:

(a) Difficulties in accessing treatment and support.

(b) Lack of understanding and knowledge of autistic people with co-occurring mental health difficulties.

(c) Appropriate treatment and support, or lack of, impacted autistic people’s wellbeing and likelihood of seeing suicide as their future.

Quality assessment: CASP Score (Max = 10)

10

Chandler (2019)

Study aims

To explore how men talked about alcohol in relation to mental health and self-harm.

Setting (Country)

Community mental health organisation (Scotland).

Participants

Men who had self-harmed or planned suicide (n=10.) All white. Most from ‘working class’ backgrounds.

Methods

• Life story interviews.
• Thematic analysis.

Definition/understanding of self-harm used within study

Self-harm, attempted suicide or planned suicide.

Summary of findings, themes, and concepts

Key concepts identified:

(a) On being stopped – embodied distress in context

(b) Body as object, body as agent

Quality assessment: CASP Score (Max = 10)

9

Griffiths et al. (2019)

Study aims

To explore how women experience peer support provided in prison.

Setting (Country)

Women’s prison (England)

Participants

Women in custody who self-harm (n=30). Prison staff (n=65)

Methods

• Mixed qualitative methods including a questionnaire, focus group and semi-structured interviews.
• Grounded theory approach.

Definition/understanding of self-harm used within study

Self-defined by participants.

Summary of findings, themes, and concepts

Professional and peer support understood as extensions of each other. Preferences influenced by how severe women viewed their self-harm to be and the degree to which they regarded their relationships with staff as trusting and/or supportive.

Quality assessment: CASP Score (Max = 10)

10

Harris (2019)

Study aims

To explore experiences and views of people who frequently use hospital A+E services for self-harm or suicide attempts.

Setting (Country)

Psychiatric liaison service and therapy service for people with diagnosis of borderline personality disorder. (England)

Participants

People with experience of using A+E for self-harm (n=10). Gender: Male (n=1)

Methods

• Semi structured interview.
• Thematic analysis.

Definition/understanding of self-harm used within study

Self-harm in the context of borderline personality disorder.

Summary of findings, themes, and concepts

Three overarching themes identified:

(a) Development of beliefs

(b) Experience of the journey through services

(c) Seeking help as a significant moment

(d) Beliefs about the unavailability of help.

Quality assessment: CASP Score (Max = 10)

10

Troya et al. (2019)

Study aims

To explore how older adults experience self-harm

Setting (Country)

Third sector services (England)

Participants

Older adults over the age of 60 with experience of self-harm (n=9). Gender: Male (n=3)

Methods

• Semi-structured interviews.
• Thematic analysis.

Definition/understanding of self-harm used within study

Suicidal intent as a spectrum in self-harm.

Summary of findings, themes, and concepts

Experiences of self-harm identified:

(a) Cry for help

(b) Coping mechanism

(c) Regain control versus gratification.

(d) Secrecy, shame and stigma

Quality assessment: CASP Score (Max = 10)

8

Troya et al. (2019a)

Study aims

To identify and explore barriers and facilitators to accessing care within primary care for older adults who self-harm.

Setting (Country)

Third sector services (England)

Participants

Older adults over the age of 60 with experience of self-harm (n=9). Gender: Male (n=3). Age range 60-72 years.

Methods

• Semi-structured interviews.
• Thematic analysis.

Definition/understanding of self-harm used within study

Self-defined by participants.

Summary of findings, themes, and concepts

External, practical, and internal barriers to support identified. Older adults’ help seeking behaviour was facilitated by previous positive experiences.

Quality assessment: CASP Score (Max = 10)

9

Turrell (2019)

Study aims

To investigate what males chose to share about their experiences of self-harm in vlogs posted on YouTube.

Setting (Country)

Online study (United Kingdom)

Participants

Males (n=14.) No participant demographic data available.

Methods

• Thematic analysis of vlog content.

Definition/understanding of self-harm used within study

Self-defined by participants.

Summary of findings, themes, and concepts

Themes identified:

(a) Motives and methods: Vloggers talk about how and why they self-harmed.

(b) Concealment: Vloggers talk about hidden aspects of self-harm

(c) Addiction and intensification: Vloggers talk about obscure characteristics of self-harm.

(d) Emotional expression: Vloggers talk about their affective experiences.

(e) Thoughts about help: Vloggers talk about their relationship to help.

(f) Sharing knowledge and expertise: Vloggers talk about their desire to help others

Quality assessment: CASP Score (Max = 10)

9

Ballantyne (2020)

Study aims

To explore transgender peoples’ experiences of self-harm and suicidality and how they make sense of these experiences.

Setting (Country)

Community setting (Scotland)

Participants

Transgender people (n=4) who reported a history of self-harm or suicidality.

Methods

• Semi-structured interviews.
• IPA.

Definition/understanding of self-harm used within study

Self-harm or suicidality

Summary of findings, themes, and concepts

Four super-ordinate themes identified:

(a) Early experiences: How individuals made sense of early experiences which increased their self-harm and suicidal distress

(b) Intent: The motives underlying participants’ self-harm and suicidality

(c) Hope and resilience: The protective resilience factors that reduced participants’’ self-harm and suicidal distress.

(d) Threats to resilience: How participants made sense of additional minority stressors that were relevant to their experience

Quality assessment: CASP Score (Max = 10)

10

Higgins (2020)

Study aims

To understand the expectations and experiences of adults who self-harm when they disclose to non-professionals.

Setting (Country)

NHS and third sector organisations (England)

Participants

Adult participants (n=10) aged 26-51. Gender: 50% split male and female

Methods

• Semi-structured interviews.
• Thematic analysis.

Definition/understanding of self-harm used within study

Self-defined by participants.

Summary of findings, themes, and concepts

Four themes identified:

(a) The insular nature of self-harm

(b) Imagined vs reality.

(c) Self-preservation

(d) New ways of relating

Quality assessment: CASP Score (Max = 10)

10

Lavis and winter (2020)

Study aims

To better understand why young people engage with self-harm content online, and its impact on wellbeing.

Setting (Country)

Online study (United Kingdom)

Participants

Interview participants (n=10). No demographic data available.

Methods

• Online ethnographic observation.
• Semi-structured interviews.
• Triangulation of two data sets.

Definition/understanding of self-harm used within study

Self-defined by participants.

Summary of findings, themes, and concepts

Study authors stress that moves to eradicate self-harm content must be undertaken with caution so as not to cause unintentional harm. Highlights need to think beyond models of contagion, instead attending to other mechanisms of harm and benefit.

Quality assessment: CASP Score (Max = 10)

10

Lockwood et al. (2020)

Study aims

To better understand the role of impulsivity in adolescent self-harm.

Setting (Country)

Community based (United Kingdom)

Participants

Adolescents attending Further Education colleges (n=15). Age range 16-22 years. Gender: Male (n=1)

Methods

• Exploratory card-sort tasks and semi-structured interviews.
• Thematic analysis.

Definition/understanding of self-harm used within study

Self-defined by participants

Summary of findings, themes, and concepts

Two overarching themes and associated subthemes identified:

(a) How I respond to strong emotions

(b) Impulse vs deliberation – how much I think through what I’m doing before I do it.

Quality assessment: CASP Score (Max = 10)

9

Owens et al. (2020)

Study aims

To elicit the views of people who self-harm on the most commonly used outcomes measures. And to identify the outcomes that matter to them.

Setting (Country)

Hospital and community settings (England)

Participants

Adults with histories of self-harm (n=18). Age range 19-46 years. Gender: Male (n=4)

Methods

• In depth interviews.
• Thematic analysis using framework approach and visual mapping.

Definition/understanding of self-harm used within study

Self-defined by participants. Included suicidal and non-suicidal self-harm.

Summary of findings, themes, and concepts

Participant account challenged validity and meaningfulness of current trial outcomes measures. Five broad themes identified:

(a) Relationship between frequency and severity of self-harm

(b) Behavioural substitution

(c) Self-management skills

(d) The role of self-harm as a survival tool and affect regulator.

(e) Strategic self-presentation.

Outcomes that mattered to participants focused on positive achievements in three domains:

(a) General functioning and activities of everyday living

(b) Social participation

(c) Engagement with services

Quality assessment: CASP Score (Max = 10)

8

Steggals et al. (2020)

Study aims

To make a case for a sociological focus on the communicative, relational, and interactional dimensions of nonsuicidal self-injury.

Setting (Country)

Community setting. (England)

Participants

N=2. One adult, one teenager.

Methods

• Case study approach.
• Theoretical rather than empirical design.

Definition/understanding of self-harm used within study

Non suicidal self-injury as communicative.

Summary of findings, themes, and concepts

Authors present a sociological consideration of self-harm as a form of social communication.

Quality assessment: CASP Score (Max = 10)

8

Wadman et al. (2020)

Study aims

To explore young peoples’ views of harm minimisation strategies.

Setting (Country)

CAMHS, Children’s’ Social Care Services and the community (England)

Participants

Interview participants (n=45). Age range 11-21 years. Care experienced (n=24).

Methods

• Mixed methods.
• Online questionnaire.
• Semi structured interviews.
• IPA.

Definition/understanding of self-harm used within study

Self-defined by participants.

Summary of findings, themes, and concepts

Three themes identified:

(a) Harm minimisation strategies (as a proxy for self-harm) are perceived to be ineffective.

(b) Harm minimisation strategies are helpful (to some limited extent)

(c) Harm minimisation strategies as self-harm

Quality assessment: CASP Score (Max = 10)

8

Coronel (2021)

Study aims

To explore lived experience of self-harm in the context of school bullying.

Setting (Country)

Community setting.

Participants

Young people with experiences of bullying and self-harm (n=7). Gender: Male (n=2).

Methods

• Semi-structured interviews.
• IPA.

Definition/understanding of self-harm used within study

Self-harm as response to bullying at school.

Summary of findings, themes, and concepts

Themes identified:

(a) Dealing with rejection

(b) I felt like a pariah.

(c) Just get over it

(d) Identifying with icons

(e) Expressing self-hatred

(f) But, why me?

(g) I became my own bully.

(h) Screaming alone and in silence

(i) I isolated myself.

(j) I kept my secret.

(k) I needed a distraction.

Quality assessment: CASP Score (Max = 10)

10

Boyce (2021)

Study aims

To examine lived experiences of adults who self-harm.

Setting (Country)

Online setting. User-led forum. (United Kingdom)

Participants

Adult members of online self-harm forum (n=18). Age range 26-58 years (mean=32). Gender: (male n=3).

Methods

• Thematic analysis of open-ended survey responses.

Definition/understanding of self-harm used within study

Self-defined by participants.

Summary of findings, themes, and concepts

Responses grouped into five themes:

(a) Role of self-harm

(b) Support received.

(c) Experiences of sharing self-harm with others

(d) Stigma and shame

(e) Managing and lessening of self-harm

Quality assessment: CASP Score (Max = 10)

8

Chandler et al. (2021)

Study aims

To offer a sociologically informed, qualitative exploration of self-harm as a gendered practice.

Setting (Country)

Community setting (Scotland)

Participants

Small groups. (n=unknown).

Methods

• Arts-based approach.
• Group discussions.
• Thematic analysis.

Definition/understanding of self-harm used within study

Self-defined by participants.

Summary of findings, themes, and concepts

Gender as frequent presence- and absence- within discussions. Themes identified:

(a) Unsettling talk about gender and self-harm

(b) Violence and aggression

(c) Inside and outside

Authors call for more interdisciplinary explorations of self-harm, and greater use of arts-based and qualitative methodologies.

Quality assessment: CASP Score (Max = 10)

10

Guest et al. (2021)

Study aims

To explore young peoples’ experiences of the role and processes underpinning the use of alcohol in attempts to end their life.

Setting (Country)

Community setting (England)

Participants

Young people (n=7) aged 16-25 years. Gender: Male (n=1).

Methods

• Semi-structured interviews.
• IPA.

Definition/understanding of self-harm used within study

Suicide attempt.

Summary of findings, themes, and concepts

Superordinate themes identified:

(a) The complexity of relationships

(b) The double-edged sword of alcohol and substance use

(c) The straw that broke the camel’s back

(d) Reflecting on ongoing process of recovery

Quality assessment: CASP Score (Max = 10)

8

Miller et al. (2021)

Study aims

To improve understanding of young people who self-harm

Setting (Country)

NHS specialist child and adolescent mental health services (England)

Participants

Adolescent girls (n=9) aged 13-17 years.

Methods

• Semi-structured interviews.
• IPA.

Definition/understanding of self-harm used within study

Self-defined by study participants.

Summary of findings, themes, and concepts

Themes identified:

(a) Emotion regulation: Making internal feelings visible and concrete.

(b) An addictive urge: A powerful force that cannot be controlled.

(c) Self-harm to life – A battle to survive.

(d) Interpersonal relationships as triggers to self-harming

Quality assessment: CASP Score (Max = 10)

10

Mughal et al. (2021)

Study aims

To explore help-seeking behaviours, experiences of GP care and access to general practice of young people who self-harm.

Setting (Country)

Community and third sector (England)

Participants

Young people (n=13). Age range 19-25 years. Gender: Female (n=12), transgender male (n=1).

Methods

• Semi-structured interviews.
• Thematic analysis.

Definition/understanding of self-harm used within study

Self-defined by study participants.

Summary of findings, themes, and concepts

Three themes identified:

(a) Help-seeking avenues

(b) Barriers to seeking help from general practice.

(c) Facilitators to accessing general practice care

Quality assessment: CASP Score (Max = 10)

10

O’Brien et al. (2021)

Study aims

To identify how risk factors interplay in suicidal adolescents

Setting (Country)

Inpatient unit (United Kingdom)

Participants

Adolescents (n=20) who had attempted suicide in the two weeks prior. Gender: Female (n=15).

Methods

• In-depth interviews.
• Qualitative analysis.

Definition/understanding of self-harm used within study

Suicide attempt. Self-harm as emotional dysregulation.

Summary of findings, themes, and concepts

Interaction of interpersonal factors appears to distort cognition and/or elevate emotion to the point where they became intolerable. Interpersonal factors as catalyst in process from suicidal ideation to action

Quality assessment: CASP Score (Max = 10)

8

Polling et al. (2021)

Study aims

To better understand the paradoxically low rates of self-harm in a socioeconomically disadvantaged community in London.

Setting (Country)

Community setting (England)

Participants

Residents of the area (n=12). Age range 20 to 64 year.

Methods

• Interviews and focus groups.
• Qualitative analysis.

Definition/understanding of self-harm used within study

Self-defined

Summary of findings, themes, and concepts

Impacts of stressors on mental health were partly buffered by social resources related to community solidarity and culture of self-reliance. Identifying as mentally ill- and being known to have self-harm – was seen as risky, diminishing social status and exposing them to additional stressors from the community, services and the state.

Quality assessment: CASP Score (Max = 10)

9

Quinlivan et al. (2021)

Study aims

To explore patient and carer experiences of psychosocial assessments following presentations to hospital after self-harm.

Setting (Country)

Mental health trusts, third sector organisations, community. (England)

Participants

Patients (n=88) who had attended hospital following self-harm. Age range 18 to 75 years. Gender: Female n=72.

Methods

• Qualitative online survey.
• Thematic analysis.

Definition/understanding of self-harm used within study

Self-defined. Suicidal and non-suicidal intent.

Summary of findings, themes, and concepts

Themes identified:

Stage 1. Before the psychosocial assessment: What helped? Empathetic, supportive and humanising care What did not help? Waiting times/medically cleared; Emergency department environment; Stigmatising attitudes and poor medical care; Coercion and control.

Stage 2. During the assessment: What helped? Collaborative assessments and engaged communication; Space and time to talk; Recognition and reassurance; Help What did not help? Generic tick-box assessments; Intense and invasive questions; Unnecessarily repeating details; Stigmatising attitudes during the assessment

Stage 3. After the assessment: Hope, harm, help-seeking and engagement

Quality assessment: CASP Score (Max = 10)

9

Richardson et al. (2021)

Study aims

To explore male experiences of suicide attempts and recovery.

Setting (Country)

Community setting (Scotland)

Participants

Men who had attempted suicide (n=12). Age range 10-49 years.

Methods

• Semi-structured interviews.
• IPA

Definition/understanding of self-harm used within study

Suicide attempt

Summary of findings, themes, and concepts

Four master themes identified:

(a) Characteristics of attempt/volitional factors

(b) Dealing with suicidal thoughts and negative emotions

(c) Aftermath

(d) Protective factors

Quality assessment: CASP Score (Max = 10)

10

Rouski et al. (2021)

Study aims

To better understand the experiences of young people who self-harm while in care.

Setting (Country)

Community setting (England)

Participants

Care experienced young people (n=5) who had self-harmed. Gender: Male (n=2).

Methods

• Semi-structured interviews.
• IPA.

Definition/understanding of self-harm used within study

Self-defined by participants.

Summary of findings, themes, and concepts

Themes identified:

(a) The black hole of self-harm

(b) Seeking genuine care and containment

(c) The cry to be understood.

(d) Loss of control to the system

Quality assessment: CASP Score (Max = 10)

8

Walker et al. (2021)

Study aims

To determine patterns, prevalence and functioning of self-harm among women in prison through a mixed-methods study

Setting (Country)

Prison and community settings (England)

Participants

Women in custody (n=113). Age range 18 to 65 years.

Methods

• Mixed methods.
• Questionnaire.
• Semi structured interviews.
• Thematic analysis.

Definition/understanding of self-harm used within study

Self-defined by participants. Suicidal and non-suicidal intent.

Summary of findings, themes, and concepts

Motivations for self-harm in prison are complex. Triggers include past trauma, deteriorating mental health and separation from children or family.

Quality assessment: CASP Score (Max = 10)

9

Williams et al. (2021)

Study aims

To understand the processes underlying self-harmful thoughts and behaviours among LGBTQ+ young people.

Setting (Country)

Community setting (England)

Participants

Young LGBTQ+ people with experiences of self-harm (n=19). Age range 16 to 25 years.

Methods

• Semi-structured interviews.
• Thematic analysis.

Definition/understanding of self-harm used within study

Self-harm ideation and behaviours. With and without suicidal intent.

Summary of findings, themes, and concepts

Self-harm ideation and behaviours. With and without suicidal intent. Themes identified:

(a) Struggling with processing and understanding one’s own LGBTQ+ identity.

(b) Not having the words to describe feelings and thoughts associated with LGBTQ+ identity.

(c) Internalised hatred relating to LGBTQ+ identity.

(d) Coping with gender dysphoria

(e) Difficulties of medical transition

(f) Negative responses to being LGBTQ+

(g) Unaccepted and unsupported by family

(h) Life stressors

(i) Stress of feeling responsible for others

(j) Difficulties relating to physical injuries and illnesses

Quality assessment: CASP Score (Max = 10)

9

Woodley et al. (2021)

Study aims

To explore how those who self-harm manage their own risk.

Setting (Country)

Self-harm support group (England)

Participants

Attendees of a self-harm support group (n=10). Gender: Female (n=7) Age range 19-45 years.

Methods

• Semi-structured interviews.
• IPA.

Definition/understanding of self-harm used within study

Self-defined by participants.

Summary of findings, themes, and concepts

Themes identified:

(a) Why the risk is worth taking – ‘I don’t like self-harm, but it works’

(b) Practical risk management – ‘get the job done’.

(c) The social dimension of risk management – ‘it’s my self-harm’.

(d) The riskier side of self-harm- ‘I could easily have killed myself’

Quality assessment: CASP Score (Max = 10)

9

Aktar (2022)

Study aims

To investigate experiences of self-harming behaviour in Indian, Pakistani and Bangladeshi females.

Setting (Country)

Community setting (England)

Participants

Indian (n=1), Pakistani (n=4) and Bangladeshi (n=3) females. Age range 20-28 years. Total n=8.

Methods

• Semi-structured interviews.
• IPA.

Definition/understanding of self-harm used within study

Self-harming behaviours that inflict external injury to the body.

Summary of findings, themes, and concepts

Superordinate themes identified:

(a) Powerlessness: Entrapment; Internalised negativity; Abused by my environment

(b) Mitigation: Releasing my overwhelming emotions; Connecting to my pain; Addicted to self-harm

(c) Self-harm is wrong: It must be hidden; What have I done to myself? My self-harm is sinful.

Quality assessment: CASP Score (Max = 10)

10

Brown et al. (2022)

Study aims

To investigate experiences of shame in individuals who self-injury.

Setting (Country)

NHS Mental Health Services (England)

Participants

Female only sample. N=6. White British (n=3), Pakistani (n=3).

Methods

• Online diaries over a period of 2 weeks, following by semi-structured interview.
• Thematic analysis.

Definition/understanding of self-harm used within study

Non-suicidal self-injury.

Summary of findings, themes, and concepts

Themes identified:

(a) Hidden vs. exposed.

(b) Phenomenology of shame

(c) Controlling and combatting shame

Quality assessment: CASP Score (Max = 10)

10

Cully et al. (2022)

Study aims

To document patients’ experiences of engaging with healthcare services after presenting to hospital following high-risk self-harm.

Setting (Country)

Hospital or community setting. (England)

Participants

Adult participants (n=35). Gender: Female (n=18). Age range 18-68 years.

Methods

• Semi structured interviews.
• Qualitative analysis.

Definition/understanding of self-harm used within study

High-risk self-harm.

Summary of findings, themes, and concepts

Themes identified:

(a) Relationships with healthcare professionals: Supportive and compassionate relationships - - Someone to talk to; Unsupportive and superficial relationships.

(b) Continuity and comprehensiveness of care: Timely and comprehensive care; Care lacking in continuity and intensity.

(c) Psychiatric inpatient care: Inpatient setting as a ‘safe haven’; Reluctance to being admitted due to negative experiences or expectations

(d) Help seeking: Trust in services encouraging seeking help in crisis; Negative experiences with services inhibiting help-seeking

(e) Engagement with psychotropic treatment: Acceptance of, and adherence to, psychotropic treatment; Reluctance and lack of adherence to psychotropic treatment

(f) Connecting with other patients and peer support

Quality assessment: CASP Score (Max = 10)

9

John et al. (2022)

Study aims

To investigate experiences of individuals who survived an episode of near-fatal self-harm at the time of a highly publicised suicide cluster.

Setting (Country)

Community setting (Wales)

Participants

N=8. Gender: Female (n=2). Age range 23-49.

Methods

• Semi-structured interviews.

Definition/understanding of self-harm used within study

Near-fatal self-harm, any intent.

Summary of findings, themes, and concepts

Themes identified:

(a) The impact of the cluster

(b) Prevention and support

(c) Support prior to the self-harm event

(d) Emphasis on individual biography

(e) Stigma and help-seeking

(f) Long an short-term impacts of deaths

Quality assessment: CASP Score (Max = 10)

9

Marzetti et al. (2022)

Study aims

To understand young peoples’ suicidal thoughts and attempts.

Setting (Country)

Community setting (Scotland)

Participants

Young LGBTQ+ people (n=24), age range 16-24 years. Gender: Men or male (n=7).

Methods

• Loosely structured narrative interviews.
• Thematic analysis

Definition/understanding of self-harm used within study

Suicidal thought and attempts.

Summary of findings, themes, and concepts

Themes identified:

(a) Queerphobia as inescapably everyday: Cis-heteronormative community climates; Queerphobic bullying; Coming out and family responses

(b) Understanding suicide as a response: Queer entrapment and suicide as escape; Suicide as questioning existence

Quality assessment: CASP Score (Max = 10)

9

Mason et al. (2022)

Study aims

To explore processes which link self-disgust and attempted suicide in males.

Setting (Country)

Community setting (United Kingdom)

Participants

Men (n=9) who had attempted suicide. Age range 24-54 years. All white British.

Methods

• Semi-structured interviews.
• Grounded theory.

Definition/understanding of self-harm used within study

Suicide attempt.

Summary of findings, themes, and concepts

Three concepts identified:

(a) Self-disgust

(b) Worthlessness

(c) The endured emotional distress of ‘the abyss’

Quality assessment: CASP Score (Max = 10)

10

Quinlivan et al. (2022)

Study aims

To explore reasons why some patients do not receive psychosocial assessment following self-harm.

Setting (Country)

Mental health trusts and community organisations (United Kingdom)

Participants

Patients (n=88). Age range 17-75 years. Gender: Female (n=72)

Methods

• Qualitative survey.
• Thematic analysis.

Definition/understanding of self-harm used within study

Self-defined by study participants.

Summary of findings, themes, and concepts

Factors contributing to non-assessment.

(a) Patient factors:

(b) Organisational circumstances: Gateway issues; Hierarchy of risk

Quality assessment: CASP Score (Max = 10)

10

Sass et al. (2022)

Study aims

To explore experiences of people who self-harm and perspectives on help-seeking.

Setting (Country)

Community setting (England)

Participants

Individuals with experience of self-harm (n=14). Gender: Male (n=3). Ethnicity: White British or Irish (n=12), South Asian (n=2)

Methods

• Semi-structured interviews.
• Thematic analysis.

Definition/understanding of self-harm used within study

Self-defined by study participants.

Summary of findings, themes, and concepts

Support structures significantly impacted by lockdown. Lockdown presented relational issues for those who self-harm. Help-seeking impeded by feeling like a burden and potential for spreading the virus. People who self-harm exercised self-reliance response to ‘stay home’ messaging but many struggled without formal support. Online support services an important role.

Quality assessment: CASP Score (Max = 10)

10