Content note: self-harm, suicidality
Psychiatry defines self-harm as a harmful behaviour that causes physical damage to your body to manage ‘emotional dysregulation’. This means people with lived experience (LE) are seen to be avoiding or reducing negative emotions, controlling situations or memories of events. This understanding of self-harm guides clinical treatment, which aims to prevent, stop or reduce the behaviour.
However, I think about self-harm differently. For me, it is not a ‘negative’ behaviour, but a bodily practice that expresses my sense of myself, very much tied to experiences I have had with others1. It represents lots of things all at once: it is unhelpful and helpful, unwanted and wanted, my voice and my silence, self-care and -violence, a choice whilst also being passive to something that I don’t always understand. It is to be self-reliant whilst also seeking for recognition1. In this blog, I will be speaking about the first study I completed as part of my PhD, focusing on a critical perspective of self-harm.
My research
I have a dual identity of someone with LE of self-harm, mental distress and complex trauma, and as someone who has previously worked as a general nurse with people who self-harm. When I started my degree, I wanted the space to explore my understanding of self-harm. I was inspired by the following quotation, shared by two survivor researchers: “We could not recognise ourselves in the body of clinical work on self-harm”2. However, I also was aware that as a (LE) researcher and nurse, I hold a position of great privilege by being thought of as ‘credible’. To avoid taking information from others through my research, without offering anything of myself back, I conducted an autoethnography. This research method positions the researcher as the main source of data: they use their own experiences to understand, in my case, mental distress. I did this by reading over my personal diaries (from when I was 13) and medical notes from when I was under secondary mental health services. I reflected on these to produce brief descriptions. I focused on events that I felt to be important, including my relationships with others and feelings about self-harm. I also read about the LE of others with self-harm by reading autobiographies and relevant literature. I will now summarise some of my main findings, looking at my lived and professional experiences.
My findings
Becoming a self-harmer
Self-harm originated from relational conflict both at school and home. These experiences introduced and maintained my desire to be good, worthy and self-contained. I wanted to protect others, hide myself and not be ‘too much’. I struggled to speak about self-harm because I was worried I was different. This was reinforced by witnessing people saying homophobic things at school where I learned that being queer equals being ‘bad’. I downplayed my self-harm, even to myself, because I learned that being quiet and private about your distress, and feelings, is more appropriate than shouting about it. Therefore, for me, self-harm is not just on me but exists between myself and others. It tells me about who I am and my place in the world. It expresses my fear of and need for closeness, vulnerability and disconnection. Psychiatry (briefly) acknowledges abuse and trauma as ‘predisposing’ factors to explain self-harm. However, there is often a failure to consider the ‘colour’ of difficult experiences, how they affect the person’s relationship to themselves, others and the world. Another aspect that is neglected is how difficult experiences are also linked with and maintained by social ideas of what is normal, and what is not.
The emotional world of self-harm
People with LE are seen to be ‘unable’ to recognise and manage emotionality. Engaging in self-harm is therefore seen to manage overwhelming emotions, that are seen as being separate, like “stressed”, “sad”, “angry”. However, that has not been my experience of myself. Instead, I often feel at the mercy of an immersive storm:
“… there is no beginning, middle or end (…) I feel like it is never going to end (…) it is like my brain contains lots of endless pieces of tangled up string – or perhaps (…) different coloured some twirling around one another – but there is no solidity to them” (Diary excerpt, 7th of December, 2016).
Similarly, other people with LE may describe feeling ‘a lot’ or ‘so much at once’, and so self-harm to ‘quiet the cacophony’. This could be described as ‘panic’. However, by simplifying it, we miss that not everyone may experience ‘panic’ in the same way. This also fails to consider how society itself forces people to think of some emotion as ‘acceptable’ (e.g. happiness) but others to be ‘unacceptable’ (e.g. anger).
‘Proper’ self-harm
Self-harm drew “a line in the sand”3: it made me feel balanced, it made me feel like I was good, not bad, and aided productivity. However, I also felt that self-harm showed me that I was a failure in self-managing, and constantly felt on the verge of making mistakes. In seeking to be ‘good’, I tried to self-harm ‘properly’. These ideas of ‘proper’ self-harm are maintained in healthcare, where it is still described as ‘superficial’ to ‘severe’. This hierarchy also affected how I thought of myself when I developed eating distress: “If I weigh ‘too’ much, then it would mean I wasn’t sick anymore and then I wouldn’t be deserving of help and treatment” (Diary excerpt, 1st of February 2023).
Professional interpretation of self-harm
When I worked on a psychiatric unit with people with eating distress, pacing was identified as ‘anorexic’. I felt confused, because it seemed to me that self-harm was a ‘sane response’ when “people are gagged (…) yet expected to behave in a controlled manner”4. However, people with self-harm seem to be othered from ‘normal’ people who cope ‘appropriately’. This meant when I worked on the unit, eating distress was treated as a problematic ‘symptom’ that could be stopped through behavioural and chemical restrictions. Other more implicit restrictive practice, like psychologically policing people with LE, ensured they adhered to their ‘treatment’.
I was luckier when I experienced eating distress: I was supported to (re-)learn self-care. If I had been forced to adhere to the control of a ‘rational’ clinician, I would have felt a greater pull towards self-harm to regain my sense of self and safety. Unfortunately, however, restrictive practice becomes justified as in the person’s ‘best interests’. Through this, clinicians retain their morality and good self-image, without thinking of what long-lasting harm it may cause.
Becoming a ‘mentally unwell patient’
Whilst working as a nurse, I descended into crisis. However, I suppressed what I was experiencing. I think this ‘suppression’, far from ‘maladaptive avoidance’, came from the fact that no one ever really told me that my distress was an understandable response to experiences throughout my life. The result was I became suicidal, and I increasingly used self-harm to “kill off” certain experiences. Self-harm was also a comfort: I could rely on it when nothing else helped and thinking about it got me through the day.
When I was under secondary care, I tried to feel ‘worthy of support’4. Therefore, I downplayed distress, avoided being emotional volatile, stopped self-harming, because it’s ‘bad’, and described my distress in clinically palatable language. Some experiences of trauma were referred to but my lasting memory is that they were never centred as most important. Instead, I was diagnosed with moderate to severe depression (Excerpt from medical notes, 21st of December 2020). So, I learned that I was made up of many symptoms that could be cured: I was unwell, I was different, but I could be better.
Towards a LE understanding of self-harm
In engaging with my lived and professional experiences of self-harm, as well as with the wider literature, I suggest that people with LE may experience all-encompassing emotionality, so that “it feels really big in my head” (Diary excerpt, 20th October 2022), is moulded with and through difficult experiences with others. This may result in feeling disconnected from oneself, other people and the world. Self-harm then:
- creates a sense of ‘wholeness’, or balance, signifying this sense of division and working with a sense of being ‘bad’
- marks conflict by visibly making distress ‘real’
- creates self-care and recognition from oneself and from others
- creates a boundary, protecting against loss and vulnerability whilst also seeking for meaningful connection
Overall, this de-medicalised way of looking at self-harm considers it more as a dynamic process, a bodily representation of social distress that engages with oneself and one’s experiences, substantiating what has happened to you where other people cannot or have not. By only relying on medical narratives, we judge people with self-harm needlessly, reinforcing their beliefs that they are different, damaged and beyond help. If we were instead to truly try and see them, who they are and what has happened, and is happening, to them, we may contribute to healing.
This blog summarises a published article written by Caroline as part of her PhD. It is the first study in her doctorate, called “Why can’t you just be fine?” An autoethnography of self-harm from a lived experience and nursing perspective. Content warnings: the article itself has more detail about self-harm methods and suicidality than the blog does.
C.C. da Cunha Lewin (she/they) is a PhD student, general nurse and lived experience researcher at the Service User Research Enterprise (SURE), King’s College London. Through her PhD, she is interested in developing LE-centred knowledge about self-harm, thinking more about how mental distress can be thought of a social and relational issue, rather than an individual ‘problem’. More information about her work is accessible via this link. Their work is supported by the ESRC, LISS DTP (grant number ES/P000703/1). The funding source was not involved in the research.
References
- Heney (2020). Unending and uncertain: Thinking through a phenomenological consideration of self-harm towards a feminist understanding of embodied agency. PDF accessible here: https://www.semanticscholar.org/paper/Unending-and-uncertain%3A-thinking-through-a-of-a-of-Heney/e6370d0c7f4bb953d8d1f61748370d7f40eb97bd
- Donskoy & Stevens (2013). Starting from scratch: An exploration of the narratives of the first episode of self-wounding. PDF accessible here: https://www.researchgate.net/publication/263611482_Starting_from_scratch_An_exploration_of_the_narratives_of_the_first_episode_of_self-wounding
- Kettlewell (1999) Skin Game, autobiographical non-fiction account of self-harm.
- Pembroke (1996) Self-harm: Perspectives from personal experience. PDF accessible from: chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/http://studymore.org.uk/shpfpe.pdf