Monthly Archives: November 2012

Self Harm – written for the US Network – Wales

ÜS NETWORK POLICY ON

SELF-HARM

Researched and written by Elspeth M Parris, DipSW, Service User
Under the direction of the
ÜS NETWORK
(All Wales User and Survivor Network)

ÜS Network working Paper No 5: 1999

Endorsed by the National Self Harm Network

SCARS

Cuts that don’t stop bleeding.
Wounds that don’t heal up.
Flesh that is open.
Skin that is dying –
Tears that never stop crying.

This is the pain we must endure.
This is the pain with no cure.
We try to stop cutting.
We try to be formal –
Sometimes we even try to be normal.

Lloyd Scully

(from ‘A Touch of the Winds’ – An anthology of work by the writers group of the 4Winds Association – Cardiff 1997)

Published by:
ÜS Network (All Wales User and Survivor Network)
Suite 3, 1 North Parade, Aberystwyth SY23 2JH
Tel: 01970 626230 Fax: 01970 626233
Users Freephone: 0800 216008
e-mail: US@usnetworkcymru.demon.co.uk

Thanks and acknowledgements
This policy could not have been written, or would at least have been vastly different without the help of a number of individuals and organisations. Of the organisations, particular mention must be made of the National Self Harm Network whose various leaflets have been particularly informative and which have been a source of many references. In terms of individuals, most important are those people who have personal experience of self-harm who have talked with me, shared with me some of their experience and given me a sense of reality checking as I wrote. In particular, members of what may in time become a self-harm support group in Newtown, Powys should be mentioned here, and in Cardiff, Ruth who checked and added to the written text and especial thanks to Lloyd who kindly gave permission for inclusion of his poem.

Contents
Introduction
1. Addressing the myths
1.1. What self-harm is and what it is not
1.2. Who self-harms
1.3. Ways of self-harming
2. What happens how
2.1. Attitudes in society
2.2. Support
2.3. In a crisis
3. Discrimination, Equal opportunities and Language
3.1. Discrimination associated with self-harm
3.2. Language
3.3. Culture
4. The need for change
4.1. Public education
4.2. Training for health, social and education workers
4.3. Support services
4.4. Crisis services
5. Resource List
5.1. Organisations
5.2. Publications

Introduction
The ÜS Network is an organisation of people, who use or have used mental health services, working for us all to have more control over our lives and the services which we need to manage our mental health.
The ÜS Network (The All Wales User and Survivor network) decided at its AGM in 1998) to have a policy on self-harm by September of 1999. This policy to be based on the view of self-harm held by the National Self-Harm Network. In order to produce this policy, I have read the materials provided by the National Self-Harm Network and taken into consideration the points of view demonstrated by a wide range of books. Most importantly, I have consulted with people who self-harm here in Wales to ensure that the policy addresses issues which are real here. I have also liaised Awetu, the black mental health befriending service in Cardiff to try to understand the issues for ethnic minorities in terms of self-harm.

Elspeth M Parris

Self-Harm and Society
Self-harm is a hidden subject in our society. There is enormous pressure on each of us to present ourselves as being all right and able to cope. This can act as an invalidation of emotional and mental distress and denies us all the right to be distressed in response to painful events.
Causes of emotional distress also tend to be hidden subjects. The existence of child abuse is now being more widely acknowledged but the long term effects are on the whole ignored. Where abuse is acknowledged as an issue for society it is often in terms of child protection and is usually specific to physical cruelty or sexual abuse. The effects of emotional abuse and invalidation of the child’s right to ownership of their own developing body and personality is hardly mentioned in the public media and receives comparatively little mention in those books which deal specifically with abuse.
Other issues which can cause deep distress are also ignored. Reading literature concerned with Post Traumatic Stress one would think that only major trauma received in some form of public service or mass event is truly distressing. The fact is that these forms of trauma are more socially acceptable. Long terms homelessness and domestic violence among many other issues can be causes of major distress and in general it is not socially acceptable to talk of these things, nor are they acknowledged as causing anything other than immediate distress.

Living with a distress issue in a society which denies distress is not easy. Our emotions are invalidated even further in most of our social contacts. In a world where expression of distress is at least unwelcome and frequently unacceptable there has to be an outlet. There is a book called ‘The Bright Red Scream’ (Marilee Strong); the title says a lot – expressing the concept that self-harm (in this case cutting) is a way of screaming in a world which doesn’t even permit us to cry. While individual self-harm is often very private and should not be treated as ‘attention seeking’ the issue of self-harm can be considered as a cry of distress calling for validation and support.
It is more convenient to society to leave us to turn our anger and pain on ourselves rather than out onto the situations and people who have caused it. It is more convenient to dismiss people who self-harm as ‘attention-seeking’ than to consider the attention which is needed and provide services which are appropriate for self-harm and the underlying problems.
In producing this policy, the ÜS Network is acknowledging the pain experienced and paying attention to the issues. In section 4, ‘The need for change,’ the attention of service providers and funders is drawn to the services which are needed. Provision of services is not, however the only change needed, but for as long as we live in a society which does not acknowledge emotional pain, such services will continue to be needed and are at present little available.

1 Addressing the myths
Probably the most powerful myth about self-harm is that it is attempted suicide by people who aren’t very good at it or who want, rather than to kill themselves, to attract attention to their distress by appearing to try to kill themselves. This is not only a demeaning attitude, it also denies the reality of the majority for whom self-harm is a survival strategy, a way of coping with staying alive. Those who self-harm and are alive are survivors.
Another myth is a concept coming from America, that self-harm is a fashion amongst the young, similar to tattooing or wearing clothes that attract adult disapproval. While elements of some subcultures have heightened public awareness of this issue, that does not make self-harm a fashion.

1.1 What is self-harm:
• a way of being in control
• a way of externalising internal pain
• a way of defining one’s own boundaries
• a way of recognising oneself
• a way of reclaiming ownership of one’s body
• a way of releasing inner tension
Self-harm can also be:
• a response to hearing voices
• a response to feelings about particular parts of the body
• a way of communicating with self, voices or others
• a form of self-punishment
• a way to cry with blood when crying with tears is blocked
Self-harm is not:
• A fad or fashion
• A failed suicide attempt
• A ‘cry for help’
• About enjoyment of pain – for many it doesn’t hurt at the time – or it may be more painful

1.2 Who self-harms
• 1 in every 130 people
(Guardian, quoted by National Self-Harm Network)
It seems likely that this statistic is lower than the reality, the fact that many self-harmers consider their self-harm to be a very private matter combined with the stigma associated with mental health problems in general and self-harm in particular means that many may not choose to declare their self-harm.
• More women than men
There are two gender issues concerned in self-harm. Firstly, there seems to be an effect in society which makes women more vulnerable to this problem. In recognition of this, services for self-harm tend to have arisen within the women’s movement and those men who self-harm find themselves excluded from both service and recognition that this is their problem too. Recently, it has been found that the gender imbalance among people attending accident and emergency departments for self-harm has reduced.
• People who’ve suffered a variety of abuses…or not
Certainly, it seems to be true that the majority of people who self-harm have suffered some form of major emotional trauma. Whether or not that experience constitutes a form of abuse is a matter for the individual. There is a myth that self-harm is always associated with sexual abuse which belittles those who have experienced other forms of trauma and denies people the right to come to their own conclusions as to the effect of their life experience on their current behaviour.
• People who hurt
It seems undeniable that people who self-harm are expressing a feeling of being distressed.

1.3 Ways of self-harming
• Cutting
• Burning
• Overdosing
• Inserting/swallowing objects (e.g. Glass, coins etc.)
• Eating distress can come within self harm
• Drugs and alcohol can be used to self-harm
• Biting and scratching
• Bashing and bruising
• Hairpulling (trichotillamania)

It is generally felt that it is the intention to hurt oneself which defines self-harm rather than the actual behaviour. Some self-harmers report difficulty in gaining recognition of the nature of the problem because the nature of the pattern of their self-harming behaviour is subtle ad hidden – as scars can’t be seen the patter of self-harm is harder to recognise. A lot of behaviours which are common and even necessary can be used as self-harming behaviour e.g. work or sex. A tendency to make oneself vulnerable to abusive relationships could be seen as a form of self-harm.

2 What happens now
What happens at the moment when people are faced with the fact that someone self-harms is that they see the myths rather than the person or the particular self-harming strategy. As a result, the individual gets little attention for the real issues. In combination with this there is the tendency within the mental health service to allocate service according to diagnosis; some self-harmers hear voices and are liable to receive a diagnosis of schizophrenia while others tend to get the label of ‘personality disorder.’ The diagnosis of Borderline Personality Disorder although not intended to be gender specific tends to be used as such and is often given to women who self-harm. These labels may have little meaning to the individual but have an effect on the service received.

2.1 Attitudes in society
People who self-harm hear a lot of negative attitudes suggesting that they are immature, attention-seeking time-wasters. If people were attention-seeking it could perhaps be useful to point out that there is very little attention given to the problem of deep-seated emotional pain which seems to underlie self-harm and perhaps some attention should be paid to this. In fact, most people try to be very private about their self-harm, sometimes to the extent of not seeking medical help, and if they wanted attention would try to ask for it in more appropriate ways, although they may feel they are not allowed to do so.
2.2 Support
At present, support is almost non-existent for people who self-harm. Some women’s groups are trying to provide support but there is a lack of funding and naturally this does not support the needs of men. Therapy groups run by a psychotherapist may exist in some areas.
Where people who self-harm have associated support needs such as mental health or housing support there is generally little understanding of self-harm and the same negative attitudes are presented which apply in society in general. People have been known to be refused mental health support or housing support unless they stop self-harming. As this is not in general a realistic choice, removal of what little support there is cannot be helpful.
Support for deep-seated emotional pain is also almost non-existent. There are sometimes support groups for abuse but these

Are generally for women and for sexual abuse specifically. For a man, or for anyone for whom some other source of pain is the most important issue there is little other than private counsellors, who in general cost money. There are schemes which provide funding for private counselling, but they are underfunded with long waiting lists and availability for a limited number of sessions. The provision of counsellors in GP surgeries is a very helpful idea for some but they are not thought to have the necessary expertise and like free service counsellors, availability is limited. Additionally, in rural areas, where communities are very close, there are concerns about confidentiality in using GP counsellors.

2.3 In a crisis
There is almost nothing in the way of crisis support. General helplines like the Samaritans are used but found patchy in terms of understanding of self-harm. There is a support line specific to self-harm available for women, (Bristol Women’s Crisis Line) but it is only available at limited times and there is nothing specific to Wales. A crisis line was made available for self-harm in South Wales for a short time (Cardiff Women in Mind) but this was for women only and ceased due to limited resources.
Casualty departments in General Hospitals are usually the first line of support and here the attitudes are often unhelpful or even abusive. Refusal of local anaesthetic has been known where it would have been offered if the injury were not self-inflicted. The usual attitude is that self-harm is a waste of casualty tie and as a result service is often brusque and without sympathy. Refusal of service is, unfortunately, commonplace.

3 Discrimination, Equal opportunities and Language
3.1 Discriminations associated with self-harm
Although many people do their best to hide their self-harm there is discrimination when it is perceived or is admitted, as is necessary if support is to be received. Much of the discrimination which occurs in services which support people with general problems such as housing, however there is discrimination in other areas most importantly in employment. The Clothier report, written in response to fears of risk to patients from nurses with mental health problems requires that nurses must have been free of problems and without support for two years before they can become eligible for employment or re-employment. This can act to deny employment to those who self-harm and it can also act to prevent those who self-harm who are working in the NHS from seeking support or getting crisis services such as are available from casualty departments. People who self-harm do not pose any particular risk to others.

3.2 Language
Since services for self-harm are so limited it would seem that any service would be a good thing. A service, however, which is not provided in the service users’ own language does not help very much at all. This is an area where the ability to talk about emotions and painful experiences is very important and even where the individual speaks excellent English they may not feel comfortable doing so in this context. It should also be noted that words and phrases do not always translate exactly and different languages represent different thinking patterns – even if a discussion is conducted in English, if this is not the self-harmer’s first language then miscomprehension may occur. In this context, the Welsh language deserves especial mention since, in Wales anyone should have the right to expect that they can speak Welsh in any context. Other languages should be provided where communities speaking them exist or on a national basis where people are scattered. Where a self-harm service is offered which linguistically excludes specific communities, liaison with organisations which serve those communities is particularly important.

3.3 Culture
What is considered normal in one culture may be considered as self-harmful in another. It should be recognised that people may be exerting their right to define their cultural identity in ways which may appear to be self-harming. On the other hand, since self-harm is defined here by motivation, a cultural acceptance of an injurious behaviour could be used as a disguise for self-harm. People should be allowed to define for themselves whether or not their behaviour is self-harm. Examples of cultural identification which may be seen as self-harm can be seen from the traveller community where body-piercing is popular and from some African cultures where facial markings can be of importance. People should not be denied the right to claim their cultural identity where it harms only themselves, nor should they be forced to accept harm to themselves in order to do so if they do not wish to. It is important to recognise that the impact of racism and homophobia can precipitate self-harm.

4 The Need for Change
4.1 Public education
There is a need to address the myths across society so that self-harm will be better understood wherever it is met, in families, in work, in schools and amongst friends. This should however, be tackled with care and sensitivity, some self-harmers report that public education campaigns on subjects painful to themselves can act as triggers. Billboard advertising is seen as the worst case as it could impact on an individual already sensitive to the issue while driving, whereas at least a television can be turned off. Organisations like the NSPCC who conduct public awareness campaigns on child abuse could be informed of this.
4.2 Training for health, social and education workers
People working in these fields (including those whose work is not defined as nurse, social worker or teacher) are likely to come into contact with people who self-harm. Current experience is that there is little understanding in these fields and where support could reasonably be expected, negative and unhelpful attitudes are often met. Training could be targeted toward individuals working in these fields to enable a better understanding, This would require funding and organisations seeking to offer training should ensure that the training used has been sourced from the experiences of those who self-harm rather than purely from those whose expertise is external to the situation. The use of survivors of self-harm by training providers would be ideal.

“According to the perspective of the National Self-harm Network the concept of harm minimisation is vital, accepting the need to self-harm as a valid method of survival until survival is possible by other means. This does not condone or encourage self-injury. It is facing the reality of maximising safety in the event of self-harm. If we are going to harm, it is safer to harm with information than with none.” Louise Pembroke, 1999
4.3 Support Services
• 24 hour crisis line – specific to self-harm and Wales
• Counselling – should be freely available to all who have need for it and from a variety of sources. Some would be happy with

Counselling more widely available from GP surgeries, some with counselling provided by mental health workers. Some people would have problems with either or both of these. There are some highly trained private counsellors available and if these were funded via the NHS this would satisfy most people’s needs. Counselling should not be limited to the short term as the emotional problems involved cannot be dealt with in a few sessions.
• Self-help groups – people who self-harm can feel isolated and crazy, feelings which can be reduced by meeting others who cope with distressing feelings or situation in similar even if not the same ways. Some people who self-harm would argue personally and politically that these should be facilitated by survivors of self-harm rather than ‘professionals’ but even if a meeting others who have or do self harm is. Although such groups should be available if they are poorly facilitated they can exacerbate existing problems. Support networks would also be helpful.
• Crisis cards and advance directives may have a role to play here, setting out how people would like to be treated when they have self- harmed.
All and any services provided should be available by choice rather than requirement. Self-harm is associated with feelings of powerlessness and removal of choice can reinforce the problem.
4.4 Crisis services
• Casualty – provision of a psychiatric liaison nurse in casualty units may be helpful for some, where provided, on the hand, some people may be put off from approaching casualty departments if a mental health assessment is necessarily part of the process. A specific self-harm service within casualty in each area would be more useful, providing the option of a mental health assessment as one of a variety of forms of support which can be freely chosen. Where there are people with personal experience of self-harm willing to assist in a self-harm unit as employees or volunteers, this should be made possible and emotional support should be provided for them if desired, the provision of advocacy in Accident and Emergency departments

Would be important, ensuring that people are able to receive an appropriate service.
• A safe place to go – Many people in the mental health service have talked about a need for some kind of refuge – a staffed, non-medical place to go and be cared for. I f available, this would be suitable for self-providing mutual support, however, some people feel that putting them together with others who self-harm might make the problem worse. Extension of a system of ‘accredited accommodation’ available in Newtown, Powys is seen as more helpful. This would provide individual support in a household with an understanding person.

5 Resources
5.1 Organisations
Organisations are included which are either Welsh, or have a presence in Wales. Organisations in England are also included where they may be of use to people in Wales and there is no Welsh equivalent.

National Self-Harm Network
Survivor-led organisation committed to campaigning for the rights and understanding of people who self-injure.
PO Box 1619, London NW1 3WW

Bristol Crisis Service for Women
Has a focus on self-injury and provides a national help-line for women in distress: Friday/Saturday 9pm to 12:30 am 0117 925119
BCSW, PO Box, Bristol BS99 1XH

Pen-friend Network – SASH – Survivors of Abuse and Self-harming
Offers support and friendship on a one to one basis in writing.
SASH, 20 Lackmore Road, Enfield, Mddx EN1 4PB

MINDlink
Organisation linked to MIND for people with personal experience of mental health problems.
MIND, 15-19 Broadway, Stratford, London E15 4BQ

Basement Project
Provides training, consultation, supervision, groups, workshops and publications for individuals and those working in community and mental health services; specialises in self-harm.
PO Box 5, Abergavenny NP7 5XW Tel: 01873 856524

Survivors Speak Out
A network of mental health system survivors, groups and allies.
34, Osnaburgh Street, London NW1 3ND
Tel: 0171 9165472

Hearing Voices Network
A network of people who hear voices
c/o Creative Support, Fourways House, 16 Tariff Street, Manchester M1 2EP

UKAN (UK Advocacy Network)
A co-ordinating network for user-led advocacy groups
Room 302, Premier House, 14 Cross St, Sheffield S1 2HG

NSPCC
Free 24hr help-line for abused children, families and survivors.
Has information on local resources.
Tel: 0800 800500

Childline
24hr help-line for children and teenagers
Tel: 0800 1111

Survivors
Helpline for male victims or survivors of sexual violence.
Mon, Tues, Weds, 7-10pm. Tel: 0171 8333737

Welsh Women’s Aid
Advice, help and information for women suffering from domestic violence.
Access to refuge in most areas.
38-42 Crwys Road, Cardiff Tel: 01222 390874

WISH – Women in Special Hospitals
Head Office, 15 Great St Thomas Apostle, London EC4V 2BB
Tel: 0171 3292415

Wales MIND
3rd Floor, Quebec House, 5-19 Cowbridge Road East, Cardiff CF11 9AB
Tel: 01222 395153
Information Helpline: 0845 7660163
User Development Project: 01597 825528

42nd Street – A mental health youth service (15-25yrs) specialising in self-harm and suicide.
2nd Floor, Swan Buildings, 20 Swan St, Manchester, M45 JW
Tel: 0161 8320170

To find out what’s going on in your area, or to find support to start a local group, contact US Network, Mind User Development Project, or your local mental health development project:

Cardiff and the Vale Mental Health Development Project:
G.A.V.O. (Newport)
West Glamorgan Mental Health Forum
Powys Agency for Mental Health
Unllais (N.E) (holywell)
Unllais (N.W.) (Bangor)
Dyfed Association of Voluntary Services
B.A.V.O (Bridgend)
InterLink (Pontypridd)

5.2 Publications
There is a wide range of books available on mental health issues in general, including those which are specific to depression, hearing voices, experience of abuse, and experience of the mental health services, many of which may be relevant to self-harm. There is not, however, space to include all of these here; libraries, good book shops, local mental health and women’s projects, the Mind publications list and the National Self-Harm Network’s resource list can all be used as sources of information on such books. The books included here are, in general, specific to self-harm.

Newsletters

SHOUT
(Self-harm overcome by understanding and tolerance)
Newsletter for women who self-harm

c/o PO Box 654 Bristol BS99 1XH

WAVES
Women making waves about abuse
Newsletter for women who have experienced abuse
c/o 82 Colston St Briston BS1 5BB

Books listed below marked A/M may be available from other sources including, in many, direct from the publisher but are definitely available:
A Over the internet via Amazon.co.uk
M via Mind Mail Order Service. 15-19 Broadway. Stratford, London E15 4BQ The address for Good Practices in Mental Health is 380-384 Harrow Rd, London W9

BOOKS

Women and Self-harm Gerrilyn Smith et al. Women’s Press 1998AM
Report of a Review by HM inspector of Prisons…Self Harm in Prison…Self-Harm Stephen Tumin The Stationary OfficeA
Self Harm Louise Pembroke Survivors Speak Out 1994A
Self-Harm Help Book Lois Arnold The Basement Project 1998A
Suicide & Deliberate Self-Harm Alison Faulkner Mental Health Foundation 1997A
Suicide & Deliberate Self-Harm N.E.J. Wells Office of Health and Economics 1981A
A Bright Red Scream: Self Mutilation and the Language of Pain Marilee Strong Penguin, 1991A
The Language of Injury Babiker and Arnold BPS Books, 1997M
Who’s hurting Who? Young People, Self Harm and Suicide Helen Spandler 42nd Street, 1996M
Cry of Pain – understanding suicide and self-harm Mark Williams Penguin 1997M
Cutting – Understanding & over-coming self-mutilation Steven Levenkron WW Norton, 1998M
National Self-Harm Network Information pack NSHN Available from NSHNM
The Hurt Yourself Less Workbook NSHN Available from NSHNM
Viscious Circles An exploration of women and self harm in society Diane Harrison Good Practices in Mental Health
Cutting the Risk – self-harm, self care and risk reduction NSHN Available from NSHN

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