Journal of Psychiatric and Mental Health Nursing, 2013, 20, 105113

We are all in this together: working towards a holistic

understanding of self-harm
M. LONG1 ba hons msc, R. MANKTELOW2 ba msc phd &
A. TRACEY3 phd hpc registered practitioner psychologist
1

Lecturer, School of Communication, University of Ulster, Jordanstown Campus, Newtownabbey,

Lecturer, School of Sociology and Applied Social Studies, and 3Lecturer, School of Psychology,
University of Ulster, Magee Campus, Derry, UK
2

Keywords: language, religion,

self-harm, stigma, suicide
Correspondence:
M. Long
School of Communication
University of Ulster
Jordanstown Campus
Shore Road
Newtownabbey BT37 0QB
UK
E-mail: m.long@ulster.ac.uk
Accepted for publication: 4 February
2012
doi: 10.1111/j.1365-2850.2012.01893.x

Accessible summary

This paper has been informed through systematic literature searches of research
databases and core texts on the subject of self-harm.
Despite the increase of self-harm, stigma and misunderstanding surround the issue,
which often compound the sense of emotional pain felt by those people who are
affected by self-harm.
Gaining an understanding of the cultural, historical and religious origins of selfharm can illuminate the ways in which self-harm has evolved with us as part of our
humanity.
This paper aims to increase understanding of self-harm, and by doing so to question
commonly held assumptions and foster more empathic responses to self-harm
among practitioners.

Abstract
Self-harm is a widespread and controversial issue in contemporary society. Statistics are
based on reported incidents and therefore do not accurately reveal prevalence, as
self-harm is often a hidden behaviour. This highlights the essential need for practitioners and society to work towards reducing the stigma surrounding self-harm. This
paper goes some way towards understanding the impact of self-harm on individuals
and communities. It begins by exploring terminologies and definitions of self-harm and
discusses the importance of sensitivity in language use relating to self-harm. It continues by examining types of self-harm and subsequently presents life experiences that
may contribute to the onset of self-harm. The paper elucidates the cultural, historical
and religious origins of self-harm, indicating the ways in which self-harm has evolved
with us as part of our humanity. Moreover, literature relating to the significance of
stigma and attitudes is examined, followed by issues around psychiatric diagnoses
pertaining to self-harm. The paper concludes by synthesizing literature relevant to the
relationship between self-harm and suicide.

Background
Evidence suggests that self-harm in the form of selfpoisoning and self-injury is the reason for 170 000 hospital
presentations in England and Wales each year (Hawton
2012 Blackwell Publishing

et al. 2007). Moreover, there are around 11 000 presentations of self-harm annually to hospitals in the Republic of
Ireland (National Suicide Research Foundation Ireland
2006). Self-harm is responsible for over 7000 hospital
admissions per year in Northern Ireland and this figure
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M. Long et al.

increased by 9% between 2000 and 2006 [The Department

of Health Social Services and Public Safety in Northern
Ireland (DHSSPSNI) 2006]. As these figures are based on
reported incidents they do not reveal the true scale of the
problem, as self-harming behaviour is typically hidden and
therefore difficult to measure accurately. It is evident that
self-harm is a significant public health issue throughout the
UK and Republic of Ireland and that its occurrence may be
escalating.
The social stigma that surrounds self-harm renders it
much more complex in terms of identifying the scale of the
problem as well as understanding the true nature of the
self-harming population and individual motivations for
the behaviour. A common myth surrounding self-harm
implies that it is attention-seeking behaviour, in the derogatory sense (Fox & Hawton 2004). The fact that many
people who self-harm do so in secret and rarely disclose or
ask for help dispels the myth that it is used for secondary
gain (Turp 2003, Fox & Hawton 2004, Mental Health
Foundation 2006). Self-harm is often understood to be an
adolescent phenomenon; while the age of onset is typically
reported as around 13 or 14 (Klonsky & Muehlenkamp
2007), evidence suggests that self-harm reaches far beyond
the confines of adolescence (Chan et al. 2007).
The stigma, myths and lack of understanding that foster
burgeoning resentment among others can perpetuate the
cycle of shame and guilt among people who self-harm,
which subsequently increases their dependence on the
behaviour. Consequently, the majority of people who selfharm never present to formal health services (Ystegaard
et al. 2008). In health services, patients who self-harm are
often perceived to be particularly difficult or demanding
(Schoppmann et al. 2007). The negative and discriminatory notion that the behaviour is a waste of time and
resources can exist among staff (Simpson 2006).

Search strategy
The paper analyses contemporary literature, which is
informed by ongoing systematic literature searches of
electronic databases including PsychARTICLES, PsychCRITIQUES, PsychINFO, MEDLINE and the Cochrane
Library as well as rigorous manual literature searches of
relevant articles and core texts (see Appendix I). Searches
have been ongoing from 2008 to the present time.

Terminology
Types of self-harm may present in various ways and hold
multiple meanings for each individual who enacts the
behaviour. Self-harm is a general term that refers to a range
of more specific self-harming behaviours including: self106

poisoning (overdose with or without suicidal intent) and

self-injury (self-cutting or self-burning). Some scholars
employ the term deliberate self-harm or DSH. Other
writers deem this to be insensitive and inappropriate terminology (Pembroke 1996, Allen 2007). Allen (2007,
p. 174) suggests, . . . the use of deliberate as a prefix to
self-harm is not only redundant but could also convey a
somewhat pejorative belief that the person could refrain
from doing this if he or she tried. Consequently, use of the
term deliberate self-harm will not be adopted in this paper.
Numerous terms are used to describe acts of self-harm
including parasuicide, self-mutilation, self-laceration, selfinjury or self-injurious behaviour. Kreitman (1977) coined
the term parasuicide, to refer to non-fatal acts of deliberate
self-harm. According to the Oxford English Dictionary,
often in modern definitions the word para is understood to
mean abnormal, hence implying that parasuicide is an
abnormal suicide. The insensitive undercurrents of this etymology justify the decision to refrain from using the word
parasuicide to conceptualize self-harm in this paper.
Favazza (1996) uses the term self-mutilation to refer to
acts that are now more widely conceptualized as self-injury.
Mangnall & Yurkovich (2008) refer to the negative connotations associated with the word mutilation. The word
mutilation perhaps evokes the sense of horror or disgust
that society should endeavour to move beyond when confronted with self-harm. Therefore the term self-mutilation
will not be employed in this paper. In a similar vein, the
term self-harmer will not be used, to describe people who
self-harm. This position is based on the belief that such
labels reinforce stigma and effectively dehumanize people
who are much more complex and unique than the sum of
one facet of their behaviour (Allen 2007). For the purpose
of this paper, the chosen terminology is that of self-harm.
This decision is based on experience searching for literature
on the subject, communication with practitioners who
work within the field and personal understanding about the
crucial nature of communicating in a language that is both
appropriate to the action and non-oppressive for the actor.

Definition of self-harm
In this paper, Turps (2003) definition is used to conceptualize the activity of self-harm. Turp (2003) seeks to define
self-harm in a way that reflects the multifaceted nature
thereof:
Self-harm is an umbrella term for behaviour:
(1) that results, whether by commission or omission, in
avoidable physical harm to self
(2) that breaches the limits of acceptable behaviour, as
they apply at the place and time of enactment, and hence
elicits a strong emotional response. (p. 36)
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Working towards a holistic understanding of self-harm

This definition captures the various dimensions of selfharm for both individuals and society. It can be an action or
a non-action, causing harm by deed or by neglect. Selfharm is not confined to a particular gender, age group,
culture or type of behaviour.

Types of self-harming behaviour

There is a plethora of behaviours defined as self-harm. The
two most commonly reported types of self-harm have been
selected for review in this section: self-poisoning and
self-cutting.

Self-poisoning
According to Hawton & Harriss (2008), Self-poisoning is
defined as the intentional self-administration of more than
the prescribed dose of any drug, and includes poisoning
with noningestible substances, overdoses of recreational
drugs, and severe alcohol intoxication where clinical staff
consider such cases to be acts of deliberate self-harm (p. 5).
In Hawton & Harrisss (2008) study, analysis was carried
out of self-harm presentations to a general hospital in
Oxford over a 10-year period and 82.2% of self-harm
presentations were the result of self-poisoning. This compared with 13.5% resulting from self-injury. DHSSPSNI
(2010) has identified drug overdose as the most common
method of self-harm in the Western Health and Social Care
Trust (WHSCT) catchment area of Northern Ireland,
accounting for 73.9% of accident & emergency (A&E)
presentations for self-harm in 2009. Figures based on hospital presentations may not reflect the true nature of selfharm, in terms of both prevalence and demographics.
Episodes of self-cutting are less likely to result in hospital
presentation than self-poisoning (Hawton & Harriss
2008), which may account for the increased incidence of
self-poisoning in figures based on hospital presentations.
There is literature which suggests that self-poisoning
varies from other forms of self-harm involving cutting or
burning (Gallop 2002, Simpson 2006). Simpson (2006)
articulates, . . . self-poisoning is more usually concerned
with ending consciousness, to end life, thus holding a significantly different meaning to self-harming (p. 429). Thus
overdose or self-poisoning appears to diverge from other
forms of self-harm which are often used to restore feeling
and which communicate emotional distress through the
visible traces held on the body. Much of the literature
focuses on hospital presentations which are often a result
of overdose; there is limited available research on those
people who self-harm and never present to hospital, among
whom the most common method of self-harm is understood to be self-cutting or self-injury (Hawton & Harriss
2008).
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Self-cutting
DHSSPSNI (2010) has identified cutting as the second most
common method of self-harm in the WHSCT catchment
area of Northern Ireland, accounting for 17.2% of all
self-harm A&E presentations in 2009. The National
Inquiry into self-harm among young people suggests that
rates of self-cutting are between one in 12 and one in 15
among young people in the UK (Mental Health Foundation
2006). It is widely recognized that prevalence of cutting is
difficult to estimate as, those who cut themselves are less
likely to attend accident and emergency departments
(McLaughlin 2007, p. 72). Ystegaard et al. (2008) state
that self-cutting is the most commonly reported method of
self-harm in their study, accounting for 62.6% of self-harm
among young people. This indicates that among community populations, self-cutting may be the more prevalent
method of self-harm (Hawton & Harriss 2008); however,
the extent of this will not be recorded in statistics based on
hospital presentations.
Cutting can incorporate a variety of behaviours, dependent on the severity and frequency of the injury, as well as
the location of the injury on the body and the instrument
used. Favazza (1996) distinguishes between repetitive moderate self-harm and episodic moderate self-harm. Repetitive
moderate self-harm is employed by people who become so
engaged with their self-harm that they . . . may adopt an
identity as a cutter or burner and . . . describe themselves as addicted to their self-harm (Favazza 1996,
p. 251). Subsequently, repetitive moderate self-harm may
involve ritual about how, when and where people cut themselves. People who hide their injuries may opt to cut less
visible parts of the body, such as the stomach or legs.
Episodic moderate self-harm includes random acts of selfcutting or burning, which are neither habitual nor ritualistic. It represents the means . . . to get rapid respite from
distressing thoughts and emotions (Favazza 1996, p. 243).
With episodic moderate self-harm, people may cut themselves with any object immediately available to them, for
example a knife or broken glass.
Huband & Tantam (2004) differentiate between
planned and impulsive acts of self-cutting in their qualitative study of women who repeatedly self-cut (n = 10).
Huband & Tantam (2004) highlight two main pathways
to cutting: the spring, which is characterized by a
build-up of emotion or tension; and the switch, which
involves a sudden impulse to cut. The spring pathway is
defined by an intolerable mounting of tension and the
relief that the self-cutting provides is soon replaced by a
negative emotion such as guilt. In the switch pathway,
there is no plan or rumination, simply a desire to cut.
The switch pathway indicates the potentially addictive
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M. Long et al.

nature of the behaviour. Huband & Tantam (2004)

suggest that the effectiveness of therapeutic interventions
will depend on the pathway to cutting that the individual
experiences, for example participants who switch ranked
counselling and psychotherapy as less helpful than those
who follow the spring pathway.
Self-injury is distinct from self-poisoning insofar as
acts such as repetitive burning or cutting are often said to
recover feeling rather than end it (Simpson 2006), to
transfer psychological distress into a visible and physical
reality (Babiker & Arnold 1997) and to transform the
body into the site of communication for emotional distress (Mangnall & Yurkovich 2008). Much of the
research on self-harm is based around presentations to
hospital following an episode of self-poisoning or overdose. Huband & Tantams (2004) study captures an
under-researched area of self-harm, by qualitatively
exploring the experiences of people who self-cut. Subsequently, more qualitative research on self-harm in the
form of self-injury would be welcomed as an area of
focus that has often been overlooked.

Life experiences that may contribute to the

onset of self-harm
There are many life experiences which may increase the
likelihood of self-harm; the list presented in the discussion
below is not exhaustive. Evidence relates the significance of
negative early life experiences such as: sexual abuse; physical abuse; neglect; separation and loss; and insecure attachment relationships, as risk factors contributing to the
likelihood of self-harm (Gratz 2003). The impact of such
experiences on a persons capacity to meaningfully communicate their feelings may lead to self-harm, which becomes a
means of communicating psychological distress through the
body (Babiker & Arnold 1997, Mangnall & Yurkovich
2008). Negative early life experiences may result in a failure
to achieve object love and subsequent inability to trust
others, which can impede a persons capacity to develop
secure and trusting interpersonal relationships (Walsh &
Rosen 1988), thus perpetuating the cycle of self-harm.
Turp (2007) presents process material from psychotherapy practice, which transposes Bicks (1968) skin
containment theory for the comprehension of adult selfharming behaviour. The physical skin acts as a boundary to
and a container for the internal functions of the body. It is
both tough and porous. Mother and child share their skin
at initial development; the child then develops their own
skin while maintaining their connection with the mother.
Similarly the psychic skin develops as a boundary to and
container for the psychic functioning of the mind. Where
psychological development has been impeded in early
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development, the individuals psychic skin may become too

tough or too porous. If it is too tough, a second skin may
form whereby nothing or no one can permeate. The individual is overly self-reliant. If their psychic skin is too
porous, the individual is weakened and vulnerable by an
intrinsic lack of discernment. Turp (2007) suggests issues of
skin containment predominate in clinical encounters with
individuals who self-harm.
It is not only childhood experiences that may lead a
person to self-harm, traumatic experiences in adulthood
such as rape, assault or political conflict can facilitate the
environment wherein self-harm may flourish among individuals. For some people negative and/or traumatic experiences may occur throughout the life cycle. Dorahy
(2008) conducted a study on adults attending the Trauma
Resource Centre in Belfast, Northern Ireland (n = 81). All
of the participants in Dorahys (2008) study had experienced Troubles-related trauma, as a result of the political violence in Northern Ireland. For some participants
this occurred during childhood, for others during adulthood, and in addition all but four of the sample had
experienced childhood abuse. Dorahy (2008) identified
that among participants, . . . two thirds of the sample
reported a history of self-harm, with a quarter (27%) also
reporting suicide attempts (p. 42). Dorahy (2008) concludes that self-harm has presented within this community as a less-than-helpful response to the trauma of
political violence (p. 48).
Self-harm serves a number of functions for people who
have experienced negative life events. For example, selfharm may enable a person to communicate their distress
through their body (Babiker & Arnold 1997, Mangnall &
Yurkovich 2008); to transform overwhelming emotional
pain into tangible physical pain (Babiker & Arnold 1997);
to punish the self for acts of abuse perpetrated against the
self which become sources of shame, self-hatred and selfblame (Walsh & Rosen 1988, Tantam & Huband 2009) or
to regain a sense of control when life feels inherently
chaotic (Pembroke 1996). It is crucial to remember that
reasons for and functions of self-harm are unique to each
individual. Subsequently, if self-harm is to be understood in
all its complexity it must be considered holistically in the
context of a persons life.

The cultural, historical and religious origins

of self-harm
In gaining a comprehensive understanding of self-harm, it
is imperative to reflect upon the cultural, historical and
religious origins of the behaviour, which throughout time
has been used in many cultures to restore harmony and
balance at perceived moments of chaos. In a similar way
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Working towards a holistic understanding of self-harm

the person who self-harms becomes a microcosm of the

world of mythology and religious symbolism, sacrificing,
. . . a body part or a portion of blood in order to achieve
a modicum of well-being. A partial sacrifice achieves
only partial peace (Favazza 1996, p. 25).

Armando Favazza (1996) is esteemed as the seminal

author to provide a comprehensive understanding of selfharm in the context of culture and psychology. Favazza
(1996) differentiates between culturally sanctioned practices such as tattoos and pathological acts of self-mutilation
such as self-cutting. Individuals who engage in self-harming
behaviours often have been regarded as attention-seekers
in the pejorative sense, who are perhaps merely following
some new teenage fad (Fox & Hawton 2004, Mental
Health Foundation 2006). Favazza (1996) suggests that
behaviours that cause harm to self have socio-historical
gravitas and are embedded in our cultural psyche.
In Christianity the path to martyrdom and sainthood
was paved with self-sacrifice. The term mortification of the
flesh, meaning literally putting the flesh to death hails
from St Pauls quotation,
For if you live according to the flesh you will die, but if
by the spirit you put to death the deeds of the body you
will live (Epistle to the Romans 8:13).

This belief has a long history in many religions: exemplified in Christianity by Christ, who sacrificed his own life
through crucifixion to redeem humankind. The crucifix is
perhaps the most widely recognized religious symbol in the
Western world, representing Christs self-sacrifice and suffering for the expiation of sins. Believers partake in Christs
divinity through the sacramental meal which involves the
consumption of His flesh and blood (Favazza 1996).
There are countless biblical stories about martyrdom
involving acts of self-destruction such as self-flagellation in
order to attain atonement. Saint Anthony (251356) was
understood to live in an isolated pit for 20 years: eating
once every 6 months, refusing to wash and wearing a
coarse garment that caused his skin discomfort and wounding (Favazza 1996). Saint Mary Magdelene dePazzi born
in 1566 devoted her life to self-sacrifice, At age 10 she
made a vow of perpetual chastity, secretly whipped herself
and wore a crown of thorns (Favazza 1996, p. 41). Similar
pictures can be gleaned in indigenous tribal cultures,
whereby the revered status of Shaman is achieved by
enlightenment through great suffering (Favazza 1996). Acts
of self-harm often evoke alarm, horror and disgust. Yet,
these examples indicate that the notion of healing through
pain, pain as a means to enlightenment and the interchange
between body and soul are concepts with socio-historical
resonance.
Favazza (1996) frames understanding of self-harm in the
context of cultural determinism, whereby behaviours will be
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interpreted differently within and between cultures. Culturally sanctioned rituals in one culture may be deemed pathological behaviour in another. For example, the New Year
festival of the Abidji Tribe from the Ivory Coast was photographed by Micahel Kirtley & Aubine Kirtley (1982) and
involved practices of trance-induced states where people
plunged knives into their abdomens. When such acts are
transposed to Western culture, they are likely be deemed
needless acts of bodily mutilation. Tattooing may be a
ritualized practice among groups of people where it symbolizes a sense of shared identity, but among other groups of
people the permanent alteration of ones body may evoke
disdain or be entirely prohibited. Favazza (1996) suggests
that acts which are harmful to the self have been an elemental aspect of curing and preventing disease . . . from the
earliest days of human existence (p. 227). For example, in
the Middle Ages, blood-letting was used as treatment for
many diseases that were understood to be caused by an
excess of blood in the body. While self-harm may be considered an abhorrent or incomprehensible behaviour by many
people, locating it in its cultural and historical context can
bring it from obscurity to enlighten understanding about the
existence of self-harm in every society.
Self-harm is a term that can encompass a wide range of
behaviours conducted by individuals in all societies, age
groups, social classes, religions and races. Self-harming
behaviours are dependent on cultural interpretations of
intent and acceptability. Turp (2003) coins the useful term
. . . cashas an acronym for culturally acceptable selfharming acts or activities (p. 9). An activity such as
smoking, for example, may cause more physical harm to an
individual than self-cutting. Yet the former is not generally
met with the same level of shock or disdain as the latter. In
distinguishing between cashas and other self-harming
behaviours, Turp (2003) acknowledges the plethora of
activities that can be defined as self-harm, such as tattoos,
religious pilgrimages, alcohol consumption or overwork. In
this paper, self-harm relates to the acts of self-harm that are
often interpreted as pathological, rather than cashas.
Turps (2003) distinction between the behaviours affords
clarity and helps to avoid misinterpretation or dual interpretations of the term self-harm.

Stigma and attitudes

The term stigma originated with the Greeks, . . . to refer to
bodily signs designed to expose something unusual and bad
about the moral status of the signifier (Goffman 1963, p.
11). In more recent conceptualizations, Goffman (1963)
extrapolated three major types of stigma: the first is . . .
abominations of the body, the second refers to . . . blemishes of individual character, and the third relates to . . .
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M. Long et al.

the tribal stigma of race, nation and religion (p. 14).

Stigma is thus of profound significance in relation to selfharm, in that people who self-harm may be stigmatized on
account of both the physical marking of their body as well
as the inferred defamation of their individual character.
Goffmans (1963) work is crucial in emphasizing the role of
stigma in discriminating and isolating people based on
prejudicial assumptions. Subsequently, the impact of
stigma on people who self-harm may be powerfully detrimental to their capacity for self-care at an emotional or
physical level.
For many people who self-harm, their behaviour is
hidden, perhaps a powerful acknowledgement of their
awareness that the behaviour breaches social boundaries
and the consequences of such breaches becoming common
knowledge, such as labelling, psychiatric diagnoses and
impact on personal and professional relationships. With
societys increased emphasis on appearance and the exterior self (Lemma 2010), there are many reasons for people
choosing to reject the situational status quo. These may
be part of societys dysfunctions when so many people
renounce them with their own hidden, private and ultimately self-destructive revolutions. Goffman (1963) states,
A mental symptom, however, is a situational offense that
the offender does not get away with (p. 240). For people
who self-harm and endure their distress in silence, they
endeavour to get away with their offense by concealing it
at all costs. Those people who self-harm and want to seek
and access help face an arduous task in overcoming internal and external situational bias.
Professional attitudes to self-harm reflect wider societal
attitudes and these both enhance and are enhanced by
prevailing stigmatization of people who engage in selfharm. Walsh & Rosen (1988) articulate, . . . we inevitably
experience discomfort when encountering fellow human
beings so intensely distressed that they cause themselves
concrete physical harm (p. 3). While those words were
written more than 20 years ago, they seem to reflect a level
of discomfort shared by many people in society. Other
writers in the field of self-harm relate that self-harm often
evokes discomfort, confusion and even disgust among care
providers (Babiker & Arnold 1997, Shepperd & McAllister
2003, Simpson 2006). Indeed, Shepperd & McAllister
(2003) suggest that, . . . the whole experience of healthcare can be another ordeal which the consumer finds traumatic, invalidating and may even trigger further need to
self-harm (p. 443). Professional attitudes to self-harm can
impact on responses to presentations of self-harm, subsequently affecting individuals experiences of psychiatric
and mainstream services.
Simpson (2006) questions the viability of therapeutic
interventions for people who self-harm in the National
110

Health Service. She maintains that despite efforts by

National Institute for Clinical Excellence to review these
services, . . . it is difficult to see how this might be
achieved inside organisations that, for the most part,
appear to have become institutionally prejudiced towards
people who self-harm (Simpson 2006, pp. 434435).
Simpson (2006) suggests that in a climate of risk assessment, patient and health professional operate within
different realms of understanding. For patients their communication is limited in that words are not sufficient to
express their pain, as such they resort to self-harm, . . .
inscribing individual life stories on the body in the form
of self-cutting (Simpson 2006, p. 433). Where a patient
presents who is unable to articulate their pain, . . . the
professional helper may feel lost and deskilled (Simpson
2006, p. 433). A lack of mutual understanding in a healthcare environment may compound already existing prejudicial attitudes and further iterate the cycle of stigmatization
against people who self-harm.

Psychiatric diagnoses and self-harm

Borderline personality disorder (BPD)
There is a wealth of evidence which demonstrates that
there is a link between self-harm and diagnosis of BPD.
Klonsky & Muehlenkamp (2007) suggest this relationship
is, not surprising because both have negative emotionality
and emotion dysregulation as core features (p. 1048). Selfharm features as one of nine symptoms listed by Diagnostic
and Statistical Manual of Mental Disorders (1994) in the
diagnostic criteria for BPD. Five of the nine symptoms must
be present for a diagnosis of BPD to be made; however,
according to Proctor (2010), the diagnosis of BPD is often
made on the basis of self-injury alone (p. 19). Crowe &
Bunclark (2000) suggest that diagnoses of BPD have been
made about people who self-harm, irrespective of the presence of other criteria. Diagnoses made on this basis may
indicate that the association between BPD and self-harm
may be not only erroneous but also detrimental to the lives
of individuals who self-harm, who are further exposed to
systematic stigmatization as a result of the diagnosis of
BPD (Simpson 2006).
There is research evidence which seeks to move beyond
the stereotypic interpretations of self-harm as the symptom
of disorders such as borderline personality. McAndrew &
Warne (2005) present a case study on three UK-based
women with a history of self-harm, using feminist praxis to
analyse the womens discourse and understand the unique
meanings for their self-harm. Each of the women participating in the study has psychiatric diagnoses including
schizophrenia, or schizo-affective disorder, depression and
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Working towards a holistic understanding of self-harm

BPD. They have also experienced traumatic life events

which pre-dated the onset of their self-harm, including
sexual abuse and rape. McAndrew & Warne (2005)
employ a feminist praxis approach, to inform the studys
methodology in an attempt to redress the power dynamic
inherent in the research process which mirrors that faced
by women living in a patriarchal society. In this way the
authors are able to listen to and explore the individual
voices of their participants who have often felt voiceless
and powerless in the system of psychiatric care.
McAndrew & Warne (2005) argue that it is imperative
for mental health practitioners to move beyond the confines of diagnostic labelling when working with self-harm
as this may ignore traumatic life experiences and the social
context of a persons life (p. 172). McAndrew & Warne
(2005) state explicitly that mental health services can only
effectively work with people who self-harm when they
begin to understand the complexities and variances of individual life experiences which often lead to self-harm. They
suggest that disregarding the often traumatic history of
people who self-harm is akin to sticking a plaster on [the]
wound to stop the bleeding while disregarding the bacteria
that lie beneath the surface (McAndrew & Warne 2005,
p. 178). McAndrew & Warne (2005) also assert that
mental health nurses must foster their capacity for psychodynamic understanding, if they are to work sensitively and
effectively with people who self-harm.

life-giving. Walsh & Rosen (1988) refute the conflation of

self-harm and suicide by claiming that the objective of
suicide is to end life, whereas self-harming behaviours, . . .
however limited as coping mechanisms, are nonetheless
ultimately adaptive to sustaining life (p. 51). Cutliffe et al.
(2008) articulate succinctly that suicide is death-oriented
whereas self-harm is life-oriented (p. 155). In the SANE
(2008) report on self-harm, 20.1% of respondents (n =
111/553) state that the main function of their self-harm is to
prevent suicide. Other writers in the field including Favazza
(1996), Freeman (2010) and Pembroke (1996) concur with
the idea that there is not necessarily a continuum from
self-harm to suicide; in fact they can be two very different
behaviours with divergent functions.
Self-harm and suicide behaviours are often categorized
as analogous, particularly within service provision, for
example the Protect Life Strategy is the Suicide and SelfHarm Strategy for Northern Ireland commissioned by the
DHSSPSNI. The extent to which this understanding may
impact on professional attitudes towards or treatment outcomes for individuals who self-harm, if or when they do
seek help, is unclear. In order to facilitate a comprehensive
analysis of either self-harm or suicide, it is vital to understand that self-harm serves unique functions and holds
individual meanings, which are often distinct from those
pertaining to suicidal behaviour.

Self-harm and suicide

Conclusion: implications for practice

and research

The term parasuicide was developed by Kreitman (1977)

to describe a range of non-fatal suicidal behaviours,
including manipulative acts, less serious gestures and
more serious attempts. Yet the term parasuicide can be
criticized for implying suicidal intention, when this may
not in fact be present (Fox & Hawton 2004, p. 14).
Hawton et al. (2006) suggests that there is an association
between self-harm and suicide and cites that around 40%
to 60% of people who take their own lives have a history
of deliberate self-harm. Yet Cutliffe et al. (2008) articulate
that while links do exist, there is a wealth of empirical
evidence that shows that 95% and over of people who
self-harm do not go on to take their own lives (p. 154).
The figures may capture an element of suicidal ideation
among certain individuals who self-harm; however, it is
also evident that for many people who self-harm, there is
no intention to die.
Menninger (1938) suggests that the self-destructive tendencies within individuals who substitute part of themselves
for their whole selves represent a triumph of the life force in
the Eros/Thanatos conflict. Menningers (1938) ideas were
ground-breaking in the implication that self-harm can be

Self-harm is pervasive in society, a behaviour which has

evolved with us throughout history, cutting across social
and cultural divides, affecting people in clinical and community populations. By providing an all-encompassing
definition of self-harm, examining the cultural, historical
and religious origins of self-harm and considering issues
around psychiatric diagnoses pertaining to self-harm, this
paper challenges practitioners to consider the potentially
universal nature of self-harm. The discussion around sensitivity in language use offers one fundamental means
through which practitioners can lead the way in reconstructing myths and reducing the stigmatization of people
who self-harm. Further qualitative research from the perspectives of people who self-harm would deepen understanding of the issue, enabling people to share their
experiences, advancing practice in a meaningful way.
This paper has sought to increase dialogue among practitioners, illuminate the issue of self-harm and engender
greater willingness to look beyond the behaviour in order
to understand the person. It is well documented that professional responses based on negative attitudes can compound an existent sense of shame among people who

2012 Blackwell Publishing

111

M. Long et al.

self-harm. Is it time now to rewrite the script? Working

towards a holistic understanding of self-harm, which recognizes this as a shared piece of human experience, could
foster more empathic responses to people who self-harm,
ultimately enhancing their capacity for self-care.

Acknowledgments
The authors would like to thank Professor Christopher
Lewis of Glyndw
r University, for his contributions during
the seminal stages of this research process.

conceptual review. Clinical Psychology: Science

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2012 Blackwell Publishing

Working towards a holistic understanding of self-harm

Appendix I: Search formulae and results

PsychARTICLES
Search formulae
(self-harm OR self-mutilation OR self-injur* OR self injury OR self-cutting OR
self-laceration OR self harm OR DSH OR SIB) AND (help-seek* OR help seek
OR seek help)
(self-harm OR self-mutilation OR self-injur* OR self injury OR self-cutting OR
self-laceration OR self harm OR DSH OR SIB) AND (stigma OR attitudes OR
prejud*)
(self-harm OR self-mutilation OR self-injur* OR self injury OR self-cutting OR
self-laceration OR self harm OR DSH OR SIB) AND (help-seek* OR help seek
OR seek help) AND (stigma OR attitudes OR prejud*)
(self-harm OR self-mutilation OR self-injur* OR self injury OR self-cutting OR
self-laceration OR self harm OR DSH OR SIB) AND (counselling OR counselling
OR psychotherapy)
(self-harm OR self-mutilation OR self-injur* OR self injury OR self-cutting OR
self-laceration OR self harm OR DSH OR SIB) AND (counselling OR counselling
OR psychotherapy) AND (help-seek* OR help seek OR seek help)
(self-harm OR self-mutilation OR self-injur* OR self injury OR self-cutting OR
self-laceration OR self harm OR DSH OR SIB) AND (counselling OR counselling
OR psychotherapy) AND (stigma OR attitudes OR prejud*)
(self-harm OR self-mutilation OR self-injur* OR self injury OR self-cutting OR
self-laceration OR self harm OR DSH OR SIB) AND (counselling OR counselling OR
psychotherapy) AND (stigma OR attitudes OR prejud*) AND (help-seek* OR help
seek OR seek help)

2012 Blackwell Publishing

PsychCRITIQUES
PsychINFO

MEDLINE

151

161

746

1021

64

80

899

1059

55

61

203

306

34

46

113

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