Acceptance and Constraint – Contemporary Perspectives of Self-Harm on Locked Wards

By Rebecca Fish

I began researching experiences of self-harm when I was working at an NHS inpatient unit for people with learning disabilities. In 2000, I embarked on an NHS funded long-term research study with my colleague, Helen Duperouzel, exploring understandings of self-harm from the perspective of care staff and the people detained in the unit. In the interviews, participants explained to us that there were complex relational issues around self-harm. If a person was deemed to be at risk of self-harming, staff were required to observe them constantly – sometimes for 24 hours a day – meaning that a staff member might be blamed when a person self-harmed. This had the consequence of taking the focus away from the person who was feeling distress and placing the control and responsibility with staff. We also found that there was a pervading culture of silence concerning self-harm, for fear that talking about it might trigger more harm.

The research showed how women had used self-harm as a coping strategy, often for years, and that it was counter-productive to try to prevent them. Peer support and talking about self-harm was generally helpful to the women. This is in keeping with survivor-led knowledge and practice around self-harm discussed by Anne O’Donnell in this special section.

The unit introduced a harm-minimisation policy in response to this research, meaning that some self-harm was accepted, and staff worked closely with people to help them find alternative coping strategies. This approach was incorporated into NHS clinical guidance for longer term management of self-harm in 2012.

My more recent ethnographic research on locked wards for women with learning disabilities in 2012 found that some staff assumed that self-harm was learned behaviour, because they had seen a change in the self-harm of women after they arrived at the unit. As Sarah Chaney points out, institutional knowledge throughout the years has reinforced this assumption. Some of the women I spoke to said that this was because they didn’t have the opportunity to do their usual self-harm, for instance because things had been removed from their room, or because they were subjected to constant observations. Swallowing dangerous items like batteries or pens became an easier and quicker way to self-harm for some participants. For example, Nina* said she began swallowing because she was stopped from cutting:

Rebecca: You said you felt like cutting up but you couldn’t, so you swallowed.  Is that right?

Nina: Yes.

Rebecca: Why couldn’t you cut?

Nina: Nothing to do it with.

Rebecca: Do you think if you were allowed to scratch and cut just a little bit that would have stopped you swallowing?

Nina: Yes, probably.

Most of the women I spoke to had started self-harming before the age of 10, generally in response to a very traumatic event. Mandy had told me that the self-harm had been a survival strategy for years:

Rebecca: Do you think you could stop self-harming?

Mandy: Unless my life improves and then I might be able to. It’s just like stopping smoking and stopping drinking, it’s very hard, very hard. Especially when I’ve been doing it for years, and that’s what I’ve been doing – years and years.

The majority of detained women disclosed experiences of sexual abuse and violence growing up. Staff members recognised the resulting distress that caused some women to continue to self-harm, but a common perspective was that the women had learned self-harm from each other:

Sophie (staff member): I think there’s probably inevitably a sense that people who’re distressed living with other people who’re distressed, it’s not ideal is it really? Whether it’s distress from the past or they self-harm, and learning new behaviours. There’s that sense of, ‘Well I haven’t done that before, but I wonder what’ll happen if I do.’

Continuing my research on self-harm, in 2017 I interviewed staff working with men who self-harm on locked wards. Some of the staff attributed men’s self-harm to the increasing acceptance and therefore visibility of self-harm:

Bill (staff member): Because there does seem to be this ability to learn from each other. And it seems to be. . . it seems to be more accepted. So whereas one time as I said earlier, it would have been a hidden situation, now it seems to be something that’s out in the open.

Bill’s notion was that because other methods of coping are off-limits on the locked wards, self-harm as a coping strategy becomes more likely. Natalie felt a similar way, attributing self-harm to the limitations of masculinity:

Natalie (staff member): I suppose you could say that [self-harm] is an acceptable approach you know. I can imagine a lot of men in this service saying that self-harm is better than crying. You could see people doing that, that sort of bravado approach. Because you could still have lots of scars and look tough, rather than somebody who’s crying.

Many staff acknowledged that self-harm can be a response to feelings of powerlessness as a result of being detained in a unit, as well as a form of communication or a plea for help. As other blogs in this series show, restrictive institutional regimes can exacerbate anxiety and distress, and medical models continue to shape our understanding of self-harm. Yet, the increase of self-harm incidence on the unit was often put down to the general acceptance of self-harm:

Sally (staff member): I think it’s become more accepted for whatever reason. I think, services are generally more geared up as well to deal with. Self-harm in presentation, I mean if you go back a few years ago you were ushered into a casualty department and never the words were said, you know. But now it’s much more open and on the table.

The notion that self-harm was increasing on the unit because it was accepted behaviour is understandable. The staff I spoke to recognised the complexity of this notion; they acknowledged that people are in distress when they self-harm and noticed the onset or change in a person’s manifestation of that distress. They described using nurturing and therapeutic strategies to help men express and deal with their feelings. However, as illustrated by the recent debate about social media representations of self-harm, there are dangers in representing self-harm as exacerbated by increased visibility as this can become the dominant consideration.

On the one hand, speculating that self-harm is a response to the pervading culture can sometimes work to limit opportunities for finding out the underlying reasons. As Brigit McWade argues, this stigmatises self-harm and polices expression, shutting down discussion about experiences – and therefore the opportunity for peer support.

Conversely, focussing too much on the inevitability of individual distress could obscure how self-harm is relational and communicative, necessitating a response. Thinking that self-harm is in some way calculated leads to care staff using strategic methods in response, like refusing to engage through fear of reinforcement.

The way forward is to talk to people themselves. Participants in our research described their self-harm as survival, as coping. They ascribed meaning to their scars, as emblems of survival, as getting through the bad times. A significant minority of participants in my research had managed to stop self-harming with the help of talking therapies and intense care and encouragement from support staff as well as other women who lived with them. As shown by Amy Chandler, as well as other writers in this series of blogs, discussions about self-harm purely as learned behaviour detach the self-harm from lived experiences, and from the need for care and understanding.

*All names are pseudonyms

Rebecca Fish is a lecturer in Sociology at Lancaster University. Her work explores the experiences of people with learning disabilities and the staff who work alongside them. 

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