A study of service providers' understanding of self-harm

Abstract

An understanding of self-harm among various occupational groups who may be involved in caring for and supporting people who self-harm was investigated. A questionnaire was constructed to assess understanding of self-harm. It was completed by a number of occupational groups including psychiatrists, psychologists, medical workers (general practitioners and nurses) and social/community care workers. It was also completed by a group of individuals who engage in deliberate self-harm. The results showed psychiatrists and medical workers have a poorer understanding of self-harm in comparison to self-harmers and workers with psychological or social/community care training. Psychology workers, self-harmers and social/community care workers did not differ significantly in their understanding of self-harm. It was concluded that there is a need to enhance awareness and understanding of self-harm among psychiatrists and medical workers so that the referral and treatment process may be more accurately targeted towards the needs of the individual.

Full text

Journal of Mental Health (2002) 11, 3, 295–303
ISSN 0963-8237print/ISSN 1360-0567online/2002/030295-09 © Shadowfax Publishing and Taylor & Francis Ltd
DOI: 10.1080/09638230020023679
Address for Correspondence: Debra Jeffery, 68 Gresham Drive, West Hunsbury, Northampton, NN4 9SB, UK.
Tel: 01604 768278; E-mail: debrajeffery@hotmail.com
A study of service providers’ understanding of self-harm
DEBRA JEFFERY & ANNA WARM
Liverpool Hope University College, Hope Park, Childwall, Liverpool, UK
Abstract
An understanding of self-harm among various occupational groups who may be involved in caring for
and supporting people who self-harm was investigated. A questionnaire was constructed to assess
understanding of self-harm. It was completed by a number of occupational groups including
psychiatrists, psychologists, medical workers (general practitioners and nurses) and social/community
care workers. It was also completed by a group of individuals who engage in deliberate self-harm. The
results showed psychiatrists and medical workers have a poorer understanding of self-harm in
comparison to self-harmers and workers with psychological or social/community care training.
Psychology workers, self-harmers and social/community care workers did not differ significantly in
their understanding of self-harm. It was concluded that there is a need to enhance awareness and
understanding of self-harm among psychiatrists and medical workers so that the referral and treatment
process may be more accurately targeted towards the needs of the individual.
Introduction
Self-harm is a significant clinical problem
(Haines et al., 1995). Incidents of self-harm
have been estimated to be around 750 per
100,000 population per year (Favazza &
Conterio, 1989 in Haines et al., 1995), which
is comparable to incidences of mental illness
like schizophrenia and manic-depressive dis-
orders (Houghton, 1998). Furthermore, there
is evidence to suggest that the problem is
growing rapidly and becoming more wide-
spread (Pembroke, 1994). Although an in-
crease in media attention (Bristow, 1999;
Levenkron, 1999) has led to a general in-
crease in awareness of the occurrence of self-
harm (Bristow, 1999; Levenkron, 1999), it
remains a subject that is unduly neglected
within the psychological research literature
(Soloman & Farrand, 1996) and information
on the subject is poor (Hogg & Burke, 1998).
Most studies about self-harm have been
based on self-poisoning and overdosing
(Hawton, 1986; Reder et al., 1991) rather
than behaviours like self-cutting. This may
be because self-poisoning cases tend to be
referred to a psychiatrist more often than
cases of self-harm (Scott & Powell, 1993).
There have been some reports (Scott & Powell,
1993; Solomon & Farrand, 1996) that have
dealt solely with self-harming behaviour s
such as cutting and burning, but these are
rare. In addition to this, there is some confu-
sion over what is exactly meant by the term
‘self-harm’. Some studies have incorporated
into their definition of self-harm both self-
poisoning and other self-harming behaviours
(Hawton et al, 1999), others have used the

296 Debra Jeffrey & Anna Warm
term to refer exclusively to acts of self-poi -
soning (Crawford et al., 1998; McLaughlin
et al., 1996), whereas others have excluded
self-poisoning from their definition of self-
harm (Pattison & Kahan, 1983). Thus, mean-
ingful comparisons between studies are made
difficult.
Pattison & Kahan (1983) propose the exist-
ence of a deliberate self-harm syndrome,
which differs substantially from self-poison-
ing and other classes of self-destructive be-
haviour. They argue that the deliberate self-
harm syndrome consists of direct, intentional
behaviours that have low lethality and are
repetitive in nature. Examples of these be-
haviours from their investigations were cut-
ting, burning and hitting. A slightly adapted
version of this definition will be used in this
study. It has been modified to encompass a
broader range of self-harming behaviours ,
such as self-poisoning, so not to isolate indi-
viduals who engage in any form of self-harm.
Therefore, for the purpose of this study, self-
harm will be classified as a deliberate and
direct act of inflicting damage to oneself.
Recent research on self-harm has found
that most of the clinical and academic under-
standing of the issue is based on a number of
self-serving myths rather than the real as-
pects (Harrison, 1998; Hogg & Burke, 1998;
Lynn, 1998; Pembroke, 1998a, 1998b). These
myths present self-harm in a negative manner
and encourage stereotypical views of self -
harmers in both the medical and clinical
fields and in the public sphere (Harrison,
1998). They often involve self-harm being
labelled as a manipulative act or as attempted
suicide, but from the limited research that has
been conducted into the motivations and in-
tentions behind self-harm, it would appear
that these perceptions of self-harm are not
accurate (Harrison, 1996; Hogg & Burke,
1998; Pembroke, 1994, 1998a; Solomon &
Farrand, 1996; Spandler, 1996). Further-
more, these inaccurate perceptions have a
negative impact on the ways in which self-
harm is treated.
Studies have shown that people who self-
harm are often subjected to appalling treat-
ment in Accident and Emergency depart-
ments (Martinson, 1998; Pembroke, 1994,
1998a). Cases have been reported where
local anaesthetic has been withheld, even
when there has been stitching, and frequently
self-harmers have been given inappropriat e
dressings and treatments (Ahuja, 2000;
Babiker & Ar nold, 1997; Batty, 1998 ;
Pembroke, 1994, 1998a). They are often
ignored or treated with contempt or little
respect (Martinson, 1998) and have been
refused treatment on the basis that the wounds
were self-inf licted and are therefore ‘not
worth’ treating (Pembroke, 1998b). The fun-
damental reason why this type of treatment is
a common response of A&E departments is
because most staff have a lack of understand-
ing about the issue (Harrison, 1998; Lynn,
1998; Pembroke, 1998a).
Misunderstanding of self-harm within the
medical field, in part, may be attributable to
a lack of information and training about self-
harm in this sphere. One of the most promi-
nent myths is the notion that self-harmers are
merely ‘attention seeking’ (Hogg & Burke,
1998; Pacitti, 1998; Pembroke, 1994, 1998a;
Pembroke et al., 1996; Spandler, 1996) this
label, which is usually portrayed as a fact,
encourages A&E staff to react in a manner of
deterrence towards self-harmers. Staff are
taught that self-harm is ‘attention seeking’,
and are therefore encouraged not to reinforce
the behaviour by taking notice, showing
emotion and giving care ( Pembroke, 1998b).
Degrading the self-harmer and making them
feel that they are wasting time and resources
will reinforce their negative feelings perpetu-
ating the cycle of worthlessness and self-
hatred, of which self-harm is a part (Pembroke,
1994).

Service providers’ understanding of self-harm 297
There are also a number of other myths
surrounding this issue, that are likely to have
similar damaging consequences for self-harm-
ers, particularly if they are believed by serv-
ice providers. Such myths have been high-
lighted by National Self-Harm Network, 42nd
Street and the Bristol Crisis Service for
Women. One common false belief is that
self-harm is not serious because it is self -
inflicted. Of course the fact that it is self-
inflicted does not negate the seriousness of
self-harming behaviour. Another inaccurate
perception is that self-harm is symptomatic
of Borderline Personality Disorder (Pembroke
et al., 1996). This statement is also incorrect.
Causes of self-harm cannot be diagnosed so
straightforwardly as being indicative of an
underlying psychological disorder.
Another common misconception amongst
medical workers is that ‘if they (self-harm-
ers) do not want to see a psychiatrist, then
they can not want to get better’ (Pembroke et
al., 1996). This idea is unjustified; people
who self-harm often reject psychiatric help
after it has been tried and has failed to be of
any benefit (Pembroke, 1994, 1998a). The
behavioural and drug treatments prescribed
by psychiatrists are of no assistance to a self-
harmer, as it is their self-worth that needs
building, not their ability to follow contracts
of reward and punishment (Pembroke et al.,
1996). Self-harmers are often portrayed as
‘hysterical women under the age of thirty
who grow out of it’ (Pembroke et al., 1996).
This stereotype is inaccurate because recent
research has shown that the difference in rate
of self-injury between men and women is less
marked than might once have been assumed
(Pembroke et al., 1996) and there is no evi-
dence to show people ‘grow out of it’. It is not
a behavioural or developmental ‘disorder’
(Pembroke, 1994).
Other myths about self-harm have been
highlighted by 42nd Street, who have found
that a very common misconception is the
belief that people who self-harm ‘should be
made to stop’ (42nd Street, 1999b). Until
people who self-harm have an understandin g
of why they do it and develop other ways of
coping with their feelings, then it is poten-
tially harmful for them to stop. Furthermore,
using authoritarian approaches to stop a per-
son from self-harming is likely to block dis-
cussion of what the person is feeling and
increase their perceived lack of control. Con-
trol has been found to be an important func-
tion of self-harm (Spandler, 1996). They also
highlight the myth that ‘everybody who self-
harms has been sexually abused’ (42nd Street,
1999b). Although many people who have
been sexually abused do self-harm, it is not
the case that people harm themselves solely
as a response to sexual abuse during child-
hood. Such a simplistic causal link is com-
pletely unfounded. People, who self-harm
may be coping with painf ul feelings linked to
all sorts of experiences, not just abuse.
Research has shown that individuals who
self-harm do so for many different reasons,
one such reason often cited in the literature, is
because they are experiencing overwhelm-
ing feelings of emotional distress (Pembroke,
1994, 1998a, 1998b; Solomon & Farrand,
1996; Spandler, 1996). However, there are
other reasons that are also frequently high-
lighted in the research, implying that there
are some similarities behind an individual’s
self-harming behaviour. These reasons are
usually centred around self-harm providing a
means of communicating feelings (Pembroke,
1994, 1998a, 1998b; 42nd Street, 1999a;
Solomon & Farrand, 1996; Spandler, 1996),
a form of control over feelings (42nd Street,
1999a; Soloman & Farrand, 1996; Spandler,
1996), a release of negative emotions
(Favazza, 1992; Miller, 1994) and/or a cop-

298 Debra Jeffrey & Anna Warm
ing mechanism (42nd Street, 1999a; Murray,
1998; Solomon & Farrand, 1996).
But any research in this area has to recog-
nise that although there are common themes,
as illustrated, the act of self-harm is a very
individual and personal one. Each engage-
ment of this behaviour can be the result of
different reasons and can have a variety of
meanings depending on the individual and
their circumstances at the time. Thus any
attempt to quantify or explain self-harm is
limited to only highlighting common percep-
tions among self-harmers. This research
aims to clarify what the common reasons are
in comparison to the myths derived from the
literature.
Prevalence of these false ideas and myths
can have negative effects on the way service
providers communicate and try to help peo-
ple who self-harm and, as evidence has shown,
these flawed assumptions and misunderstand-
ings are prevalent in A&E departments
(Harrison, 1998; Pembroke, 1994, 1998a,
1998b). However there has been no system-
atic attempt to establish workers’ understand-
ing of self-harm in other areas of service
provision.
This study investigated perceptions of self-
harm in the various occupational groups who
may become involved with individuals who
self-harm. In addition, the views of those
who engage in self-harm were also assessed.
It was predicted that those groups which have
a solely medical background with no psycho-
logical knowledge, such as general practi-
tioners and nurses would have a poorer un-
derstanding of self-harm than workers in
psychological and social care fields of work
and people who self-harm. In addition, based
on the previous literature (Hawton et al.,
1981) psychiatrists’ understanding of self-
harm was expected to be relatively similar to
those who have had solely medical training.
Method
Participants
Opportunity sampling was used to recruit
general practitioners, nurses, psychiatrists,
psychologists and counsellors from three NHS
trusts. Mental health support workers were
contacted through a number of mutual self-
harm support groups, such as the MIND
Fountain Project and The Basement Project.
The same organisations were used to recruit
participants who were self-harming. Social
workers were recruited from local social serv-
ices network.
Respondents had to be qualified in their
particular occupation and for the self-harm
group, the members had to have self-harmed
according to the definition used in this study
and belong to a support group. There were no
educational, age, gender, social or ethnic
specifications though the majority of the par-
ticipants were women.
The sample of service providers was bro-
ken down into different occupations consist-
ing of qualified psychiatrists, psychologists ,
general practitioners, nurses, social workers
and mental health support workers. These
occupations were then grouped together de-
pending on the type of experience they have
with self-harm. The first group, psychia-
trists, consisted of a sample of nine respond-
ents. The second group consisted of 19
respondents who worked within the field of
psychology. This group was made up of one
psychotherapist and 18 clinical psycholo -
gists. The third group, medical workers, was
centred on respondents who worked solely
within the f ield of medicine. This group
consisted of six general practitioners and 21
nurses. The fourth group was made up of
respondents who worked within a social/
community care context and was composed
of 13 social workers and 12 mental health
support workers. This group was labelled

Service providers’ understanding of self-harm 299
social/community care workers. The final
group consisted of 16 self-harmers and was
labelled self-harmers.
Measures
This study used a questionnaire design to
examine perceptions of self-harm. It con-
tained 20 statements consisting of 10 items
that have been highlighted in the psychologi-
cal literature as being accurate perceptions of
self-harm and 10 items deemed to represent
common myths about self-harm. All these
statements were obtained from literature and
research carried out on self-harm. The 20
items are listed below (see Table 1).
Responses were made on a five-point Likert
scale, consisting of: strongly disagree (1),
disagree (2), unsure (3), agree (4) and strongly
agree (5). To assess respondents’ under-
standing of self-harm, the statements relating
Table 1: Questionnaire statements about self-harm
Accurate statements about self-harm
Self-harm is a form of communication (Pembroke, 1994, 1998a; 42nd Street, 1999a; Solomon &
Farrand, 1996; Spandler, 1996).
Self-harm provides a way of staying in control (42nd Street, 1999a; Solomon & Farrand, 1996;
Spandler, 1996).
Self-harm provides distraction from thinking (42nd Street, 1999a).
Self-harm can obtain feelings of euphoria (Favazza, 1992; Miller, 1994).
Self-harm is a release for anger (Favazza, 1992; 42nd Street, 1999a; Solomon & Farrand, 1996).
Self-harm expresses emotional pain (Favazza, 1992; Miller, 1994).
Self-harm is a coping strategy (42nd Street, 1999a; Murray, 1998; Soloman & Farrand, 1996).
Self-harm helps a person maintain a sense of identity (Spandler, 1996).
Self-harm provides escape from depression (Favazza & Rosenthal, 1993).
Self-harm helps to deal with problems (42nd Street, 1999a).
Myths about self-harm
Self-harm is a sign of madness (Bristol Crisis Service for Women, 1999).
People who self-harm will ‘grow out of it’ eventually (Pembroke, 1998b; Pembroke, Smith &
National Self-Harm Network, 1996).
Self-harm is a manipulative act (42nd Street, 1999b; Hogg & Burke, 1998; Pembroke, 1998b;
Pembroke, Smith & National Self-Harm Network, 1996).
Self-harm is a ‘woman’s problem’ (Pembroke, 1998b; Pembroke, Smith & National Self-Harm
Network, 1996).
The best way to deal with people who self-harm is to make them stop (42nd Street, 1999b;
Harrison, 1998; Spandler, 1996).
People who self-harm have been sexually abused (42nd Street, 1999b)
Self-harm is a failed suicide attempt (BSCW, 1999; 42nd Street, 1999b; Hogg & Burke, 1998;
Martinson, 1998; Pembroke, Smith & National Self-Harm Network, 1996; Soloman & Farrand,
1996).
Self-harm is attention-seeking (BSCW, 1999; 42nd Street, 1999b; Hogg & Burke, 1998;
Pembroke, 1994, 1998b; Pembroke, Smith & National Self-Harm Network, 1996).
Everybody who self-harms suffers from Munchausens Disease (self-inflicted injuries which are
calculated to produce specific symptoms that will lead to medical hospital admission)
(Martinson, 1998).
People who self-harm should be kept in psychiatric hospitals (42nd Street, 1999b).

300 Debra Jeffrey & Anna Warm
to myths about self-harm were reverse scored
so that high scores reflected a better under-
standing of self-harm. These were added
together with the total scores from the accu-
rate statements to obtain an overall score
from the questionnaire. Thus, scores ranged
from 20 (poor understanding of self-harm) to
100 (good understanding of self-harm).
In order to assess the reliability and validity
of the questionnaire a number of methods
were used. The face validity was checked by
a clinical psychologist and a number of men-
tal health support workers. The reliability
was checked using Cronbach’s alpha coeffi-
cient (0.75) and the split-half reliability test
(0.84), thus the questionnaire was deemed to
be sufficiently reliable.
Procedure
Organisations were approached via tel-
ephone. Those that were willing to partici-
pate were mailed questionnaires. A group
worker mediated participation by the self-
harm group. Thus, all the respondents in this
group were receiving some form of group
therapy.
Results
Table 2 presents the mean scores and stand-
ard deviations for each group on the ques-
tionnaire measuring perceptions. The self-
harm group, psychology workers group and
the social/community care workers, on aver-
age, demonstrated a more accurate under-
standing of self-harm than the psychiatrist
and medical workers groups .
A homogeneity of variance-test was also
conducted to see if there were any marked
differences in the variances of the different
groups. The results showed that the data was
homogenous (p >0.05) and therefore did not
violate any assumptions f or parametric analy-
sis. A one-way ANOVA showed that there were
significant differences in understanding of
self-harm between the groups (F(4, 91.)=
7.12, p<0.0001). Table 3 presents the results
of a post-hoc Scheffe test that illustrates
which groups differed significantly in their
understanding of self-harm.
The results from this test show that there is
a significant difference between self-harm-
ers’ understanding of self-harm and the psy-
chiatrists’ and medical workers’ understand-
ing of self-harm. It also shows that psychol-
ogy workers’ understanding of self-harm is
significantly different from the psychiatrists’
and medical workers’ understanding. There
is no significant difference in their under-
standing of self-harm between self-harmers,
psychology workers and social/community
care workers. Furthermore, there is also no
significant difference between psychiatrists ,
medical workers and social/community care
workers in their understanding of self-harm.
Discussion
The results supported the hypothesis that
medical workers and psychiatrists have a
poorer understanding of self-harm than work-
ers with psychological and social care/com-
munity training. There were no significant
differences between self-harmers, psycholo-
gists and social/community care workers in
their understanding of self-harm. Although
Table 2: Table of means and SD (standard
deviations) for the total scores of each
group on their understanding of self-
harm
Mean SD
Psychiatrists 69.78 8.76
Psychology workers 79.37 6.55
Medical group 71.00 5.98
Social/Community 77.16 8.71
Self-harmers 79.81 6.46

Service providers’ understanding of self-harm 301
medical workers and social/community care
workers generally demonstrated a better un-
derstanding of self-harm than psychiatrists,
the difference was not statistically signifi-
cant. However, post-hoc analyses indicated
that differences in the social/community care
workers’ understanding of self-harm com-
pared to that of the medical workers ap-
proached statistical significance. A larger
sample may have produced a statistically
significant difference between these two
groups.
Thus it appears, from the results of this
study that perceptions and understanding of
self-harm varies amongst different occupa-
tional groups. Professionals with psycho-
logical and social/community care training
tend to have a more accurate perception of
self-harm than medical workers and psychia-
trists, or at least their ideas about self-harm
seem to be congruent with views of self-harm
that are promoted in research literature.
Professionals whose work necessitates the
development of a therapeutic relationship
with people who self-harm may come to have
a better understanding of the issues that give
rise to such behaviour than professionals
whose work tends to be based on assessment
and treatment. This lack of understanding
may contribute towards the ineffectiveness
of intervention-based treatments f or self-
har m ers pre scri b ed b y ps y chia tri s ts
(Pembroke 1994, 1998b).
Medical workers in this study acknowl-
edged their lack of understanding in relation
to self-harm. Several general practitioners in
the comments section of the questionnaire
noted that they had never received any train-
ing on this subject at medical school and a
number of nurses mentioned that the knowl-
edge and information they had on this issue
was poor and that they would like to know
more. This highlights a gap in medical train-
ing that needs to be addressed. Indeed train-
ing does not have to be extensive to increase
awareness among professions. Crawford et
al. (1996) found that a 1-hour training session
improved approaches to the treatment of self-
harm in a medical setting.
There are one or two limitations to this
study that need to be addressed in future
research. Although the present findings have
usefully illustrated some limitations of work-
ers’ knowledge and understanding within
various care settings, the sample sizes of the
various occupational groups are fairly small.
Replication of these findings using a larger
sample would lend further weight to the re-
sults. It would also be beneficial to make
comparisons between more specialised oc-
cupational groups in order to gain a clearer
picture of which types of professionals are
likely to offer the most supportive conditions
for facilitating change. Apart from the obvi-
ous implications for adapting the referral
process to more appropriately meet the needs
Table 3: Table of probabilities for post-hoc comparisons
(1) (2) (3) (4) (5)
Psychiatrists (1)
Psychology workers (2) 0.04
Self-harmers (3 ) 0.03 0.10
Medical workers (4) 0.10 0.01 0.01
Social/Community (5) 0.15 0.91 0.86 0.06
Note – figures represent probability values.

302 Debra Jeffrey & Anna Warm
of the individual, this would enable a more
accurate assessment of training needs.
Finally, it should be taken into account that
this study w as based on a questionnaire that
was developed f rom various points of view
that have been postulated within the litera-
ture. At present the inclusion of a self-harm
group does provide some evidence that the
questionnaire items are appropriately classi-
fied as being myths or accurate statements.
Although the inclusion of a sample of self-
harmers lends credence to the validity of the
questionnaire, it would be beneficial to make
a more systematic attempt to validate this
questionnaire as representing the views of
self-harmers. As much of the literature on
myths has been based on a limited number of
qualitative accounts, such an undertakin g
would provide some useful quantitative data
upon which some further clarification and
integration of the research literature relating
to the nature self-harm can be made. The
authors view this as being the most appropri-
ate direction for future research.
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