Please note: This piece contains mentions of self-harm and suicide
When I [Veronica] present my work, I often begin with statistics highlighting the disparity between the prevalence of self-harm and rates of help-seeking. It often feels that this disparity communicates something of the urgency I feel around the topic of self-harm, and particularly the way we talk and think about self-harm. And I also feel a sense of solidarity and familiarity with the low rates of help-seeking, reflecting the secrecy and isolation my own experience of self-harm was so bound up with.
A recent conversation with Courtney Sommer, the co-author of this blog, prompted me to think about some of the implications of communicating urgency through a lack of help-seeking by those with experience of self-harm. We wondered what a framing of urgency in terms of help-seeking communicates about the availability and appropriateness of care for those with experience of self-harm. We also wondered whether an emphasis on help-seeking reflected the realities of people with experience of self-harm (such as ourselves and others we work with through Make Space, a user-led organisation we co-founded) — we realised it very much does not.
By framing help-seeking as the barometer of whether or not the system is successful, efforts can be (and often are) directed toward getting people to seek help, rather than looking at the ways in which help may be unavailable, inappropriate, or harmful. Imogen Tyler describes frustration at the claim that challenging stigma “can overcome ‘barriers to help-seeking’ without an acknowledgement of the ways in which stigma is deliberately designed into systems of social provision in ways that make help-seeking a desperate task” (pg 18). Positioning stigma as the most pressing problem turns attention toward individuals and away from some of the difficulties regarding the availability and appropriateness of help — this may be especially so in the case of self-harm where it is particularly easy to locate ‘problem-ness’ of self-harm in the act or individual, rather than the contexts in which self-harm arises.
Where is the help?
Stephen Fry recently called for the creation of self-referral or ‘walk-in’ mental health hubs for young people. Fry does not however, open up questions about what kinds of care would be available, led/designed by whom, and whether or not this would or should be accompanied by an increase in resources to deliver the service. Just because someone has sought help, does not mean they have received it – and many may very well find themselves at the tail end of a waiting list of unspecified length. This is certainly my (Courtney’s) experience of seeking help as a young person with experience of self-harm and suicidality. I found myself in the grey area between low-intensity services (such as IAPT, the Increasing Access to Psychological Therapies program, which offers low-intensity psychological therapies on a self-referral basis) and high-intensity support (such as inpatient care). My disclosure of self-harm and suicidality made me too risky for low-intensity services, but because I was both familiar with and comfortable with these experiences, I was not risky enough for immediate support. I, therefore, found myself in the midst of a suicidal crisis with very little support. Contrary to the push to increase ‘help-seeking’, I would have been better off if I hadn’t mentioned my self-harm at all. I wish my experience were uncommon, but it isn’t.
Fry’s apolitical call for a walk-in service for young people is representative of a broader focus on the ‘seeking’ element of ‘help-seeking’. This primacy of ‘seeking’ over ‘help’ can be seen not just in Fry’s messaging but also more broadly across public health messaging, mainstream media on mental health, and in the work of mainstream mental health charities (e.g. Time to Talk Day)
What is the help?
Help can be complex and contradictory, both as a concept and a practice, and it warrants attention. I (Veronica) conducted interviews with people with experience of self-harm as part of my PhD, exploring fictional representations of self-harm and how this impacted people with experience. With one participant, Francesca (participants selected whether to be referred to by their own names or pseudonyms), we spoke about how help for self-harm is represented in fiction, either as emotional care or psychological treatment. When discussing the film Girl Interrupted, something that annoyed her was;
“In TV depictions of any kind of mental health especially self-harm the, the long term resolution of the situation is always hospital. […]
As it appears on American television, you only have to have kind of a fraction of the symptoms that you would have to have here to be hospitalized. […]
And also, as we all know, that fantasy of, you know, you go to hospital and you get, you know, the, the father figure substitute psychiatrist who takes an interest in you and like, you know, really turns your life around is like not real. […]
The real version of it here, like, it would probably be a nightmare […] You know, the thing of like, people getting traumatized by the things that are supposed to be the interventions. […]
But it does sort of leave you thinking, well, what am I supposed to do then?”
Not only does Francesca’s experience reflect the previous point about the availability of help, but also the concern that ‘treatment’ might not always equate with ‘help’ or ‘care’. Francesca notes the ‘fantasy’ of inpatient care, as a kind of total and benevolent removal from the everyday, in contrast to its often complicated, traumatising, and nightmarish reality. For many, seeking help for self-harm starts the ball rolling on complicated and often unclear safeguarding processes that lead to care that can feel more like coercion and punishment as opposed to ‘help’ or ‘care.
The StopSIM Coalition (made up of service-users, survivors, and allies) highlights how coercion and punishment are often woven into care around self-harm. SIM refers to the Serenity Integrated Mentoring program led by the High-Intensity Network, which began in London in 2018 and has since been rolled out across various NHS Trusts in the UK. SIM is a model of care designed for people who are in frequent contact with emergency services for their mental health (often with experience of self-harm). SIM advocates for police involvement in the care of “high-intensity users”, and advocates (among other things) for colder responses to help-seeking to both to deter reattendance and prevent positive reinforcement of risky behaviours.
The StopSIM coalition highlight how “SIM criminalises people for experiencing mental distress, and does nothing to address their unmet need for support”. StopSIM has successfully resulted in a halt to the national roll-out of SIM, and hopefully a nationwide reconsideration of both the program itself and the way in which it came to exist. But the fact that SIM exists at all demonstrates exactly what Francesca suggests: that in the context of mental health, particularly intense mental distress associated with self-harm and suicide, asking for help might not only result in the absence of care, it might result in punishment and harm.
So, should help-seeking remain the indicator of urgency when it comes to care for those with experience of self-harm? We think not. Emphasis on seeking ignores not only the availability of help but crucially, the deep pain and frustration of calling for help and having nobody come. It also ignores the fact that care for self-harm can often feel very little like ‘help’ at all. Francesca asked “what am I supposed to do, here?” – a question that captures the difficulty of trying to access appropriate help and support around self-harm. But we shouldn’t be wondering what Francesca needs to do. We should be wondering how far and how fast we can change the help that is available in response to self-harm. For help seeking to happen, there must be help that can be sought, and that help should feel genuinely helpful. We should start there, with the help – and we must start immediately.
About the Authors: Veronica Heney is a member of the Cost of Living Editorial Collective. Courtney Sommer(she/they) is Director at Make Space. She is also a Doctoral Researcher in Sociology, exploring the impact of Evidence-Based Medicine on mental health policy and practice. Make Space is a user-led collective that creates spaces for more generous, nuanced, and caring ways to support those with experience of self-harm. You can find about Make Space’s work on their website or through their Twitter.