Self-help books on deliberate self-harm

Self-help for self-harm trips nicely off the tongue but is less easily translated into helpful, practical literature – or, indeed, into effective professional treatment. The grim truth is that there is no successful treatment for deliberate self-harm (Hawton et al, 2003), although much of the self-help literature, urges patients to seek help from professionals. So, people who deliberately harm themselves may well have to rely on self-help, which no longer takes a ‘no-nonsense, pull yourself together’ attitude but has become an empathic, sharing, practical notion that you, yourself, can do something about your problem, often through learning about the experiences of others.

There is no shortage of self-help advice for people who deliberately harm themselves, with the explosion of web-based information and an increasing number of books rolling off the printing press. Prior to 1988 there were almost no self-help books on deliberate self-harm but now they are published with increasing frequency, giving the behaviour its own acronym of ‘SIV’ (self-inflicted violence) or ‘SI’ (self-injury). Some books seem written primarily to promote the success of the therapist (Levenkron, 1999), others describe the personal experience of deliberate self-harm (Pembroke, 1994) and yet others focus on practical advice about how to stop. All have evocative titles, most notably A Bright Red Scream (Strong, 1999). Most are by women. Few target specifically the adolescent. The books and websites are not solely for patients. Professionals who read these books will gain insight into the emotional struggles surrounding deliberate self-harm and obtain hints, if not direct advice, about helpful attitudes. In the era of user empowerment, people who deliberately harm themselves are a vociferous group who feel let down by professionals.

WEB-BASED INFORMATION

A recent straw poll locally of people attending a self-harm clinic suggested that only a minority had referred to any self-help books, perhaps because self-help remains more embedded in American than British culture (most of the books are American). But when the question was rephrased to ask whether the individual had sought information on deliberate self-harm from any source, most patients who responded stated they had used the internet. Not surprisingly, there is an abundance of information to be found. At the site of the National Self-harm Network (http://www.nshn.co.uk) there is an abundance of advice and information, checklists to guide treatment, and an attempt to debunk some of the myths surrounding deliberate self-harm: ‘it's attention-seeking’, ‘they're manipulative’, ‘it's self-inflicted and so it's not serious’, ‘they enjoy pain’. I particularly liked the treatment checklist, which is more of a request list, to give to the triage nurse when attending the accident and emergency department, and would be interested to know if the response it evokes in the staff is sympathy and greater professionalism.

Motivation to stop is a common theme in most of the self-help information. Motivation fluctuates, and it is easy to vow abstinence in the midst of a hangover but less so during the excitement of a party. Herein lies the problem for those who deliberately inflict self-harm, who have to find a way to maintain motivation to stop in the face of a compulsive desire to cut or harm themselves when emotions run high. A well-developed website entitled ‘Self-injury: You are NOT the only one’ (formerly ‘secret shame’) offers a checklist to help individuals to decide if they are ready to stop self-harm (http://www.palace.net/~llama/psych/injury.html) as well as giving many ideas of what to do instead. Techniques recommended include the inevitable distraction and relaxation, along with writing about how you feel, talking to friends, holding ice for a painful sensation and, if you like the sight of blood, making ice with redcurrant juice in it. A further useful list of self-help techniques taken from questionnaire results is available at http://members.tripod.com/helen-scott/self_help.htm. Other information is helpfully listed at http://www.users.zetnet.co.uk/bcsw, the site of the Bristol Crisis Service for Women, where their Women and Self-Injury leaflet is available, or at the Basement Project, http://freespace.virgin.net/basement.project/default.htm.

BOOKS

Although the internet is the royal road to information, there is nothing like a good book to keep you on track when motivation is weak and a morale-booster session is necessary. It can be grabbed from the shelf within seconds and is a permanent reminder of having decided to give up deliberate self-harm. If there was only room for one book, it would have to be (and I told you they all have evocative titles, redolent with meaning) The Scarred Soul: Understanding and Ending Self-Inflicted Violence (Alderman, 1997). It is clear, accessible and practical, containing exercises on stopping ‘right now’, with suggestions about how to get to ‘the roots of why you hurt yourself’ and how to cope with the feelings that lead to deliberate self-harm. No panacea is offered and the struggle associated with stopping is palpable from beginning to end.

A more personalised account is available in A Bright Red Scream: Self-mutilation and the Language of Pain (Strong, 1999) which, although not specifically a self-help book, gives insight into the mind of the person who deliberately inflicts self-harm and is likely to reassure people that they are not alone with their struggle. Marilee Strong interviewed a number of people, many of whom belonged to the self-help group ‘Bodies-under-Siege’ (http://www.palace.net/~llama/psych/injury.html), and chronicles through poetry and stories the lives of people who deliberately harm themselves. She has a tendency to assume that such people have inevitably experienced sexual abuse, which gets in the way slightly, but nevertheless this book contains lots of common sense. A UK book in a similar vein is Healing the Hurt Within: Understand and Relieve the Suffering Behind Self-destructive Behaviour by Jan Sutton (Sutton, 1999). She uses quotes and poems by people with personal experience of deliberate self-harm, mixed with facts and statistics to weave a comprehensive account of the meaning and understanding of this phenomenon. Self-help sections and useful further reading are included.

Self-harm: Perspectives from Personal Experience (Pembroke, 1994) is another book giving graphic first-person accounts of deliberate self-harm and of the rather fumbling attempts of professionals to intervene. Based on a conference held in 1989, the book gives an overriding impression of individuals receiving inadequate treatment using ill-conceived interventions which are sometimes cruelly implemented. Nevertheless, good examples of care and support are documented as well. The sections on ‘attention seeking’, accident and emergency treatment, social consequences of deliberate self-harm and the psychiatric interpretation of such self-harm are strident but informative. For the self-help seeker there is a useful points and suggestions section towards the end.

Partners, relatives and others may need help if they are to react constructively to deliberate self-harm, but for these people there is limited advice available. One of the best books, equally useful for men despite its title, is Women and Self Harm (Smith et al, 1998). The section for family and friends will help all involved to remain calm and to feel less responsible. The three (British) female authors suggest strategies for recovery and give practical advice for those caring for women with this problem.

Finally, although they are not strictly self-help books, two accounts are required reading for everyone involved with a person who inflicts deliberate self-harm. The first, Skin Game by Caroline Kettlewell (Kettlewell, 2000) gives a disquieting and startlingly honest account of her self-harm, which began in adolescence and quietly embedded itself into a way of life in early adulthood. Her descriptions are frighteningly graphic and yet retain a gripping poignancy, linking body and mind:

‘There was a very fine, an elegant pain, hardly a pain at all.... Then the blood welled up and began to distort the pure, stark edges of my delicately wrought wound. The chaos in my head spun itself into a silk of silence. I had distilled myself to the immediacy of hand, blade, blood, flesh.’

The second is an account by a young and innocent psychiatrist (Walker, 2003) about his whirlwind relationship and marriage to a self-destructive patient with borderline personality disorder, whom he met as a medical student when assessing her after an episode of self-harm. Here you will find a riveting account not only of the desperation often found behind deliberate self-harm but also of the suffering of those most closely involved. Not all people who thus harm themselves have borderline personality disorder but when they do, the problems are magnified. If you never believed in transference and counter-transference and the effect of deliberate self-harm on self and others, then read this book. It is not so much a psychiatrist's tale as a human story.