The Ethical Dilemmas of Working With Those That Self Harm.

What is self-harm? :

 “Self-harm is when you hurt yourself as a way of dealing with very difficult feelings, old memories, or overwhelming situations and experiences. The ways you hurt yourself can be physical, such as cutting yourself. They can also be less obvious, such as putting yourself in risky situations, or not looking after your own physical or emotional needs’” (MIND)

Self harming behaviour is a coping method used by some people as a way to help them manage intense and painful emotions. The need to purposely inflict physical harm on themselves, for example cutting, can provoke confusion, anxiety and concern for all those involved in delivering care and support. Just talking about self harm can cause intense feelings and emotions and many end up questioning their own morals, values and beliefs on the matter.

Self harming behaviours can cause deep feelings of disgust and unease for the observer and whilst understandable, such responses are counterproductive. Simply because they fail to provide any sort of solution for people who self-harm and such judgemental views can alienate and stigmatise. The majority of people who self harm do so in private and secretly.

A judgemental attitude can lead to professionals projecting their own anxieties and escalating responses which do nothing to address the underlying causes of this misunderstood and complex coping mechanism.  We need to start thinking about self-harm in a more rational way that takes in to account the perspectives of person who injure themselves rather than simply trying to stop their behaviour or overreacting to what are essentially none life threatening self inflicted injuries.

Self-harm doesn’t have age restrictions, research has shown that children as young as five years old and elderly people in their nineties can and do use self harming behaviours as a way of coping and expressing difficult emotions. More women seek help for self-harm than men – however, research suggests that men are equally likely to hurt themselves as well as face more cultural barriers when asking for help. The roots of self-harming behaviour are often found in Adverse Childhood Experiences including physical, verbal, sexual abuse and neglect . Or , it may be a nurtured maladaptive coping strategy, strengthened and developed over time to help some cope with being an emotional hostage to trauma they cannot articulate. Whatever the reason, it rarely has anything to to do with wanting to die, contrary to belief most people who self-harm, do so to preserve life. 

“In case you didn't know, dead people don't bleed. If you can bleed, see it, feel it, then you know you're alive. It's irrefutable, undeniable proof. Sometimes I just need a little reminder.”

Mental health issues can affect anyone, at any time, and military service personnel are no different.

Research suggests that some veterans are at an increased risk of self-harm, the risk reduces steadily the longer someone serves but I think the biggest risk factors come from pre-service life experiences coupled with adjustment and assimilation difficulties. after service.

During basic service recruits are indoctrinated to believe that they are ‘the best’ and in many ways better than their civilian counterparts. This re-programmed concept of self is both functional and necessary during military service. It takes on average just three months to strip military members of their civilian identity and replace it with a military mindset that reflects military culture and life. However, this causes significant adjustment problems when they return to civilian life. The loss of identity, structure and team membership can result in deep feelings of alienation and disconnection when returning to a fast-moving world where thousands of people are competing for both jobs and security . The reality is most people end up doing nothing more than trying to survive. To not spend the same time and effort to reverse the process at the end of a servicemember's time in uniform is neglectful.

The long term consequence of not adopting a reverse culture training programme can result in many feeling that they are no longer in a place that they recognise as home, and consequently become isolated lonely and depressed. This can lead to self-harm, confusion anxiety and a sense of hopelessness.

There are over a hundred military service charities in UK that support the well- being of veterans and their families. There are also over three hundred specialist mental health/suicide and self harm organisations.  I think we are now at the point where there is so much replication and duplication in this sector that it has become damaging and toxic.

If I feel this way, how on earth do Veterans feel? Something isn’t right and it isn’t working. An article printed in the Guardian stated 70% of the public think there are too many charities doing similar work and competing with each other. Sadly, it would appear to be true , we recently picked up a referral who had twenty two different agencies working with him and none of them were in contact with each other.

Care planning and care coordination is the way forward but in a sector where everyone is fishing in the same pool and competing for funding, we are a long way off the delivery of needs led, coordinated specialist support where the veteran is at the centre, for those that self harm the need is acute.

 Paula Edwards

Mental Health Therapist

Salute Her Women Veterans Project.