The non-display of authentic distress: public-private dualism in young people's discursive construction of self-harm

Development and validation of the self-injury stigma scale

Non-suicidal self-injury is a prevalent and concerning behavior. Negative beliefs and stereotypes about NSSI are associated with negative outcomes, and negative, self-referential beliefs (e.g., self-stigmatizing beliefs) related to engagement in NSSI may be particularly harmful. Despite this, there is no validated measure specifically designed to assess for NSSI self-stigma. As this significantly hinders the ability to understand and quantify the effect of NSSI self-stigma, this study sought to validate the newly developed Self-Injury Stigma Scale (SISS). It was hypothesized the SISS would follow a four-factor structure that parallels a widely cited theoretical model of stigma. It was also hypothesized measures of shame and help-seeking self-stigma would be moderately, negatively, correlated with the SISS subscales, supporting the measure's validity. Participants from Study 1 were college students (n = 264, 65.8% female) with at least one lifetime NSSI act. A series of factor analytic models revealed a one-factor structure for the Application of Stigma subscale (i.e., third step of the four-step model). As this was the only SISS subscale to achieve an appropriate model fit, this scale alone was retained as the final SISS. The factor structure was tested via confirmatory factor analysis on a second sample (i.e., community participants with at least one past month of NSSI act; n = 240, 41.3% female). An acceptable fit on most, but not all, indices was reached. Convergent and discriminant validity were supported. The SISS retrospectively predicted past 3 month NSSI frequency and method versatility, and lifetime NSSI versatility, but not lifetime NSSI frequency or disclosure. Thus, the clinical utility of the SISS was partially supported. Findings offering evidence in favor of the SISS's appropriateness and utility as a measure of self-stigma of NSSI. Future work using this measure has the potential to clarify the risk associated with NSSI self-stigma and inform behavioral interventions.

Understanding suicide clusters through exploring self-harm: Semi-structured interviews with individuals presenting with near-fatal self-harm during a suicide cluster

There was a highly publicised cluster of at least ten suicides in South Wales, United Kingdom, in 2007-2008. We carried out a qualitative descriptive study using cross-case thematic analysis to investigate the experiences and narratives of eight individuals who lived in the area where the cluster occurred and who survived an episode of near-fatal self-harm at the time of the cluster. Interviews were conducted from 01.01.2015 to 31.12.2015. All interviewees denied that the other deaths in the area had affected their own suicidal behaviour. However, in other sections of the interviews they spoke about the cluster contributing to difficulties they were experiencing at the time, including damage to social relationships, feelings of loss and being out of control. When asked about support, the interviewees emphasized the importance of counselling, which they would have found helpful but in most cases did not receive, even in the case of close contacts of individuals who had died. The findings suggest that effective prevention messaging must be subtle, since those affected may not be explicitly aware of or acknowledge the imitative aspects of their behaviour. This could be related to stigma attached to suicidal behaviour in a cluster context. Lessons for prevention include changing the message from asking if people 'have been affected by' the suicide deaths to emphasising the preventability of suicide, and directly reaching out to individuals rather than relying on people to come forward.

'Faking it': Exploring adolescent perceptions of depression (in)authenticity and 'attention seeking'

OBJECTIVES

Attitudes towards peers who are not perceived to be legitimately depressed, or whose depression 'authenticity' is questioned, represent a current gap in adolescent depression stigma research. This research study, therefore, investigated how perceptions of depression inauthenticity are framed in adolescent Reddit communities.

METHODS

This observational study used an internet-mediated, qualitative methodology to analyse forum posts from April 2019 to January 2020 on three adolescent-based subreddits. Posts were extracted using the Baumgartner Reddit Corpus. Identifiable information was removed to protect anonymity.

RESULTS

Inductive thematic analysis identified two overarching themes, namely, public stigma and self-stigma associated with depression inauthenticity. Public stigma could be further dissected into five subthemes: (i) dichotomy between 'real' and 'fake depression'; (ii) aggression towards 'fakers'; (iii) stereotypes; (iv) attention; and (v) diagnosis. On the other hand, the theme of self-stigma consisted of subthemes: (i) self-doubt and (ii) validation and invalidation.

CONCLUSIONS

Adolescents framed a dichotomy between so-called 'real' and 'fake depression', with hostility directed at peers perceived to be 'fake depressed'. Perceptions of depression inauthenticity were confused and inconsistent. Public and self-stigma towards depression inauthenticity enforced barriers to help-seeking. While future research should investigate to what extent these observations based on online forums mimic stigma in real-life settings, our findings have highlighted the needs for 'fake depression' stigma to be addressed by adolescent depression literacy and stigma interventions. Recent movements towards reconceptualizing depression as a dimensional construct may help to challenge these stigmatizing views of a dichotomy between 'real' and 'fake' depression.

PRACTITIONER POINTS

There is widespread stigma concerning perceived inauthenticity related to depression in these online adolescent communities, with vitriol targeted at peers perceived to be so-called 'fake depressed'. Adolescent depression literacy and stigma programmes should tackle stigma towards perceived inauthenticity and promote the message that all adolescent distress deserves attention and help. This involves challenging perceptions that only supposedly 'authentic', diagnosed, or diagnosable, depression is worthy of attention and support. Prevention Programmes should work to mitigate barriers to help-seeking posed by misunderstandings that distress which is kept secret is more 'authentic', and tackle gender and age stereotypes surrounding perceived inauthenticity. There is a need for clinically approved online resources targeted at adolescents who feel unsure about whether their symptoms could be indicators of depression, and to make professional advice and help more accessible for young people.

The Politics of LGBT+ Health Inequality: Conclusions from a UK Scoping Review

This scoping review of UK evidence aimed to describe what is known about Lesbian, Gay, Bisexual, and Trans (LGBT+) health inequalities in relation to cancer, mental health, and palliative care to inform research, policy and public health interventions. Using a scoping review methodology, we identified studies from database searches, citation tracking, and expert consultation. The in/exclusion criteria was based on the PICOS framework. The data were charted and then summarised to map the theoretical approaches and the main types of evidence and identify knowledge gaps. In total, 279 articles were screened and 83 were included in the final review. We found that there is limited UK research examining LGBT+ health inequality in cancer, mental health and palliative care. We would argue that this thin evidence base is partly due to national policy discussions of LGBT+ health inequality that are framed within a depoliticised ‘it’s getting better’ narrative, and an unwillingness to adequately acknowledge the unjust social and economic relations that produce LGBT+ health inequality. In addition, LGBT+ health inequality is depoliticised by existing public health explanatory theories, models and frameworks that exclude sexual orientation and gender diversity as dimensions of power that interlock with those of socio-economic, race and ethnicity. This is a barrier to developing public health interventions that can successfully tackle LGBT+ health inequality

Theorising health professionals' prevention and management practices with children and young people experiencing self-harm: a qualitative hospital-based case study

Self-harm in young people remains a significant concern. Studies of emergency departments have centred on negative professional attitudes. There has been limited interrogation and theorisation of what drives such attitudes, and the contexts that sustain them. Adopting a complex systems lens, this study aimed to explore how systems shape professional and patient interactions. It draws upon interviews with healthcare and affiliated professionals (n = 14) in a UK case study hospital, with primary focus on the emergency department. Data were analysed using a thematic approach and the principles of grounded theory. Four themes emerged, with the first three centralising how professionals' practices operate within: (1) a framework of risk management; (2) expectations of progressing patients through the care pathway; and (3) a culture of specialist expertise, with resulting uncertainty about who is responsible for self-harm. The fourth theme considers barriers to system change. A small number of participants described efforts to enact positive modifications to practices, but these were frustrated by entrenched system structures. The potential detrimental impacts for patient care and professional wellbeing are considered. Future practice needs systemic action to support professionals in treating patients experiencing self-harm, while future research requires more ethnographic explorations of the complex system in situ.

'I couldn't say the words': communicative bodies and spaces in parents' encounters with nonsuicidal self-injury

There is a growing recognition that nonsuicidal self-injury commonly incorporates communicative and interactional dimensions. But regardless of whether we approach self-injury within the terms of deliberate interpersonal communication, it is undeniably something that conveys a significant impact into the social and communicative field between people. As such, it is something that can be approached and analysed as communicative in this more general sense. In this paper, we draw on 13 in-depth qualitative interviews with the parents of people who self-injure, conducted for a larger pilot study, to explore some of these more general communicative processes, spaces and impacts associated with self-injury. By providing a phenomenologically informed examination of parents' experiences, we argue that self-injury is in fact a richly communicative phenomenon, albeit one that cannot be adequately mapped using the traditional sender-receiver communication paradigm. To provide a more nuanced mapping, we look beyond this paradigm to include more subtle, ambiguous, pre-reflexive and bodily forms of communication. Indeed, self-injury offers a particularly powerful case study with which to think through a more complex model of communication, one that connects the interpersonal, intersubjective and intercorporeal levels, and that, as such, is more appropriate to the sociologies of everyday life and embodiment.

The social life of self-harm in general practice

Research engaging qualitatively with clinical practitioners' understanding of, and response to, self-harm has been limited. Self-harm offers a particularly compelling case through which to examine the enduring challenges faced by practitioners in treating patients whose presenting symptoms are not clearly biomedical in nature. In this paper, we present an analysis of 30 General Practitioners' (GPs') accounts of treating patients who had self-harmed. Our analysis demonstrates the complex ways in which GPs seek to make sense of self-harm. Illustrated through three common 'types' of patients (the 'good girl', the 'problem patient' and the 'out of the blue'), we show how GPs grapple with ideas of 'social' and 'psychological' causes of self-harm. We argue that these tensions emerge in different ways according to the social identities of patients, with accounts shaped by local contexts, including access to specialist services, as well as by cultural understandings regarding the legitimacy of self-harming behaviour. We suggest that studying the social life of self-harm in general practice extends a sociological analysis of self-harm more widely, as well as contributing to sociological theorisation on the doctor-patient relationship.

The social life of self-injury: exploring the communicative dimension of a very personal practice

This article makes the case for a sociological focus on the communicative, relational and interactional dimensions of nonsuicidal self-injury. While current research tends to be dominated by highly individual and intrapsychic models, it is increasingly observed that such models leave a social dimension to the practice unexplained. A burgeoning sociological literature has begun to address this paradox of the social in self-injury; however, we argue that the role of the social must be considered beyond the issues of aetiology, social learning and social construal/construction that are typically covered in this literature. Specifically, we argue that, since the lived meanings of self-injury directly implicate the interactional along with the intrapsychic, a more systematic focus on the role of social relations and social communication is vital. To illustrate this conceptual argument and embed it in the lived experiences of self-injury, we draw on two case studies taken from pilot research conducted by the authors. The more thoroughly sociological approach to self-injury that we present here offers an important compliment to the existing evidence base by reframing the absent presence of social communication contained within it, and suggesting important future directions for research.

Survival, Signaling, and Security: Foster Carers' and Residential Carers' Accounts of Self-Harming Practices Among Children and Young People in Care

Research on clinicians' interpretations of self-harming practices has shown that they can often be negative. To date there has been limited consideration of other professionals' narratives, notably those working in social care. This article presents focus group and interview data generated with foster carers ( n = 15) and residential carers ( n = 15) to explore the symbolic meanings ascribed to self-harm among the children and young people they care for. Three repertoires of interpretation are presented: survival, which conceives self-harm as a mechanism for redefining the identity of "looked-after"; signaling, which understands self-harm as a communicative tool for the expression of emotion; and security, which sees self-harming practices as testing the authenticity and safety of the caring relationship. Through their focus on sociocultural narratives, carers position themselves as experts on self-harm due to their intimacy with young people's social worlds. This construction potentially creates distance from health professionals, which is problematic given the current privileging of interprofessional working.

The influence of online images on self-harm: A qualitative study of young people aged 16-24

To date, research on the role of the Internet in self-harm has focused on young people's interaction via the medium of text, with limited consideration of the effect of images. This qualitative study explores how young people understand and use online images of self-harm. Semi-structured interviews were conducted with a community sample of 21 individuals aged 16–24 living in Wales, UK, with a previous history of self-harm. Interviewees reported the role of the Internet in normalising young people's self-harm. Images rather than textual interactions are the primary reason cited for using the Internet for self-harm purposes. Images invoke a physical reaction and inspire behavioural enactment, with Tumblr, which permits the sharing of images by anonymous individuals, being the preferred platform. Viewing online images serves a vital role in many young people's self-harm, as part of ritualistic practice. Online prevention and intervention need to attend to the importance of images.

General Practitioners' Accounts of Patients Who Have Self-Harmed: A Qualitative, Observational Study

Abstract.Background: The relationship between self-harm and suicide is contested. Self-harm is simultaneously understood to be largely nonsuicidal but to increase risk of future suicide. Little is known about how self-harm is conceptualized by general practitioners (GPs) and particularly how they assess the suicide risk of patients who have self-harmed. Aims: The study aimed to explore how GPs respond to patients who had self-harmed. In this paper we analyze GPs’ accounts of the relationship between self-harm, suicide, and suicide risk assessment. Method: Thirty semi-structured interviews were held with GPs working in different areas of Scotland. Verbatim transcripts were analyzed thematically. Results: GPs provided diverse accounts of the relationship between self-harm and suicide. Some maintained that self-harm and suicide were distinct and that risk assessment was a matter of asking the right questions. Others suggested a complex inter-relationship between self-harm and suicide; for these GPs, assessment was seen as more subjective. In part, these differences appeared to reflect the socioeconomic contexts in which the GPs worked. Conclusion: There are different conceptualizations of the relationship between self-harm, suicide, and the assessment of suicide risk among GPs. These need to be taken into account when planning training and service development.

Asking for help online: Lesbian, gay, bisexual and trans youth, self-harm and articulating the ‘failed’ self

International evidence suggests that young people are less likely to seek help for mental health problems in comparison with adults. This study focused on lesbian, gay, bisexual and trans young people who are a population group with an elevated risk of suicide and self-harm, and little is known about their help-seeking behaviour. Utilising qualitative virtual methods, lesbian, gay, bisexual and trans youth web-based discussions about seeking help for suicidal feelings and self-harming were investigated. Findings from a thematic analysis indicate that these young people wanted assistance but found it difficult to (1) ask for help, (2) articulate emotional distress and (3) ‘tell’ their selves as ‘failed’. This analysis suggests that key to understanding these problems are emotions such as shame which arise from negotiating norms connected to heterosexuality, adolescence and rationality. I argue that these norms act to regulate what emotions it is possible to feel, what emotions it is possible to articulate and what type of young lives that can be told. The future development of health and social care interventions which aim to reduce lesbian, gay, bisexual and trans youth suicide and self-harm need to work with a nuanced understanding of the emotional life of young people if they are to be effective.

Inviting pain? Pain, dualism and embodiment in narratives of self-injury

The role of pain in the practice of self-injury is not straightforward. Existing accounts suggest that self-injury does not cause 'physical' pain, however self-injury is also said to alleviate 'emotional' pain by inflicting 'physical' pain. This article explores these tensions using sociological theories regarding the socio-cultural and subjective nature of pain. Analysis derives from in-depth, life-story interviews carried out in the UK with people who had self-injured. Findings contribute to on-going debates within social science regarding the nature of pain. Participants' narratives about pain and self-injury both drew on and challenged dualistic models of embodiment. I suggest that self-injury offers a unique case on which to extend existing theoretical work, which has tended to focus on pain as an unwanted and uninvited entity. In contrast, accounts of self-injury can feature pain as a central aspect of the practice, voluntarily invited into lived experience.

Pushing the boundaries: understanding self-harm in a non-clinical population

This study investigates 122 people's descriptions of their self-harm experiences using thematic analysis. Analysis revealed four themes: What counts as self-harm, What leads to self-harm, Intentions and Managing stigma. Our participants challenged commonly accepted understandings in terms of method, outcome and intentions. Several difficulties associated with discriminating between suicidal and non-suicidal self-harm were highlighted, which may be important in clinical practice. Few participants mentioned diagnosed psychiatric disorders; they best understood self-harm through their social experiences. Focusing on social understandings of self-harm may help reduce associated stigma and barriers to help-seeking.