SUPPORTING UNIVERSITY STUDENTS WHO DELIBERATELY SELF-HARM
A CASE STUDY
Ron Best
Paper presented at the British Educational Research Association Annual Conference, Institute of Education, University of London, 5-8 September 2007
Background to the Study
The research reported here has its origins in an earlier (Nuffield Foundation-funded) study: Deliberate Self-Harm in Adolescence, which investigated the perspectives and perceptions of teachers and ancillary staff (counsellors, school nurses etc) of pupils’ deliberate self-harm (DSH) in a small number of schools, pupil referral units and a secure unit for young offenders. This was undertaken in 2003/2004 and was conceived as a pilot study for a major project for which funding is still sought. The findings were, however, presented at a number of conferences and CPD events, and were considered of sufficient moment to warrant publication in their own right (Best 2005a; 2005b; 2006a). A comprehensive summative paper was also presented to the 2006 European Conference on Educational Research (Best 2006b).
In consequence of the publicity resulting from publications and presentations in higher education contexts, I was approached by the head of a hall of residence in a university in the Greater London area (Note 1), where DSH amongst resident students was causing some concern. Initially I was invited to visit the hall concerned and provide a professional development session for staff. On the basis of this experience, I secured funding (Note 2) and permission from the appropriate authorities in the University and its halls of residence to undertake a similar study in the University.
The focus of the study is one that has received a good deal of attention in recent years. Reports and disclosures of self-harm by some high-profile individuals, inclusion as a theme in television ‘soaps’, and the report of a two year-long National Inquiryinto Self-harm and Young People, (National Inquiry, 2006) have all raised awareness of this phenomenon. However, it is arguable that levels of awareness and understanding in educational institutions remain low, and that this is of concern in circumstances where mental health issues amongst the student body may be increasing due to the changing nature of higher education with ‘widening participation’, student debt and personal circumstances of one kind or another add to the stresses of academic study (Tinklin et al, 2005).
The Issue
DSH is a complex phenomenon which takes many forms. Attempting to produce a succinct definition is a considerable challenge. The National Inquiry into Self Harm and Young People revised their working definition as the collection of evidence proceeded, arriving at the following in their final report:
Self-harm describes a wide range of things that people do to themselves in a deliberate and usually hidden way. In the vast majority of cases, self-harm remains a secretive behaviour that can go on for a long time without being discovered. Self-harm can involve:
cutting
burning
scalding
banging or scratching one’s own body
breaking bones
hair pulling
ingesting toxic substances or objects.
[National Inquiry, 2006, p. 5]
However, the concept of self-harm might quite sensibly be extended to embrace a range of other behaviours including attempted suicide, alcohol and drug abuse, eating disorders, unnecessarily risky behaviour and self-neglect of various kinds. Obviously, the wider the definition, the greater will be the reported prevalence of ‘self-harming’ behaviours.
The research-based literature of mental health reflects the complexity of the concept and contains a plethora of terms (some with accepted acronyms) including self-harm; deliberate self-harm[DSH]; self-mutilation [SM]; self-injury; self-injurious behaviours [SIBs]; self-destructive behaviour; self-poisoning; overdosing; self-cutting; self-wounding; delicate cutting; attempted suicide; para-suicide [Gunter, 1984; Graham and Fletcher, 1992; Suyemoto and MacDonald, 1995; Babika and Arnold, 1997; Hawton et al, 2000; Zila and Kiselica, 2001; Ross and Heath, 2002]. Favazza has offered a classification which includes majorself-mutilation; stereotypic self-injury; and moderate/superficial self-mutilation. He further categorizes the most common forms of self-injury into episodic, repetitive and compulsive [cited in Strong, 2000, pp. 26-27]. DSH may therefore be understood to vary significantly in terms not only of motive but also in the pattern and frequency of the behaviour and the scale of the injury.
The variety of explanations varies correspondingly and according to the discipline or paradigm within which one is working. Within psychiatry, DSH is frequently linked to borderline personality disorder (BPD) [Gardner, 2001, p.9]. Self-mutilating behaviour is one of nine of the criteria for BPD in the American Psychiatric Association’s [1994] manual for diagnosing mental disorders [DSM-IV], and may be treated with medication or various therapies such as dialectical behaviour therapy. However, it is important to note that classifying a patient in this way is not to explain their behaviour; indeed, one might not self-harm but be diagnosed as ‘BPD’ against other criteria, or one might self-harm but not sufficiently satisfy the other criteria to achieve such a diagnosis.
From psychodynamic and psychoanalytic perspectives, DSH may be understood in terms of object relations where the body being injured is seen as standing-in for significant persons (often the mother), and the harming behaviour as an acting-out of emotions derived from inadequate attachments or ambivalent feelings towards significant others in early childhood. From such a perspective, Gardner [2001] proposes that DSH in the form of cutting is a response to an ‘irreconcilable psychic conflict’ which she associates with a feeling both of being held captive by a significant relationship yet fearful of the freedom or lack of attachment which would follow breaking free from it. In this way the cutting of the skin may represent both the bondage and the release [p.12].
DSH may be explained from a phenomenological perspective without subscribing to the models of the psyche offered by psychoanalysis. Here, the purpose of the therapist is not so much to analyse as to empathise, seeking to understand something of the subjective experience of the client through her/his eyes. Such interpretations may be found in (amongst others), Turp [2003], Strong [2000] and Spandler [2001]. From such perspectives, DSH may be seen as a punishment on the body which is felt to be unclean or disgusting (as, for example, in the aftermath of sexual abuse); as a release of evil which, at some level of consciousness, the person feels is within them; or as an opportunity, in tending the wounds, to provide nurturing or loving care for oneself when this has not been forthcoming from significant others.
The prevalence of self-harm is difficult to determine, not least because it may be defined in more or less inclusive ways, but also because it is by nature often a solitary and secretive act. Even if others (such as family members) know someone is self-harming, it will often not come to the attention of the relevant authorities and will not be represented in the statistics. One study [Hawton et al, 2002, p1210] found that as few as 12.6% of self-harming 15-16 year-olds presented at hospital. Even where acts of self-harm require medical attention, numbers are not systematically monitored [Fox and Hawton, 2004, p. 19]. Even so, it seems that some 25,000 of the 142,000 admissions following self-harm to accident and emergency (A&E) departments each year are young people [ibid, p. 11].
Hawton et al [2002] used an anonymous self-report questionnaire with over 6000 pupils aged 15-16 in 41 secondary schools in England. 13.2% of respondents reported a ‘lifetime history of deliberate self-harm’ with just under 7% of respondents reporting having deliberately self-harmed (according to the study criteria) during the previous year [p.1208]. A survey carried out by the National Statistics Office [Meltzer et al, 2001, pp 8-9], found that 5.8% of 11-15 year-olds reported that they had tried to harm, hurt or kill themselves at some time. In a study of a community sample of 649 adolescents in two high schools in Canada, Ross and Heath [2002] found that just under 14% of students reported self-mutilating at least once (p. 74), but noted that such behaviour may be engaged in for a limited time only (p. 75).
The study reported here set out to investigate prevalence, awareness and response to DSH in a community sample in a university, with a view to raising awareness of the issue and contributing to the improvement and expansion of support to students who are affected by self-harm, either in their own behaviour or in the behaviour of their peers.
Methodology
The approach adopted is broadly interpretive and involved a questionnaire to students and semi-structured, in-depth interviews with a range of staff and student volunteers.
The questionnaire included demographic data, students’ definitions of DSH, self-reporting of experience of DSH and details of the help, advice and treatment received by self-harming students, and their perceptions of support received by others. Questionnaires [Note 3] were distributed by a variety of means. Supplies were made available (with a box for depositing completed questionnaires) in the library, in the Student Union reception area and in the reception area of the student support department. Student Union representatives were asked to distribute questionnaires in their halls of residence, and academic staff were approached to do the same in their lectures. In some cases, the researcher visited lectures specifically to distribute questionnaires. The need to have responses from as wide a range of students as possible (whether they had experience of DSH or not) was emphasised throughout.
In all, 349 completed questionnaires were returned, mostly from students on the undergraduate programmes but with occasional returns from international and Master’s students [Note 4]. The responses were inputted to an Excel spreadsheet and descriptive statistics (totals and percentages) produced.
Concepts, perceptions and case descriptions of students and of specific episodes involving DSH and responses to it, were explored in interview. Staff interviewed were selected by role - e.g. if they held positions of pastoral responsibility in a hall of residence or were involved in other caring roles (such as student services, the counselling service etc), and in some cases, through ‘snowballing’. Student Union officers with welfare roles were approached directly, but other students were contacted after volunteering for interview by completing an optional section in the questionnaire.
Interviews were undertaken on a one-to-one basis and lasted between 25 minutes and 1.25 hours, with a typical interview being of 50 minutes duration. Interviews were recorded on a digital voice recorder and were transcribedto provide hard copies for analysis. Twenty-nine interviews were completed as follows:
Staff 21
Student Union Officers 2
Students 6
TOTAL 29
To-date, 25 of the 29 interviews have been transcribed and 20 of these checked against the recordings to ensure accuracy.
In what followsthe descriptive statistics from the questionnaires and the first level of analysis of just 10interviews with staff are reported.
Concepts of Deliberate Self-Harm (DSH)
Thequestionnaire listed eight behaviours as often included in the category ‘deliberate self-harm’ and respondents were asked to indicate any of these which they would not include in their definition of DSH. 113 (33.4%) of the respondents indicated that they would exclude one or more as shown in Table 1.
TABLE 1
Number of students excluding one or more behaviours from DSH definition
Students were invited to add any other behaviours which they would include in their definitions of DSH. 81 (23.3%) of respondents added one or more of the following (the statements are indicative):
Eating disorders
“over-eating”; “not eating/starving (Anorexia)”; “binging/vomiting (Bulimia)”; “starving yourself”; “dieting to the point it affects your health”; “food related self-harm e.g. refusing yourself food”; “deliberately making yourself sick, not eating properly and therefore becoming ill”; “making oneself sick in order to be thin”.
Suicide/suicidal ideation
“methods of attempted suicide e.g. self-strangulation”; “maybe committing suicide, the thought of it”; “self-harm is also having an intent to kill oneself”.
Psychological self-harm
“mental self-harm”; “mentally tourturing (sic) yourself with thoughts”; “mental issues e.g. thinking negatively towards yourself”; “abusive to yourself in the mind, punishing yourself for bad things that happen”; “emotional self-harm, for example blaming yourself for an event which can result in self harm”.
Sexual deviance
“masochism in sexual terms”; “sado-masochistic sex”.
Physical self-abuse
“people deliberately cutting/pulling their hair out”; “pulling out eyelashes, hair”; “extreme hair cutting to the scalp”; “washing self with abrasives (vim/jiff/scourers etc)”; “hurting oneself with ice, icy water”; “sticking sharp objects into yourself”; “excess exercise/fighting”; “over-exercising”; “squeezing spots”.
Substance abuse
“drug-taking”; “taking pills”; “inhaling/sniffing harmful substances”.
Sleep deprivation
“not giving yourself enough time to relax from stress so that it affects your sleep”; “not allowing yourself the minimum number of hours of recommended sleep per night/getting much less sleep than you need on a regular basis”; “sleep deprivation”.
Prevalence of DSH
Students were asked how many times they had intentionally done any of the above since beginning university, and offered an opportunity to list any other ways in which they self harm. The results were as follows:
TABLE 2
Self-reported Behaviours
Continued….
TABLE 2 (Continued)
Self-reported Behaviours
Altogether, just over half (175 or 50.4%) of the 349 students who returned questionnaires reported having engaged in some form of self-harm since beginning university. The percentages of students reporting engaging in each of the listed behaviours are shown in Table 3. (Since respondents could indicate that they engaged in more than one of these behaviours, the figures exceed 100%):
TABLE 3
Percentage of students who reported engaging in one or more listed behaviours
14 respondents listed additional behaviours as follows:
14 respondents listed additional behaviours as follows (Table 4):
TABLE 4
Additional self-harming behaviours
If we exclude alcohol abuse and the additional behaviours listed in Table 4, the categories correspond more closely to those of the National Inquiry (op cit). Overall, a quarter (25.6%) of students report having harmed themselves intentionally at least once since beginning their university career. This is very significantly higher than the figure of 10-12 per cent which is frequently quoted, but as we have already noted, this is dependent on the breadth or precision of the definition: if any categories are excluded, and if we concentrate only on repeated behaviours, the prevalence will be significantly lower.
Students were also asked to indicate how many other students they knew who engaged in any of these behaviours. The results are shown in Table 5.
TABLE 5
Other Students’ Behaviours
TABLE 5 (Continued)
Other Students’ Behaviours
Altogether, 244 or 70.1% of the 349 students who returned the questionnaire reported knowing one or more students who engaged in one or more of the behaviours listed above. The percentages of students reporting that they knew other students who engaged in the listed behaviours were as shown in Table 6. (Again, since students could list more than one behaviour, the figures exceed 100%).
TABLE 6
Percentage of students reporting knowledge of other students engaging
in listed behaviours
9 students listed other self-harmingbehaviours by other students as follows (Table 7):
TABLE 7
Reported additional self-harming behaviours by other students
If alcohol abuse and the additional behaviours listed in Table 7 are omitted to bring the categories broadly into line with those of the National Inquiry (op cit) , well over a third (37.2%) of respondents report knowing one or more other students who have intentionally self-harmed by one or more of these methods.
Eating Disorders
Students were also asked whether they had ever had an eating disorder such as anorexia, bulimia or uncontrollable compulsive eating. 54 (15.6%) indicated that they had, at some time, suffered from an eating disorder with just 17 (5.0%) indicating that they currently do.
Support for DSH
Students were asked whether they had had help, advice or treatment for eating disorders or for any of the behaviours listed in Tables 2 and 5 above. 67 (20.5%) of those responding to this item had received some support. They were then asked to indicate if they had received ‘help’, ‘advice’ or ‘treatment’ from the following sources. (Since they might have received help and advice, help and treatment, advice and treatment, or all three, the numbers may be greater than the number of students). Respondents indicated 76 instances of help, 127 of advice and 31 of treatment.
Taken together, these forms of support were received from the following sources(Table 8). (Again, the numbers of responses may be greater than the number of students):
TABLE 8
Reported sources of help, advice or treatment
49 (21%) of respondents said they knew other students had received help, advice or treatment from some source as follows (Table 9). (Since students may have been perceived to have received support from more than one source, the total is greater than the number of respondents):
TABLE 9
Reported sources of support for other self-harming students
90 (38%) of respondents believed that other students whom they knew to have self-harmed had received no help, advice or treatment. 98 (41.4%) did not know whether support had been received or not.
Findings from Interviews
As noted above, the transcription of interviews is still in progress, so analysis is by no means complete. In what follows, no attempt is made to report systematically the findings of all of the interview data (since not all interviews have as yet been transcribed), but an initial reading of just ten interviews [Interview Nos. 1-3, 5, 7-10, 12 and 14] with staff is indicative of the richness of the data and the complexity of the professional issues raised.