Behind self-harm

Behind self-harm uncovers what might have led people to harm themselves. Several factors were directly linked to self-harm, in addition to the factors indirectly leading to self-harm by causing chronic stress and difficulties in an individual's life. These direct and indirect risk factors spanned personal, interpersonal and societal matters. Table 2 shows the reciprocal translations of ‘behind self-harm’, which include five third-order constructs: negative perceptions of self, isolation, exposure to violence, cultural risk factors and economic problems.

Negative perceptions of self were discussed in seven studies. Self-harm was directly linked to self-hate,^{Reference Chew-Graham, Bashir, Chantler, Burman and Batsleer21,Reference Aktar24–Reference Sambath26} self-worth and low self-esteem.^{Reference Aktar24,Reference Bhardwaj25,Reference Ahmed, Mohan and Bhugra27–Reference Wood31} Those who reported self-hate saw self-harm as self-punishment.^{Reference Sambath26}

Isolation and its impact on mental health were mentioned in almost all studies. Some studies explored how conceptual factors led to increased isolation in South Asian women.^{Reference Chew-Graham, Bashir, Chantler, Burman and Batsleer21} The lack of trusted companions was a commonly reported theme. Therefore, South Asian women were unable to share their difficulties, which led to ongoing distress. Also, interpersonal losses and rejections were linked to suicidal ideation and behaviours.^{Reference Hicks and Bhugra22,Reference Sambath26,Reference Sayal-Bennett30,Reference Marshall and Yazdani32} The lack of English proficiency was another factor that was associated with a lack of knowledge of health services. This prevented individuals from accessing mental health services and from knowing about available resources and their rights.^{Reference Chew-Graham, Bashir, Chantler, Burman and Batsleer21,Reference Hicks and Bhugra22,Reference Ahmed, Mohan and Bhugra27,Reference Hussain and Cochrane29–Reference Wood31}

Exposure to violence represented all kinds of experiences of racist, sexist and abusive behaviours exacerbating mental well-being, which were reported in the studies. Racism was reported as an external pressure by South Asian women.^{Reference Chew-Graham, Bashir, Chantler, Burman and Batsleer21,Reference Aktar24,Reference Sambath26,Reference Chantler28,Reference Sayal-Bennett30,Reference Wood31} Abusive relationships and domestic violence were linked in most studies to self-harm or suicide attempts when women could not receive any assistance to deal with their domestic situations.^{Reference Chew-Graham, Bashir, Chantler, Burman and Batsleer21,Reference Hicks and Bhugra22,Reference Aktar24–Reference Sambath26,Reference Chantler28,Reference Sayal-Bennett30–Reference Mafura and Charura33} Discrimination owing to gender and ethnicity also increased isolation among South Asian women.^{Reference Chew-Graham, Bashir, Chantler, Burman and Batsleer21} South Asian women have spoken about this double jeopardy they have faced:

Economic and political inequalities were reported in relation to housing issues, poverty and limited access to benefits/welfare rights.^{Reference Ahmed, Mohan and Bhugra27,Reference Chantler28,Reference Sayal-Bennett30} These issues were discussed in relation to systemic and political aspects such as the 2-year rule. The 2-year rule was a former law that mandated the deportation of foreign spouses who ended their marriage within 2 years of coming to the UK through marriage. This policy had negative outcomes of leaving some immigrant women in abusive marriages with limited options to leave or receive financial help.^{Reference Chantler28} For example, South Asian women who do not have welfare rights become economically dependent on their relatives, which perpetuates their distress when they experience domestic violence.^{Reference Chantler28} ‘State and familial oppression’ causes such distress, and has resulted in self-harm and suicide.^{Reference Chantler28} In one woman's account, the distress caused by the issue of obtaining a visa was presented as follows:

Further, the failure to provide housing to women who have escaped abusive relationships was also reported as a risk factor for suicide. Women could be easily tracked by their abusers in small communities, which makes providing safe housing to domestic survivors more crucial.^{Reference Chantler28}

Cultural risk factors were discussed in most of the studies, including gender inequality, unrealistic expectations set for women, the community grapevine, family honour, forced marriage and being controlled by family members. There are some cultural risk factors for mental health that are not specific to South Asian culture, such as gender inequality. However, personal and social resources for dealing with such external pressures might differ among ethnic minority women.

Gender inequality is reported as feeling oppressed by ‘gender-based roles and expectations’,^{Reference Sambath26} and discrimination toward women might cause distress and self-harm.^{Reference Chew-Graham, Bashir, Chantler, Burman and Batsleer21,Reference Aktar24,Reference Mafura and Charura33} South Asian women are subjected to the community grapevine as their community tends to monitor and blame women.^{Reference Chew-Graham, Bashir, Chantler, Burman and Batsleer21} Unrealistic expectations were reported as another external pressure on women; these included academic expectations in families and traditional South Asian expectations of family members and the community.^{Reference Chew-Graham, Bashir, Chantler, Burman and Batsleer21,Reference Aktar24–Reference Sambath26,Reference Wood31–Reference Thabusom34} Traditional expectations set high standards for women to follow. For example, women should protect their family's prestige with their academic achievements and ‘correct’ behaviours.^{Reference Gunasinghe, Hatch and Lawrence20,Reference Chew-Graham, Bashir, Chantler, Burman and Batsleer21,Reference Aktar24–Reference Sambath26,Reference Wood31–Reference Thabusom34} This interacts with another theme, family honour. Family honour is called izzat in South Asian culture, and is defined as ‘family or personal honour/respect, or as status and prestige in the eyes of the community’.^{Reference Chew-Graham, Bashir, Chantler, Burman and Batsleer21} Giving much importance to family honour might cause people to ignore women's struggles and to hide the abuse within the family, all of which leave women alone with their distress.^{Reference Gunasinghe, Hatch and Lawrence20,Reference Mafura and Charura33} Being controlled was another cultural risk factor for distress mentioned in many studies.^{Reference Gunasinghe, Hatch and Lawrence20,Reference Chew-Graham, Bashir, Chantler, Burman and Batsleer21,Reference Aktar24–Reference Sambath26,Reference Chantler28,Reference Sayal-Bennett30–Reference Thabusom34} Forced marriage, being prevented from having an education and lack of autonomy were some examples of controlling behaviours. All unequal behaviours toward women listed above set barriers to sharing difficulties with others and seeking help from outside of the community.^{Reference Chew-Graham, Bashir, Chantler, Burman and Batsleer21} Consequently, women had limited space and resources to discuss their difficulties and solve their problems, which caused further isolation, depression and self-harm.^{Reference Gunasinghe, Hatch and Lawrence20}

Functions of self-harm

In the literature, functions of self-harm and reasons for self-harm were used interchangeably.^{Reference Nock35} In the current review, we define ‘functions of self-harm’ as how self-harm was perceived and what meanings and motivations were attributed to it. The theme of functions of self-harm was elaborated from the participants’ comments of what had happened just before, during or after self-harm. Table 3 shows the five third-order constructs that were generated from the findings of the studies: emotion regulation, communication and expression, taking or losing control, provoking change and negative experience.

Emotion regulation refers to the temporary positive effects of self-harm in easing the burden of a situation. In most studies, this situation was synthesised as a coping mechanism. Specifically, self-harm was viewed as relief from emotional pain.^{Reference Aktar24–Reference Sambath26,Reference Sayal-Bennett30–Reference Thabusom34} Self-harm functions to convert emotional pain into physical pain and, consequently, to produce a sense of relief just afterward.^{Reference Wood31,Reference Marshall and Yazdani32} Among women with depression, self-harm was seen as a way of releasing anxiety.^{Reference Hussain and Cochrane29}

Communication and expression associated with self-harm was seen as the expression of anger, emotional pain and distress.^{Reference Gunasinghe, Hatch and Lawrence20,Reference Chew-Graham, Bashir, Chantler, Burman and Batsleer21,Reference Klineberg, Kelly, Stansfeld and Bhui23,Reference Aktar24,Reference Sambath26,Reference Wood31–Reference Mafura and Charura33} Self-harm was also described as a way of communicating when there is a lack of words to describe emotions.^{Reference Sambath26} Also, the intention to be noticed by others was reported.^{Reference Klineberg, Kelly, Stansfeld and Bhui23,Reference Wood31} This is beyond attention-seeking and is a sign of unspoken struggles.^{Reference Wood31}

Control was mentioned when describing self-harm in different ways. Self-harm was seen as taking control when participants felt that they had no control or power over their lives.^{Reference Bhardwaj25,Reference Sambath26,Reference Wood31–Reference Thabusom34} However, self-harm might mean losing control when it becomes a daily practice or only an option for temporary positive side-effects, such as feeling relief. Some participants reported that they could not stop self-harming even if they wanted to, and that they lost control of the frequency of self-harm.^{Reference Aktar24,Reference Wood31,Reference Marshall and Yazdani32}

Provoking change represents the theme of self-harm being used to change situations or others’ behaviour. For some, self-harm was a way of obtaining care from others,^{Reference Klineberg, Kelly, Stansfeld and Bhui23,Reference Wood31} including external professional support.^{Reference Bhardwaj25,Reference Sambath26}

In terms of negative experience, self-harm was described as having negative features and consequences. Self-harm was attached to feelings of shame and guilt afterward,^{Reference Aktar24,Reference Sambath26,Reference Wood31,Reference Mafura and Charura33} rather than bringing real change.^{Reference Sayal-Bennett30,Reference Marshall and Yazdani32} It was also described as unhelpful and sinful.^{Reference Aktar24,Reference Sambath26}

Recovery from self-harm

Recovery from self-harm included self-help, positive and negative mental health service experiences, and suggestions for improving mental health services, which are presented in Table 4.

Self-help represents the second-order constructs of religion and volunteering. Religion was mentioned as a positive aspect of managing unbearable circumstances. Believing in Islam, which does not permit any harm to the self, praying to Allah and accepting the faith helped the participants to deal with their problems.^{Reference Gunasinghe, Hatch and Lawrence20,Reference Ahmed, Mohan and Bhugra27,Reference Hussain and Cochrane29,Reference Sayal-Bennett30,Reference Thabusom34} Doing voluntary work provided the participants with some social gain, such as helping others, spending their time well and getting away from difficult home situations.^{Reference Sayal-Bennett30}

Positive health service experiences included receiving good counselling and community services support. The features of good counselling were described as ‘being listened to and understood’ with empathy by professionals who encourage women to express themselves.^{Reference Thabusom34} Cognitive–behaviour therapy was helpful because it provided ‘practical solutions’.^{Reference Wood31} Some participants explicitly stated that having counselling prevented them from attempting suicide^{Reference Sayal-Bennett30} and self-harm.^{Reference Wood31} Community services were valued because they provided mental health support, offered housing and benefits support, and made effective referrals to the appropriate agencies.^{Reference Chantler28}

Negative health service experiences were presented in terms of barriers to accessing services and inadequate service responses. Mistrust of health services was one of the barriers to seeking help. Participants reported that they would mistrust professionals from outside their community as these professionals might not understand them because of limited knowledge of South Asian culture.^{Reference Chew-Graham, Bashir, Chantler, Burman and Batsleer21,Reference Bhardwaj25,Reference Sambath26,Reference Wood31} Similarly, they mistrusted professionals from within their community, who might break confidentiality or judge them according to traditional views.^{Reference Chew-Graham, Bashir, Chantler, Burman and Batsleer21,Reference Bhardwaj25,Reference Sambath26,Reference Wood31} Further, lack of knowledge about available services was another barrier to obtaining help.^{Reference Bhardwaj25,Reference Chantler28} Some studies evaluated service responses to self-harm and suicide. Primary care workers provided limited support because of their lack of understanding of self-harm^{Reference Marshall and Yazdani32} and non-referral of patients to mental health services.^{Reference Chantler28} Some respondents had experienced health workers not listening with empathy and understanding.^{Reference Chantler28}

Suggestions for improving access to support services and service responses were synthesised. To improve mental health access, South Asian women recommended that trust in healthcare services and professionals should be built to enable South Asian women to discuss their personal concerns.^{Reference Chew-Graham, Bashir, Chantler, Burman and Batsleer21} Also, the stigma around help-seeking and self-harm should be reduced.^{Reference Sambath26,Reference Wood31,Reference Marshall and Yazdani32} This could be achieved by increasing awareness about psychology and mental health,^{Reference Chew-Graham, Bashir, Chantler, Burman and Batsleer21,Reference Bhardwaj25,Reference Sambath26,Reference Wood31} along with promoting knowledge of self-harm and of the services available in the community and in educational institutions.^{Reference Chew-Graham, Bashir, Chantler, Burman and Batsleer21,Reference Bhardwaj25,Reference Sambath26,Reference Marshall and Yazdani32} For instance, support groups in schools could create a space to talk about self-harm and mental health openly.^{Reference Sambath26} The availability of services should be increased by providing telephone or online helplines.^{Reference Klineberg, Kelly, Stansfeld and Bhui23,Reference Chantler28,Reference Wood31,Reference Marshall and Yazdani32}

For the improvement of service responses, the participants suggested that health professionals should have a greater understanding of the socioeconomic and cultural aspects of mental health among ethnic minority communities.^{Reference Sambath26,Reference Mafura and Charura33} Moreover, mental health services should address privacy and confidentiality concerns among patients.^{Reference Klineberg, Kelly, Stansfeld and Bhui23,Reference Marshall and Yazdani32} Ethnic minority patients’ preferences about health professionals’ ethnicity and gender should also be taken into account.^{Reference Marshall and Yazdani32}