Locating culture in accounting for self-harm amongst Asian young women

Perceived powerlessness and self-harming behaviours in UK-based Bangladeshi, Indian and Pakistani women

This study investigated self-harming behaviours among UK-based women of Bangladeshi, Indian and Pakistani origin (UKBIP). Through purposive sampling, eight participants who had engaged in self-harm, specifically through cutting, were selected for semi-structured interviews. The qualitative data gathered from these interviews underwent analysis using interpretative phenomenological analysis (IPA), which involved analysis at individual and group levels. Consequently, three super-ordinate themes and nine sub-ordinate themes emerged. The themes were 'Powerlessness' ('Entrapment', 'Internalised Negativity' and 'Abused by my Environment'), 'Mitigation' ('Releasing my Overwhelming Emotions', 'Connecting to my Pain' and 'Addicted to Self-harm') and 'Self-harm is Wrong' ('It must be Hidden', 'What have I done to Myself?', and 'My Self-harm is Sinful'). This paper focuses specifically on the 'Powerless' theme, exploring its relevance to self-harming behaviours in UKBIP women. The analyses provided novel insights into the impact and significance of the South-Asian cultural values and beliefs on the relevance to self-harming experiences in UKBIP women.

Understanding self-harm and suicidal behaviours in South Asian communities in the UK: systematic review and meta-synthesis

BACKGROUND

Previous findings have indicated that self-harm and suicide are associated with different rates, and different risk and protective factors in South Asian people compared with White people in the UK. Substantial qualitative research has explored experiences of self-harm and suicide in South Asian people.

AIMS

The study aims to review the existing qualitative evidence on self-harm and suicidal behaviours in South Asian communities in the UK.

METHOD

Systematic searches were conducted on Medline, EMBASE, PsycINFO, CINAHL, Open Dissertations and the British Library Ethos databases. We selected qualitative studies from both journals and grey literature that included South Asian participants who were resident in the UK and presented perceptions or experiences of self-harm and/or suicidal behaviour. Analysis was undertaken based on the meta-ethnographic approach.

RESULTS

Fifteen studies were included in the analysis. Experience of self-harm was discussed based on three aspects: behind self-harm, functions of self-harm and recovery from self-harm. 'Behind self-harm' refers to factors associated with self-harm and suicide. 'Functions of self-harm' captures the meaning attributed to self-harm and suicide. 'Recovery from self-harm' encapsulates personal and professional help, and practical suggestions for the improvement of mental health services.

CONCLUSIONS

Although some similarities with the majority White population were present, there were also crucial differences that need consideration when shaping health policies, improving access to health services and developing culturally sensitive psychosocial interventions for self-harm and suicide specific to South Asian communities in the UK.

Understanding ethnic inequalities in mental healthcare in the UK: A meta-ethnography

BACKGROUND

Evidence regarding the presence and persistence of ethnic inequalities in mental healthcare is well established. The reasons for these inequalities and lack of progress in diminishing them are less understood. This meta-ethnography aims to provide a new conceptual understanding of how ethnic inequalities are created and sustained; this is essential to develop effective interventions. Specifically, we sought to understand why people from ethnic minority groups are underrepresented in primary care mental health service provision and overrepresented in crisis pathways and detention.

METHODS AND FINDINGS

Following eMERGe guidelines for meta-ethnographies, we searched OpenGrey, Kings Fund, CINAHL, Medline, PsycINFO, and Social Care Online databases for qualitative articles published from database inception until October 2, 2022, using broad categories of search terms relating to "ethnicity AND (mental illness/mental health/emotional distress) AND (help-seeking/service utilisation/experience/perception/view)." We included all conceptually rich articles that used qualitative methods of data collection and analysis and excluded non-UK studies and those that focused solely on causation of mental illness. Our patient, public, and practitioner lived experience advisory group provided feedback and input on key stages of the project including search terms, research questions, data analysis, and dissemination. A total of 14,142 articles were identified; 66 met the inclusion criteria. We used reciprocal, refutational, and line of argument analytical approaches to identify convergence and divergence between studies. The synthesis showed that current models of statutory mental healthcare are experienced as a major barrier to the delivery of person-centred care to those in ethnic minority groups due to the perceived dominance of monocultural and reductionist frameworks of assessment and treatment (described as "medical" and "Eurocentric") and direct experiences of racist practice. The lack of socially oriented and holistic frameworks of knowledge and understanding in medical training and services is experienced as epistemic injustice, particularly among those who attribute their mental illness to experiences of migration, systemic racism, and complex trauma. Fear of harm, concerns about treatment suitability, and negative experiences with health providers such as racist care and medical neglect/injury contribute to avoidance of, and disengagement from, mainstream healthcare. The lack of progress in tackling ethnic inequalities is attributed to failures in coproduction and insufficient adoption of existing recommendations within services. Study limitations include insufficient recording of participant characteristics relating to generational status and social class in primary studies, which prevented exploration of these intersections.

CONCLUSIONS

In this study, we found that the delivery of safe and equitable person-centred care requires a model of mental health that is responsive to the lived experiences of people in ethnic minority groups. For the people considered in this review, this requires better alignment of mental health services with social and anti-racist models of care. Our findings suggest that intersections related to experiences of racism, migration, religion, and complex trauma might be more relevant than crude ethnic group classifications. Strategies to tackle ethnic inequalities in mental healthcare require an evaluation of individual, systemic, and structural obstacles to authentic and meaningful coproduction and implementation of existing community recommendations in services.

The complex role of social care services in supporting the development of sustainable identities: Insights from the experiences of British South Asian women with intellectual disabilities

BACKGROUND AND AIMS

Carers and service users with intellectual disabilities from minority ethnic groups have typically been reported to be dissatisfied with the social care services they receive. However, service users themselves have rarely been asked directly about their experiences of social care. This paper aims to understand the meaning of social care services in the lives of South Asian women with intellectual disabilities, in the United Kingdom.

METHOD AND PROCEDURE

10 British South Asian women with mild-moderate intellectual disabilities were interviewed about their experiences of social care services. The transcripts were analysed using interpretative phenomenological analysis.

RESULTS

The analysis produced three super-ordinate themes, which focus on how services facilitate the development of complex identities, how the participants explored their sense of being 'stuck' between cultures as they negotiated their journeys towards independence, and the triple disadvantage which they experienced as a consequence of the intersection between gender, ethnicity and disability. The participants were broadly satisfied with the role which services played in these domains, and appeared to find them valuable and helpful.

CONCLUSIONS

The results suggest that the participants successfully managed complex identity issues, such as acculturation processes, with the support of services. It may be helpful to give more explicit consideration to the positive role which good services can play in supporting people with intellectual disabilities in the development of their identities and goals, alongside the more traditionally 'concrete' objectives of such social care. Engagement with families in 'positive risk-taking' is likely to be an important component of success.

Talking of Taste: A Discourse Analytic Exploration of Young Women's Gendered and Racialized Subjectivities in British Urban, Multicultural Contexts

This article presents an analysis of interviews conducted with young Asian and white women living in urban, `multicultural' areas in the UK. Specifically, the article explores how these young women constitute their own and others' differently gendered, sexualized and racialized identities and subjectivities through their talk about styles of appearance and tastes in, for example, clothing, clothing labels, hairstyles and cosmetics. In so doing, the article aims to elucidate, first, some of the complex intertwinings of gender and ethnicity in these young women's accounts and, second, the equally complex and shifting politics of gender and ethnicity, which are simultaneously constituted, subverted and reconstituted in these young women's talk about styles of appearance.

Shifting Conversations on Girls' and Women's Self-Injury: An Analysis of the Clinical Literature in Historical Context

Through a historical review of girls' and women's episodic and repetitive self-injury -scholarship focusing primarily on white, middle-class women in North America and Britain - in the clinical literature from 1913 to the present, the author identifies four shifts over time. These are: 1) varying degrees of clinical interest in and numbers of publications on self-injury, 2) changing conceptualizations of self-injury, 3) changing treatment approaches for self-injury, and 4) changing characterizations of women who self-injure. Moving from research studies which indicate that self-injury typically presents in females during adolescence, this article elucidates how self-injury may reflect girls' developmental struggles within a patriarchal culture and embody a narrative of women's experiences of violation. Bringing together the history of self-injury and a feminist, relational analysis, it is argued that the historical discourse on self-injury mimics women's experiences of objectification and violence by silencing and distorting their self-injury.

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.

Nonsuicidal self-injury in an ethnically diverse college sample

Self-report data pertaining to Nonsuicidal Self-Injury (NSSI; e.g., cutting) were collected from 5,691 undergraduates at a Midwestern urban university. Consistent with the small literature on NSSI among college students, 12.8% of the sample indicated having engaged in NSSI at least once (3.4% in the past year). Women and younger students were at slightly higher risk. Important ethnic differences were found, as Caucasians and individuals self-identifying as Multiracial were at especially high risk for a history of NSSI, whereas Arab Americans and African Americans had particularly low rates. Further, links between NSSI and religion were found, such that participants with stronger self-reported religious convictions had the lowest rates of NSSI. Those who self-described as Atheist, Agnostic, or Nonbeliever were several times more likely to have engaged in NSSI (31.3%), while Muslims (7.4%) and Baptists (6.3%) had relatively low rates. Multivariate analyses revealed that ethnic differences in NSSI could not be accounted for by religious differences. Processes that may explain the associations between NSSI and ethnic affiliation and religion are discussed.

The relation between childhood maltreatment and self-injury: a review of the literature on conceptualization and intervention

The following article reviews literature pertaining to the association between child maltreatment and self-injury and the ways it varies according to maltreatment type. Research supporting various mediators of the relations between different maltreatment types and self-injury is summarized. Informing mediator models, dominant theories of functionality, particularly affect regulation theories, are summarized and granted empirical support. Following from explanations of its functionality, three developmental pathways (regulatory, representational/interpersonal, and reactive/neurobiological) leading from child maltreatment to self-injury are presented within an organizational model of psychopathology. Understanding the deviations in these pathways that perpetuate self-injury helps to inform intervention approaches that forge pathways perpetuating resilience instead. Three psychosocial treatments (i.e., Dialectical Behavior Therapy [DBT], Trauma-Focused Cognitive-Behavioral Therapy [TF-CBT], and Acceptance and Commitment Therapy [ACT]) were chosen for review, based upon their accumulating evidence bases, as well as upon the relevance of their core components in correcting or compensating for trauma-related developmental deviations.

Self-injurious behavior in adolescents

Janis Whitlock discusses the epidemiology and and care of adolescents undertaking nonsuicidal self-injury, also called “deliberate self-harm.”

Analysis of accident and emergency doctors' responses to treating people who self-harm

Self-harm is a prevalent phenomenon regularly faced by doctors and nurses working in accident and emergency (A&E) departments. We argue that the treatment decisions A&E doctors make are fundamental to decreasing the high risk of suicide among this group. In this article we present a qualitative study exploring how doctors working in A&E respond to treating people who self-harm. In total, five A&E doctors were interviewed and the data were analyzed using interpretative phenomenological analysis. Three main themes were extracted: treating the body, silencing the self, and mirroring cultural and societal responses to self-harm. Within these themes, we identified both facilitative and unhelpful aspects of the relationships between people who self-harm and A&E doctors. We consider the clinical implications of these findings within the context of A&E doctors having limited opportunities to address the relational nature of the care they offer to this group.

A prospective study of child maltreatment and self-injurious behavior in a community sample

In conjunction with prospective ratings of child maltreatment (i.e., sexual abuse, physical abuse, and physical neglect) and measures of dissociation and somatization, this study examined prospective pathways between child maltreatment and nonsuicidal, direct self-injurious behavior (SIB; e.g., cutting, burning, self-hitting). Ongoing participants in the Minnesota Longitudinal Study of Parents and Children (N = 164; 83 males, 81 females) completed a semistructured interview about SIB when they were 26 years old. SIB emerged as a heterogeneous and prominent phenomenon in this low-income, mixed-gender, community sample. Child sexual abuse predicted recurrent injuring (i.e., three or more events; n = 13), whereas child physical abuse appeared more salient for intermittent injuring (i.e., one to two events; n = 13). Moreover, these relations appeared largely independent of risk factors that have been associated with child maltreatment and/or SIB, including child cognitive ability, socioeconomic status, maternal life stress, familial disruption, and childhood exposure to partner violence. Dissociation and somatization were related to SIB and, to a lesser degree, child maltreatment. However, only dissociation emerged as a significant mediator of the observed relation between child sexual abuse and recurrent SIB. The findings are discussed within a developmental psychopathology framework in which SIB is viewed as a compensatory regulatory strategy in posttraumatic adaptation.

Exploring the meaning of separation in second-generation young South Asian women in Britain

OBJECTIVES

To explore the experiences of young second-generation South Asian women living in Britain; to try and understand their experiences, deconstruct the term cultural conflict and understand it within a psychological framework. In particular, the aim was to explore issues of separation and individuation, and the meanings attributed to these concepts.

DESIGN

An interview-based study using Interpretative Phenomenological Analysis to analyse the data.

METHODS

Interviews were conducted with six second-generation South Asian women aged 16-20, who had no prior contact with mental health services.

RESULTS

Five main themes were identified from the analysis: differences in the meaning of adulthood, community policing, pressures and stressors, protective factors/coping and barriers to coping.

CONCLUSIONS

The participants' perceived differences in the meaning of adulthood in Asian cultures in comparison with Western cultures. These differences, in conjunction with the community policing that they were exposed to, contributed to the pressures and stressors - in particular lack of control and a desire to make individual decisions. The results indicated that the differences in the meaning of adulthood in a collective culture challenged the assumptions of the separation-individuation model, and was a key element in cultural conflict. This highlighted the complexities of generalizing research findings across all social groups, and questioned the validity of applying existing psychological theory to this population. The clinical implications of coping/protective factors and barriers to coping were discussed.

Self-injurious behaviors in a college population

OBJECTIVE

The goal was to assess the prevalence, forms, demographic and mental health correlates of self-injurious behaviors in a representative college sample.

METHODS

A random sample of undergraduate and graduate students at 2 northeastern US universities were invited to participate in an Internet-based survey in the spring of 2005. Thirty-seven percent of the 8300 invited participants responded.

RESULTS

The lifetime prevalence rate of having > or =1 self-injurious behavior incident was 17.0%. Seventy-five percent of those students engaged in self-injurious behaviors more than once. Thirty-six percent reported that no one knew about their self-injurious behaviors and only 3.29% indicated that a physician knew. Compared with non-self-injurers, those with repeat self-injurious behavior incidents were more likely to be female, bisexual or questioning their sexual orientation. They were less likely to be Asian/Asian American and >24 years of age. When controlling for demographic characteristics, those with repeat self-injurious behavior incidents were more likely to report a history of emotional abuse or sexual abuse, ever having considered or attempted suicide, elevated levels of psychological distress, and > or =1 characteristic of an eating disorder. A dose-response gradient was evident in each of these areas when single-incident self-injurious behaviors were compared with repeat-incident self-injurious behaviors.

CONCLUSIONS

A substantial number of college students reported self-injurious behaviors in their lifetimes. Many of the behaviors occurred among individuals who had never been in therapy for any reason and who only rarely disclosed their self-injurious behaviors to anyone. Single self-injurious behavior incidents were correlated with a history of abuse and comorbid adverse health conditions but less strongly than were repeat self-injurious behavior incidents. The reticence of these clients to seek help or advice renders it critical that medical and mental health providers find effective strategies for detecting and addressing self-injurious behaviors.

The developmental psychopathology of self-injurious behavior: compensatory regulation in posttraumatic adaptation

This article utilizes a developmental psychopathology framework to explicate one pathway, originating in childhood traumatic experience, toward the development of self-injurious behavior (SIB). The descriptive psychopathology of SIB is summarized first, followed by an overview of theoretical interpretations of SIB within psychoanalytic, neo-analytic, behavioral, and biological paradigms. Building on these empirical and theoretical foundations, a developmental psychopathology framework is used to model the development of SIB in the aftermath of childhood traumatic experience, particularly maltreatment. In this model, maltreatment undermines positive adaptation at motivational, attitudinal, instrumental, emotional, and/or relational levels of competence. In turn, vulnerabilities in the child's adaptive resources necessitate the application of alternative regulatory and relational strategies, such as self-injury, to the negotiation of contemporaneous and prospective developmental issues. The article concludes with a discussion of the empirical and clinical implications of a developmental understanding of SIB as a compensatory regulatory strategy in posttraumatic adaptation.