Response to Call for Written Evidence on the Criminal Justice Bill

Professor Amy Chandler submitted written evidence to the Public Bill Committee on the Criminal Justice Bill (Bill 155 2023-2024), specifically relating to the clause of self-harm in the bill.

House of Commons Criminal Justice Bill

I am writing in a personal capacity, drawing on my professional expertise relating to self-harm.

1. Summary

1.1: This written evidence concerns Sections 11 and 12: Encouraging or assisting serious self-harm.

1.2: I have serious concerns about the implications of the Criminal Justice Bill in relation to the care and support that may be offered to those who self-harm.

1.3: Self-harm is a complex and diverse set of practices, with a range of meanings, and a complex – not straightforward – relationship to suicide.

1.4: Care for those who self-harm frequently accepts that self-harm cessation is not always effective or desirable in the short-medium term (https://doi.org/10.1192/bjo.2019.93)[1].

1.5: As such, care for those who self-harm may include ‘harm-reduction’, ‘harm-minimisation’, and in some exceptional cases ‘safer-self-harm’ strategies. Under the proposed Bill these approaches may run the risk of prosecution.

1.6: Further, by potentially criminalising support for those who self-harm which does not prioritise cessation, the Bill runs the risk of inhibiting open, non-judgemental care for those who self-harm, because practitioners and carers may fear prosecution if potentially deemed to be either ‘encouraging’ or ‘assisting’ serious self-harm.

2. Introduction

2.1: I am a Professor of the Sociology of Health and Illness at the University of Edinburgh. I have been researching and writing about self-harm and suicide for 18 years. My research primarily focuses on experiences and meanings of self-harm and suicide, and how these relate to social and cultural contexts. I have also researched support for those who self-harm in primary care settings. I advise Scottish Government on both self-harm (e.g. Scotland’s Self-Harm Strategy) and suicide (contributing to the Academic Advisory Group for Suicide Prevention). I have special expertise in ‘lived experience’ perspectives on self-harm, and the importance of involving those affected in designing care.

2.2: This written response draws on my extensive research on self-harm and suicide. This includes a careful and critical examination of the relationship between self-harm and suicide; the experiences of a range of people who self-harm (aged 13 to 65) across several studies; and working with people who self-harm, and organisations that support them, to understand ‘what works’ in improving the lives of those who self-harm.

3. Self-harm is complex

3.1: Self-harm is defined in many different ways, by different organisations and groups (https://pubmed.ncbi.nlm.nih.gov/21309828/)[2]. In the UK, the NICE guidelines are usually deferred to, these refer to self-harm as “self-injury or self-poisoning, irrespective of the apparent purpose of the act”.

3.2: Self-harm is understood in divergent ways such as a) a risk factor for, and predictor of, death by suicide; b) a method of coping with emotional, interpersonal and wider issues; c) a way of avoiding or reducing suicidal feelings. Many more meanings have been identified in a wide range of studies (e.g. https://acamh.onlinelibrary.wiley.com/doi/10.1111/camh.12641; https://thesociologicalreview.org/reviews/self-injury/; https://www.tandfonline.com/doi/full/10.1080/09515070.2020.1737509; https://www.frontiersin.org/articles/10.3389/fpsyg.2021.543303/full).

3.3: For those people who use self-harm as a way of coping with overwhelming or unbearable feelings, self-harm can be an effective way of ‘managing’ in daily life (https://journals.sagepub.com/doi/10.1177/0038038511422589; https://onlinelibrary.wiley.com/doi/10.1002/symb.118).

3.4: For those who use self-harm as a way to avoid suicide, self-harm can serve to (variously) a) reduce negative/overwhelming feelings so they are manageable; b) serve as a form of self-punishment that allows the individual to otherwise ‘carry on’ living; c) distract and deescalate an individual away from thoughts of suicide (https://doi.org/10.1192/bjp.2021.225) [8].

3.5: Conversely, self-harm can in some cases increase in severity over time. Self-harm – when treated in hospital (80% of which are cases of self-poisoning/overdose) is associated with an increased risk of death by suicide.

3.6: However, the majority of those who self-harm a) do so via self-cutting/burning; b) are not treated in hospital for their injuries. As such, extrapolating from hospital-studies of self-harm to the wider public who self-harm may not accurately predict the chance of suicide among those who self-harm (https://onlinelibrary.wiley.com/doi/10.1111/j.1943-278X.2010.00003.x)[2]; further – the relationship between self-harm and suicide is understood as complex, with attempts to predict risk incredibly challenging, if not counter-productive (https://eprints.whiterose.ac.uk/102798/1/BJP_2015_170050v3_Chan_accepted_version.pdf)[9].

4. Self-harm is common, and prevalence appears to be rising

4.1: Self-harm is not new, however, multiple studies indicate that rates of self-harm are rising, especially among younger people (https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(19)30188-9/fulltext#seccestitle130)[10].

4.2: Recent estimates suggest that up to 25% of young women, and 9% of young men have self-harmed (https://cks.nice.org.uk/topics/self-harm/background-information/prevalence/).

4.3: As such, the number of people seeking care for self-harm is also increasing; and the potential number of people who may be adversely affected by the implicit criminalisation of self-harm (and some responses/care for it) that the Bill indicates, may be large.

5. Care for those who self-harm, and the role of harm-reduction

5.1: As above, while the number of people affected by self-harm is significant, and growing; care for those who self-harm is acknowledged to be frequently insufficient (https://pubmed.ncbi.nlm.nih.gov/37038765/) [11]. Those who self-harm are encouraged to seek help from General Practitioners; however, studies indicate GPs often lack training or confidence in supporting those who self-harm (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7015161/).

5.2: People who self-harm often do so in the absence of diagnosable mental health conditions, which can make accessing care (e.g. via psychiatry) impossible, with waiting ist for psychology long, or involving exclusion due to the ‘complexity’ that patient who self-harm can present with (https://alcoholchange.org.uk/publication/alcohol-and-self-harm-a-qualitative-study; https://econtent.hogrefe.com/doi/full/10.1027/0227-5910/a000325; https://pubmed.ncbi.nlm.nih.gov/37038765/).

5.3: Third sector, voluntary, and charitable organisations (such as Self-Injury Support; Penumbra; Samaritans) or peer-led mutual support spaces (such as Battle Scars, or Make Space), are often left holding supportive spaces for those who self-harm [14].

5.4: These organisations are often lacking in funding or resource; despite this, they provide vital support for those who self-harm. Crucially, this support often (leading from ‘lived experience perspectives, which understand that self-harm cessation can be counter-productive in the short term) does not require people to ‘stop self-harm’ as a condition of receiving support (https://www.nsun.org.uk/self-harm-misunderstandings-about-harm-minimisation/). As research by Owens et al 2020 [1] (https://doi.org/10.1192/bjo.2019.93) indicates, those who self-harm may instead prioritise reduction in severity or frequency of self-harm, or improvements in other areas of their life and health, before considering cessation itself as an important goal of treatment.

5.5: I have concerns that the Bill in its proposed form may inadvertently criminalise those offering support to those who self-harm which involves harm reduction, does not prioritise cessation, or which – in some cases – may support those to self-harm in ‘safer’ ways.

5.6: Harm-reduction approaches are not uncontroversial (e.g. see: [15] and https://www.nice.org.uk/guidance/ng225/evidence/l-harm-minimisation-strategies-pdf-403069580823 – note the NICE evidence review problematically excluded qualitative research, which is one of the main ways research can access the views of people who self-harm).

5.7: However, there is an urgent need for design, delivery and research about care for those who self-harm to engage meaningfully with the perspectives and accounts of those who self-harm (see this Global Summit which I contributed to, hosted by the Black Dog Institute and Lancet in 2022, where world-leading experts in self-harm called for the greater inclusion of ‘lived experience’ perspectives of self-harm in these areas https://www.blackdoginstitute.org.au/news/new-views-of-self-harm-necessitate-an-urgent-change-in-strategy-and-accountability/). Lived experience perspectives frequently underline that cessation is not a priority when receiving care- https://www.tandfonline.com/doi/full/10.1080/13811118.2020.1823916; https://www.tandfonline.com/doi/full/10.1080/13811118.2019.1624669?src=recsys; see also extensive writing and research by Kay Inckle [18-20] – https://www.pccs-books.co.uk/products/safe-with-self-injury). It is imperative that practitioners (clinical and non-clinical) are able to explore (and better yet, research the efficacy of) a wide range of supports for those who self-harm – including harm reduction, and safer self-harm approaches.

6. The criminalisation of self-harm and suicide

6.1: The WHO (https://www.who.int/news/item/12-09-2023-who-launches-new-resources-on-prevention-and-decriminalization-of-suicide), and the International Association for Suicide Prevention (https://www.iasp.info/decriminalisation/), are rightly calling for the complete reversal of laws in all national settings which may criminalise self-harm or suicide. Such laws are understood to reduce the ability of people to seek and be offered care and support for the distress which often accompanies self-harm and suicide.

6.2: Suicide has not been illegal in England and Wales since 1961. It has never been illegal in Scotland. However, those who self-harm are subject to criminal prosecution (https://pubmed.ncbi.nlm.nih.gov/35766220/)[21], resulting in devastating impacts on people’s lives; and significant barriers to receiving and seeking care.

6.3: The proposed Bill would further extend the potential criminalisation of self-harm. Indeed, I am not convinced that a matter as complex as self-harm, which is frequently associated with marginalisation, oppression, and disadvantage, should be addressed in legislation which otherwise addresses acts which can be the cause of such oppression and disadvantage (e.g. sexual offences).

6.4: It is unclear what kinds of acts the Bill under Sections 11 and 12 is seeking to criminalise and facilitate prosecution of.

6.5: In the face of this lack of clarity there are real risks that those providing care for those who self-harm may be subject to prosecution, or at the very least, would feel compelled to draw back from approaches that can help, prioritising instead those that can harm (e.g. requiring self-harm cessation as a condition of care).

7. Recommendations

7.1: Definitions and examples of what exactly is meant by ‘serious self-harm’ need to be provided; bearing in mind the above points about the complexity of self-harm.

7.2: More clarity and guidance regarding what is meant by ‘encouraging’ and ‘assisting’ serious self-harm should be provided. In particular, guidance should explicitly exclude any support for those who self-harm as provided in clinical or non-clinical settings which may not require cessation of self-harm. It should be permissible for people who self-harm to be supported in such a way that their ongoing self-harm is acknowledged, can be discussed openly and non-judgementally, and that care can be engaged in with no expectation that ongoing self-harm should stop.

7.3: More clarity and detail about the types of acts that Sections 11 and 12 are seeking to prevent or prohibit.

References

1. Owens, C., et al., Measuring outcomes in trials of interventions for people who self-harm: qualitative study of service users’ views. BJPsych Open, 2020. 6(2): p. e22.
   
2. Chandler, A., F. Myers, and S. Platt, The construction of self-injury in the clinical literature: a sociological exploration. Suicide and Life Threatening Behavior, 2011. 41(1): p. 98-109.
   
3. Marzetti, H., L. McDaid, and R. O’Connor, A qualitative study of young people’s lived experiences of suicide and self-harm: intentionality, rationality and authenticity. Child and Adolescent Mental Health, 2023. n/a(n/a).
   
4. Hambleton, A.L., et al., Initiation, meaning and cessation of self-harm: Australian adults’ retrospective reflections and advice to adolescents who currently self-harm. Counselling Psychology Quarterly, 2022. 35(2): p. 260-283.
   
5. Stänicke, L.I., The Punished Self, the Unknown Self, and the Harmed Self – Toward a More Nuanced Understanding of Self-Harm Among Adolescent Girls. Frontiers in Psychology, 2021. 12.
   
6. Chandler, A., Self-injury as embodied emotion-work: Managing rationality, emotions and bodies. Sociology, 2012. 46(3): p. 442-457.
   
7. Brossard, B., Fighting with Oneself to Maintain the Interaction Order: A Sociological Approach to Self-Injury Daily Process. Symbolic Interaction, 2014. 37(4): p. 558-575.
   
8. Choo, T.-H., et al., Effect of non-suicidal self-injury on suicidal ideation: real-time monitoring study. The British Journal of Psychiatry, 2022. 221(2): p. 485-487.
   
9. Bhatti, H., et al., Predicting suicide following self-harm: systematic review of risk factors and risk scales. British Journal of Psychiatry, 2016. 209(4): p. 277-283.
   
10. McManus, S., et al., Prevalence of non-suicidal self-harm and service contact in England, 2000–14: repeated cross-sectional surveys of the general population. The Lancet Psychiatry, 2019. 6(7): p. 573-581.
    
11. Quinlivan, L., et al., Accessing psychological therapies following self-harm: qualitative survey of patient experiences and views on improving practice. BJPsych Open, 2023. 9(3): p. e62.
    
12. Mughal, F., et al., Role of the GP in the management of patients with self-harm behaviour: a systematic review. Br J Gen Pract, 2020. 70(694): p. e364-e373.
    
13. Chandler, A., et al., General Practitioners’ Accounts of Patients Who Have Self-Harmed A Qualitative, Observational Study. Crisis The Journal of Crisis Intervention and Suicide Prevention, 2016. 37: p. 42-50.
    
14. Boyce, M., C. Munn-Giddings, and J. Secker, “‘It is a safe space’: self-harm self-help groups”. Mental Health Review Journal, 2018. 23(1): p. 54-63.
    
15. Gutridge, K., Safer self-injury or assisted self-harm? Theor Med Bioeth, 2010. 31(1): p. 79-92.
    
16. Davies, J., et al., Young Peoples’ Perspectives on the Role of Harm Reduction Techniques in the Management of Their Self-Harm: A Qualitative Study. Archives of Suicide Research, 2022. 26(2): p. 692-706.
17. Wadman, R., et al., “These Things Don’t Work.” Young People’s Views on Harm Minimization Strategies as a Proxy for Self-Harm: A Mixed Methods Approach. Archives of Suicide Research, 2019: p. 1-18.
    
18. Inckle, K., Safe with Self-Injury: a practical guide to understanding, responding and harm-reduction. 2017, Monmouth: PCCS Books.
    
19. Inckle, K., The First Cut Is the Deepest: A Harm-Reduction Approach to Self-Injury. Social Work in Mental Health, 2011. 9(5): p. 364-378.
    
20. Inckle, K., Flesh Wounds? New Ways of Understanding Self-Injury. 2010, Ross-on-Wye: PCCS Books.
    
21. Thomson, A.B., et al., Criminal sanctions for suicidality in the 21st Century UK. The British Journal of Psychiatry, 2022: p. 1-2.

You can find the text above on the Parliament UK website here.