The role of women's self-injury support-groups: a grounded theory

Journal of Community & Applied Social Psychology

J. Community Appl. Soc. Psychol., 17: 35–52 (2007)

Published online 2 November 2006 in Wiley InterScience

(www.interscience.wiley.com). DOI: 10.1002/casp.868

The Role of Women’s Self-injury Support-Groups:A Grounded Theory

JENNIFER CORCORANy*, AVRIL MEWSE and GLORIA BABIKERz

Gloucestershire Partnership NHS Trust, Child and Adolescent Mental Health Service, Gloucester, UK

ABSTRACT

Research evidence suggests that services are struggling to adequately address the increasing incidence

of self-injury and the needs of women who self-injure, while national self-injury support-groups across

the UK appear to be growing in number. Despite their reported value, evidence regarding the role of

self-injury support-groups in women’s management of their self-injury is lacking although govern-

ment policy and official guidelines are advocating the incorporation of support-groups into self-injury

services. Seven semi-structured interviews were conducted and analysed using Grounded Theory to

investigate the role of three UK self-injury support-groups in women’s management of self-injury and

associated difficulties. Empowerment-as-process emerged as the core theme of self-injury support-

groups, mediated through experiences of belonging, sharing, autonomy, positive feeling and change.

Findings are discussed in relation to relevant theory and research, followed by critical evaluation and

implications of the study. Copyright # 2006 John Wiley & Sons, Ltd.

Key words: self-injury; women; support groups; service provision; empowerment; grounded theory

INTRODUCTION

In the context of increased self-injury in women (Hawton, Fagg, & Simkin, 1996), known

self-injury support-groups have similarly increased to 33 across the UK (Bristol Crisis

Service for Women (BCSW), 2003). While Warm, Murray, and Fox (2002) reported that,

after self-injury specialists, women who self-injure find support-groups the most helpful,

investigation of the role/function of such groups is lacking, despite their apparent value

(Lindsay, 1995). Prevailing literature (e.g. Hawton et al., 2001; National Health Service

Centre for Reviews and Dissemination (NHSCRD), 1998 highlights the inadequacy of

service-provision in meeting the needs of women who self-injure, in spite of UK

government policy (Department of Health, 1999 (DOH)) and official guidelines

(Department of Health & Social Security, 1984; NHSCRD, 1998; National Institute of

* Correspondence to: J. Corcoran, Gloucestershire Partnership NHS trust, Child and Adolescent Mental HealthService (CAMHS), Acorn House, Horton Road, Gloucester, GL1 3PX, UK.E-mail: [email protected] study was submitted in partial fulfilment of the principal author’s requirements for her Doctorate in Clinicaland Community Psychology, University of Exeter, Exeter, UK.zDr Babiker is affiliated to Avon & Wiltshire Mental Health Partnership National Health Service Trust, UK.

Copyright # 2006 John Wiley & Sons, Ltd. Accepted 10 April 2006

36 J. Corcoran et al.

Clinical Excellence, 2004; Royal College of Psychiatrists (RCP), 1994) advocating the

incorporation of support-groups into self-injury services.

Self-injury and service-provision

Self-injury is defined as ‘an act which involves deliberately inflicting pain and/or injury to

one’s own body, but without suicidal intent’ (Babiker & Arnold, 1997, p. 2) and is often

associated with other difficulties including eating disorders (e.g. Parkin & Eagles, 1993),

depression (e.g. Ennis, Barnes, Kennedy, & Trachtenberg, 1989) and previous abuse (e.g. van

de Kolk, Perry, & Herman, 1991). Of the few published qualitative studies investigating self-

injury (e.g. Akerstrom, 1997; Harris, 2000) conflict is generally identified between

professionals’ and women’s views of self-injury, as articulated by Pembroke (1991):

‘My distress was acknowledged only within a medical framework, which I do not share . . .Myentire experience was objectified in a way I found dehumanizing. I was never listened to.’ (p. 30)

Evidence suggests that self-injury services struggle to meet women’s needs, there

currently being no singularly effective intervention. Most research focuses on in-patient1

and/or Accident & Emergency (A&E) contexts and may therefore be limited in application

(Suyemoto, 1998). For instance, within a predominantly UK context, up to a third of

women who self-injure do not approach A&E (NHSCRD, 1998) while many are

discharged from A&E without treatment or referral (Currie & Blennerhassett, 1999);

accordingly, women are generally very dissatisfied with current self-injury service-

provision. Given that up to a third of women who self-injure do not approach A&E

(NHSCRD, 1998), if any professional services, support-groups could constitute a vital

source of information in attempting to understand the needs of those women who self-

injure but do not necessarily make contact with services.

The UK Government’s (DOH, 2001b) policy radically changed the philosophy of

service-provision in prioritizing service-users’ views in all aspects of mental-health care.

While the National Service Framework for mental health (DOH, 1999), the NHSCRD

(1998) and RCP (1994) alike advocate increased access to local self-injury support-groups

the NHSCRD nonetheless documents a distinct lack of formal evaluation of the role of such

services. It would seem, therefore, that an investigation into the role/function of self-injury

support-groups may be a timely contribution to the potential improvement of service-

provision for women who self-injure.

Self-injury and support-groups

Within a mental-health context, Nelson, Ochocka, Griffin, and Lord (1998, p. 889) define

support-groups as ‘settings in which people with . . . a common experience come together

on a voluntary and equal basis to share their experiential knowledge and to provide and

receive informal social support’. Community psychology theory purports that support-

groups assist individuals in regaining a sense of control (Levine, 1988; Reinharz, 1988)

reflecting their potential for facilitating change. Three qualitative studies examined the

benefits/functioning of support-groups. Anderson-Butcher, Khairallah, and Race-Bigelow

(2004) employed semi-structured interviews and an adapted form of Grounded Theory

(GT) (Strauss & Corbin, 1998) with support-groups for socially vulnerable families. Whilst

1This includes women in secure hospitals, of whom the majority self-injure (Liebling & Chipchase, 2001).

Copyright # 2006 John Wiley & Sons, Ltd. J. Community Appl. Soc. Psychol., 17: 35–52 (2007)

Women’s self-injury support-groups 37

interviews were double-coded to increase reliability (Miles & Huberman, 1994), they

appeared to refrain from investigating unhelpful aspects of group-membership.

Implications of the study included incorporating support-groups into service-provision

and providing suitable training to service-providers. Solomon, Pistrang, and Barker (2001)

applied quantitative measures (of perceived group helpfulness/functioning), a focus-group

and GT in investigating a parents’ support-group. Whilst the sample comprised mostly

(92%) mothers and used a focus-group as opposed to individual approach, possibly biasing

findings through group consensus, they recommended future longitudinal studies

examining time-related change within groups. In a qualitative study of a cult survivors’

support-group, Durocher (1999) employed in-depth interviews with a sample of four

participants although methodology was not specified. Key findings in all three studies

included control/agency, friendship, learning and personal/interpersonal change.

Babiker and Arnold (1997) theorize self-injury support-groups as affording, amongst

other functions, the development of acceptance, self-understanding and trust. Following

their combined qualitative/quantitative study, (Liebling & Chipchase, 1996) of a support-

group facilitated within a maximum-security hospital in which I have also previously

worked, the authors concluded in 2001 (p. 23) that ‘staff should be empowered to listen and

take risks, recognize [women’s] perspectives, and be allowed to provide more individual

control and peer support opportunities’. Given the context of this group, application of

findings is limited although the groups’ functions may be comparable to those of

community support-groups. After commencement of the present study, Smith and Clarke

(2003) published a voluntary-sector qualitative/quantitative study of community self-harm

self-help groups, applying Content Analysis to a structured questionnaire and interview.

Findings, including equality, friendship, understanding and acceptance, concurred with

those of Lindsay’s (1995) analysis of women’s self-injury needs.

The current study

As a white, European female clinical and community psychologist, observant of cultural

power imbalances, my interest in self-injury support-groups arose from various

professional support-group experiences and an assistant psychologist position in a

maximum-security hospital Women’s Service. The present study investigated the role of

support-groups in women’s management of their self-injury and possible associated

difficulties (e.g. depression or eating disorders).2 Derived from existing self-injury/

support-group literature, the research questions were:

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hat is the role of support-groups in women’s management of their self-injury?

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hat is the role of support-groups in women’s management of other possible difficulties
associated with self-injury?

METHOD

As a qualitative method effective in explicating ‘contextualized social-psychological

processes’ (Willig, 2001, p. 69) and generating new categories of meaning, GT (Strauss &

ince evidence suggests that it is predominantly women who self-injure (Hawton, Fagg, Simkin, Bale, & Bond,97), the study focused exclusively on women.

pyright # 2006 John Wiley & Sons, Ltd. J. Community Appl. Soc. Psychol., 17: 35–52 (2007)


Corbin, 1998) was deemed appropriate in the preliminary but extensive investigation of

participants’ self-injury support-group experiences. Moreover, it suited the author’s belief

in transparent research processes aimed at equalizing power between interviewer and

interviewee (Arksey & Knight, 1999). Grounded in discussion with colleagues, the

literature review and my awareness, as a clinical psychologist, of support-groups being

systemically embedded (Levy, 2000), five themes emerged in addressing the research

questions and subsequently comprised the semi-structured interview schedule employed.

The themes were (i) previous experiences of support (ii) general role of support-groups in

self-injury (iii) specific role of support-groups in self-injury (iv) role of support-groups in

associated difficulties (v) perceived limitations of support-groups.

Participants and research context

Participants were recruited from existing self-injury support-groups (BCSW, 2003).

Although 16 groups were contacted nationwide, the sample comprised 7 Caucasian women

aged between 21 and 44 years (mean age, 36) who were members of one of three city-based

support-groups with weekly or fortnightly meetings in community venues. Occupational

status ranged from unemployed to advanced professional. All had current contact with

professional services regarding self-injury and/or associated difficulties.3

Procedure

Recruitment was directed primarily by the availability/willingness of participants4 who were

selected on the basis of (a) a minimum of 2 weeks’ (previous or current) participation in a self-

injury support-group (b) being female and (c) being over 16. Following ethical approval, I

liaised with group facilitators, to whom I sent introductory letters, participant information

sheets, consent forms and stamped addressed envelopes for distribution to group-members.

Facilitators liaised with women willing to participate who returned reply slips by way of

‘opting-in’ to the study and interviews were subsequently arranged. Three interviews took

place in support-group venues, three in participants’ homes and one in a neutral community

venue. Ethical consent/confidentiality procedures were fully adhered to throughout and

recorded interviews were transcribed by a professional audio-typist cogent of these issues.

Participants received interview transcripts to involve them maximally in the research process

(Strauss & Corbin, 1998). To enhance validity (Miles & Huberman, 1994), the interview

schedule was altered according to themes/categories emerging from on-going analysis.

Data analysis

The GTanalysis was a recursive process in which concepts derived from coding/analysis of

initial interviews were tested against subsequent interview data. Data collection continued

3Two groups were facilitated by a female, professional, non-group-member (one of whom was an ex-service-user),the third by group-members themselves. Further information regarding participants and group structure/function-ing, while potentially enhancing situation of the sample (Elliott, Fischer, & Rennie, 1999), has been omitted forconfidentiality purposes. Readers are invited to contact the author directly with further questions, which will beresponded to if it is deemed as confidentially appropriate to do so.4Availability was compromised by listed groups having been disbanded or temporarily suspended, often due toinsufficient numbers, or by volunteer participants becoming ill before the scheduled interview date.


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Figure 1. Conceptual model of the role of mutual support-groups in participants’ management ofself-injury and associated difficulties.


via theoretical sampling of emerging concepts through interview development until

theoretical saturation was achieved and analysis followed open, axial and selective coding

procedures.

To optimize grounding of emerging theory in data, I used participants’ own words to

describe concepts, wherever practicable. Integral to the GT data collection/analysis process

were memo-writing (in which the detailed stages of theory development were

systematically documented) and, as Pidgeon and Henwood (1997) advocate with regard

to increasing ‘reflexivity’ in non-social-constructionist approaches, a reflective journal.

Credibility/validity checks, including supervision and feedback methods, ensured that

concepts/categories and emerging theory were identified and developed in adherence to

proposed GT evaluation criteria (Strauss & Corbin, 1998).

RESULTS

Figure 1 presents a conceptual model of the data. Regarding the research questions, the

model reflects that participants could not distinguish self-injury support from support with

other difficulties that impacted on their self-injury since ‘. . .like a ball of wool, they’re all

connected somehow’ (Frances, 162).5 The most illustrative (anonymized) quotations are

5Numbers denote the paragraph within the participant’s transcript, from which the quote was derived.



incorporated from all participants. EMPOWERMENT was abstracted as the over-arching,

explanatory theme and is represented as five cyclical core-categories: BELONGING,

SHARING, AUTONOMY, POSITIVE FEELING and CHANGE. Whilst these categories

are inter-related in many ways, the model was conceptualized to reflect the apparent

interaction of time and the evolving experience of group-membership.

BELONGING

Belonging emerged as one of the primary feelings experienced, creating a sense of

acceptance and welcome, particularly valued by new members.

there is a big importance in belonging . . . , we have . . . a welcome pack that . . . says . . . these areour ground rules, erm, this is what we hope to achieve and come and join us really. (Lou, 91)

Belonging was fostered by the anonymous and voluntary nature of the group which

facilitated otherwise difficult access for less confident members.

Acceptance

Acceptance emerged primarily as a sense of non-judgement, including acceptance of

differences, which encouraged participants to express themselves openly and contributed

to the development of self-acceptance.

. . . if I can’t accept myself as someone who self-injures or maybe I will get to a stage of someonewho has self-injured, you know I’ve got physical scars, . . . how am I going to expect the rest of theworld to? (Katie, 67)

Whilst acceptance was sometimes compromised by negativity, competition or lack of

sensitivity between group members, many believed that such struggles were worth the

rewards.

. . . being a member of a group is not easy, there are difficulties but facing them and moving onmakes you much more stronger as a group . . .. it’s the sorting the difficulties out that brings youcloser as a group . . .. (Anna, 73)

Safety

Safety emerged as an important aspect of belonging, enabling participants to share

experiences openly in ways that afforded resolution of difficulties. While many participants

emphasized their valuing of unfacilitated support, which afforded more genuine empathy,

others felt the structure provided by a facilitator was crucial to this sense of safety.

. . . they have got a lot of experience . . . and I feel quite safe knowing that if I do disassociate halfway through the session that I can be brought back quite safely. (Lou, 81)

However, the involuntary facilitation that often arose in the absence of a facilitator

sometimes compromised the feeling of safety for participants assuming that role.

I decided to take some time out and then when I came back they’d put a facilitator in place becausethe responsibility for chairing the meeting and supporting was falling on one, maybe two,individuals week in week out regardless of whether they were falling apart. (Katie, 28)



Participants also acknowledged that support-groups did not, however, constitute crisis

intervention and therefore may not be suitable for everyone, particularly when individuals

expressed ‘high needs’ (Frances, 65), demanding more than the group could offer.

SHARING

Sharing experiences emerged as a valued aspect of group-membership, which involved a

sense of ‘genuine empathy’ derived from all participants having self-injury in common.

This was often compared with professionals or family/friends who, not having experienced

self-injury, were less able to empathize

[it’s] the mutual support that comes from sharing with people who know actually what you aregoing through . . . and feel the pain . . . you’re going through and understanding the reason behindit whereas the staff just tick you off and try and give you therapy. (Rachel, 58)

Despite this, many participants felt that the depth of sharing could be compromised by

the low frequency and time restraints of meetings, sometimes preventing deeper

exploration of issues.

Perspective

Obtaining altered perspective on one’s self-injury and life experiences emerged as a valued

outcome of sharing experiences. Participants often realized that, contrary to previously

held beliefs, their experiences were shared by many others, which increased feelings of

self-acceptance. This perspective was predominantly normative, thereby reducing feelings

of isolation and subsequent desire to self-injure arising from such feelings.

. . . the knowledge that you’re not the only one, . . . because when you’re at home or you go to A&Eyou think ‘I’m the only one doing this, I must be mad!’ and people treat you as though you are madas well, the odd ones and when you go to a mutual-support group and you see that there are otherpeople . . .who are self-harming . . . and I just know that I’m not alone and they don’t judge me orcondemn me or go ‘Oh what have you done?’ (Rachel, 72)

Giving/receiving support

Integral to group-membership was giving/receiving support in general life issues.

Accordingly, most participants emphasized that self-injury was usually discussed in this

context.

. . .we hardly ever talk about actually cutting . . ., it’s about feelings and about life . . . the wholegamut really. (Anna, 123)

Giving/receiving support also afforded the imparting of information, coping

mechanisms, ideas and advice.

. . . they can . . . honestly support you and say . . . this helped me or it will get better and you believethem because they’ve been there, they have more knowledge. (Anna, 16)

Participants were consequently empowered through greater understanding of

themselves and others.



. . . if you can help the other stressful circumstances in your life,. . .control those or have moreskills . . . to . . . deal with those then I think that will automatically impact on your self-injury asself-injury is a way of coping with distress or difficult situations. (Phillippa, 113)

AUTONOMY

‘Autonomy’ emerged as important, primarily in the group being ‘led and run by the

participants themselves’ (Katie, 16). Autonomy comprised the mutuality, equality/power-

sharing and trust upon which the group was founded.

. . . it’s power sharing, . . .we’re equal, . . .we are . . . a group of women . . . tackling painfulissues . . . that we have had to deal with . . . so we are strong women, . . .we don’t feel strong all thetime but we are equal, . . . and the empathy, you couldn’t get it . . . from . . .mental healthprofessionals. . ., there is a power difference. (Anna, 73)

Autonomy, like safety, was compromised by ‘high need’ members often lacking ability

to be mutual/reciprocal in the group process.

. . . some people . . . don’t understand the mutual supportive bit and almost see the group as aservice . . . a bit selfish . . . and can sort of dump on people . . . that happens all the time outthere . . . but you learn from all these experiences. (Anna, 109)

Direction

Direction emerged as important for participants regaining structure in their lives. Direction

differed from safety in being primarily action-orientated. It could manifest as gentle

encouragement or direct challenging, like ‘building blocks’ (Frances, 130) and ‘stepping

stones’ (Katie, 67). The group also constituted an incentive and means of committing to

routine, often leading to more meaningful occupation, such as voluntary work, teaching or

returning to education.

. . .within the group . . . people have gone on to get jobs, . . . to do voluntary work . . . feel morehappier in themselves you know, they’ve just gained so much in their social life or whatever inconfidence and their self-esteem has been raised. (Anna, 103)

Control

The sense of control derived from group-membership was described by many participants

using words/phrases such as ‘taking charge’ (Frances, 176) and ‘control’ (Lou, 51). Control

manifested in, for example, choice regarding attendance, type/amount of support accessed

and decision-making about the group.

. . . it does give you a kind of control as well because you’ve sort of talked it through andunderstand a bit more, it’s packaged, it’s erm contained and you’ve had that chance to expresswhat you need to express so you perhaps don’t need to go away and self-harm. (Rachel, 138)

Nevertheless, participants indicated that a degree of self-control was required to

contribute to the mutual and reciprocal nature of the group whereby members were

expected/challenged ultimately to take responsibility for their feelings. Control was

important to empowerment in that it often extended to other areas of participants’ lives.



so as soon as I . . . sit back and say ‘Hey, this is quite an important thing, my support, and I amcontrolling it’ you know maybe there are other things I can control which sort of opened yourmind up to thinking about things differently. (Frances, 136)

POSITIVE FEELING

‘Positive feeling’ emerged as a common experience which manifested as anticipation about

the group, improved mood and light-heartedness, particularly in relation to their self-

injury.

we have a laugh . . ., it’s not all serious and sometimes I think it can be really healthy to just have alaugh, . . . not take it all too seriously which . . . [is] hard to do if you’re on your own or with peoplewho are worried. (Phillippa, 62)

Friendship

Participants described the development of caring, supportive friendships within the group

as being different from those outside, due to the level of genuine empathy and shared

experiences and how the existence of such friends is a support in itself, often extending

outside of the group and becoming part of their daily lives.

a couple of friendships I have made through that group, particularly one of those friendships wherejust occasionally I use my friend X’s as a safe house really and . . . that has been literally a lifesaverat times where other people have closed doors. (Katie, 43)

Inspiration

Inspiration, comprising achievement, empowerment and self-worth, was a highly valued

aspect of group-membership, emerging through both witnessing and supporting others’

struggles/successes.

. . . the biggest thing for me . . . is that I’ve been inspired . . . to see how some women cope withtheir lives, what they have achieved, what they do on a day to day basis and that keeps me going ina sense of may be one day I will be able to have a job. . . . (Katie, 87)

. . . even when there is one person very ill and we’re focused on them it brings up a part of methat feels above the self-harm that I do and it gives me a chance to reassure that person and helpthem to cope and in that way it gives me a bit of a boost because I have helped somebody else.(Rachel, 72)

CHANGE

The core-category ‘change’ comprised individual and interpersonal change. Change was

epitomized by a feeling of ‘been there, done that’ (Phillippa, 27) and ‘moving on’ (Anna,

55). New members expressed anticipation of change in the context of witnessed and

evident changes in established members.



Individual change

Participants expressed numerous individual changes resulting from group-membership, the

most common being increased self-confidence/self-esteem.

. . . I have changed enormously in 5 years . . ., I seem to be much more confident and . . . can spenda whole day . . . tutoring on self injury to an audience. (Phillippa, 75)

it makes you feel a whole person again. (Rachel, 98)

Many participants credited group-membership to reduced self-injury.

There have been days when I’ve felt like self-harming and thought I don’t want to go to the group,and I’ve gone and I have come away and I’ve not wanted to self-harm because it has given me achance to express myself instead. (Rachel, 138)

Other changes attributed to group-membership included development of clearer

thinking, tapping of inner strengths, discovery of new talents and the ability to do things

they had previously been unable to do.

Interpersonal change

Participants associated group-membership with development in their communication

skills, ability to trust others, negotiation of interpersonal boundaries and social network.

. . . it has certainly taught me to be a bit more open with people. You know, I’d never say boo to agoose before, . . . I wouldn’t talk openly about self-harm before at all . . . it was something veryhidden and secret, ashamed of really and I feel a bit more comfortable with that. (Phillippa, 73)

Overview of the model

EMPOWERMENT seemed to reflect the process/outcome of group-membership and its

subsequent impact on women’s self-injury. Empowerment both influenced and was

influenced by BELONGING, SHARING, AUTONOMY, POSITIVE FEELING and

CHANGE occurring as part of group-membership, which were similarly influential upon

each other in apparently recursive and interactive cycles. For example, BELONGING often

afforded participants SHARING and AUTONOMY, which could also facilitate the

POSITIVE FEELING and CHANGE that often ensued. This CHANGE seemed often to

impact on participants’ ability to create BELONGING and SHARING with newer members.

While core-categories were interdependent in many ways, sub-categories also appeared

to potentially interact across core-categories. So, for example, increased autonomy might

reinforce individual changes, possibly enhancing self-acceptance, which usually improved

positive feeling and friendship. As some participants consolidated the CHANGES

associated with group-membership, they were consequently able to support, share with and

empower newer members, which further increased their own sense of EMPOWERMENT.

And so the cycle continued . . . .

Results were sent to participants, a support-groups’ meeting, the BCSW co-ordinator

and my field collaborator (self-injury expert) for feedback. Overall, six of the seven

participants responded and agreed that the model accurately represented their experiences

of the support-group in relation to their self-injury; consequently, the results were not

altered.



DISCUSSION

Adams (1990, p. 42) defines empowerment as ‘the process by which individuals, groups

and/or communities become able to take control of their circumstances and achieve

their own goals, thereby being able to work towards maximizing the quality of their lives’.

In this study, empowerment-as-process emerged as the apparent value of self-injury

support-groups, mediated through experiences of belonging, sharing, autonomy, positive

feeling and change. Results are discussed in relation to relevant theory/research, followed

by critical evaluation and implications of the study.

Empowerment

Overall, the model seems to corroborate both support-group (e.g. Kurtz, 1997; Nelson

et al., 1998; Solomon et al., 2001) and empowerment literature (Chesler & Chesney, 1988;

Rappaport, 1987), most of which the author read following analysis. The current study’s

five core-categories are reflected in Chamberlin’s (1997) user-definition of empowerment

which includes ‘not feeling alone’ [belonging],6 ‘having access to information and

resources’ [sharing], ‘having decision-making power’ [autonomy], ‘being hopeful’

[positive feeling] and ‘effecting change in one’s life and one’s community’ [change].

Belonging, acceptance and safety

In contrast to the reported isolation that participants related regarding self-injury service-

provision, support-groups and empowerment are conceptualized within the framework of

social support. Applying Bowlby’s (1980) attachment theory to their four-part model of

social support, Sarason, Pierce, and Sarason (1990) propose that feeling accepted

positively influences self-efficacy and perceived social support in a problem-solving

context. Many participants in this study valued a facilitator in creating safety. Durocher

(1999) also emphasized safety, often enhanced by a professional facilitator, as critical to

group functioning. Similarly reflecting participants’ experiences, Kurtz (1997) identified

critical/dominant members, leader burnout and the distressing effects of ‘high need’

members on others as threatening group safety. Current participants valued a facilitator in

mediating such occurrences. Reinforcing this stance, Levine (1988) suggests that support-

groups often fare better with a professional in the background.

Arnold and Magill (1996) maintain that self-injury support-groups require the

establishment of clear and consistent boundaries in the creation of safety and containment.

Involving facilitators may respond to professionals’ reported fears regarding the potential

risks of self-injury support-groups (Walsh & Rosen, 1988). Perceived risks include group

members being re-traumatized by others’ past experiences or encouraged to self-injure

following exposure to alternative methods of self-injury (Babiker & Arnold, 1997).

Somewhat addressing these concerns, both Lindsay (1995) and participants in the current

study noted that while the groups’ independence from statutory services is critical to their

value, the potential limitations of support-groups are nonetheless recognized by members

and that additional individual support (e.g. nurse, social worker, psychologist or

psychotherapist) is often accessed alongside the group. Interestingly, Lindsay (1995, p. 24)

6Categories identified in the present study are indicated in [square parentheses] within the text.



recounted how one ‘discontented service user’ was able to make better use of the

professional services after her experiences of being in a support-group.

Sharing, perspective and giving/receiving support

Commensurate with the study’s findings, support-group literature generally attributes the

sharing of experiences, or ‘telling one’s story’ (e.g. Kurtz, 1997, p. 81), as an integral

process. Following a narrative therapy approach (e.g. White & Epston, 1990), in (re)telling

one’s story, identity evolves with the potential to more clearly define and internalize an

alternative perspective on previous experiences. Theoretical parallels might also be drawn

between the present model and professional therapeutic models, such as Herman’s (1992)

three-stage recovery from trauma model which comprises (i) establishing safety (ii) telling

one’s story and (iii) re-integration into the community. Indeed, many participants’ paths to

the support-group reflected themes of trauma, arguably compounded by experiences of

service-provision (Johnstone, 1997). In sharing experiences, current participants

relinquished the sense of being alone in their self-injury. Solomon et al.’s (2001)

participants similarly reported how sharing experiences altered their perspective and

attributions of being ‘the only one’. The positive feeling that participants reportedly

derived from giving/receiving support is consistent with Maton’s (1988) bi-directional

support hypothesis that relationships involving give-and-take are the most beneficial.

Maton (1988) found that bi-directional support within groups produced greater perceived

well-being and fulfilment, compared to one-way giving and receiving. Similarly,

Reissman’s (1965) ‘helper’ therapy principle maintains that using acquired experience in

helping others generates increased feelings of competence, equality and social value.

Autonomy, direction and control

Arnold (1995) reported that self-injury, amongst other functions, helps women to obtain a

sense of control in the context of overwhelming pain and grief (Arnold, 1995) while Katz and

Hermalin (1987, p. 156) maintain that control/autonomy is central to self-help group

functioning, comprising ‘self-direction from within members, rather than direction from

outsiders, for example professionals’. Nelson et al. (1998) found that self-injury is often the

main focus of discussion in professional-led interventions whereas in the current study self-

injury was seldom discussed outside of acknowledging the person as a whole. They contend

that it is in this power-sharing that the foundations of empowerment are established. Given

the acknowledged association between self-injury and control/power issues (e.g. Babiker &

Arnold, 1997; Shaw, 2002), it is perhaps not surprising that support-group-membership often

resulted in reduced self-injury for participants in that, through accessing control and

empowerment in support-groups, they were less likely to resort to self-injury.

Positive feeling, inspiration and friendship

The current study identified positivity, inspiration and friendship as key factors in the self-

injury support-group process. Yalom (1995) identified the instillation of hope among 11

helpful factors pertaining to psychotherapeutic groups. Drawing upon this work, Kurtz

(1997) theorizes that instillation of hope, or inspiration, is an equally important factor in

support-groups. She contends that this hope is derived primarily through sharing success



stories whereby newer members are usually inspired by established members. This notion

has been borne out in support-group studies by Durocher (1999) and Davidson et al. (1999)

in which participants were inspired by group-members’ motivation, enthusiasm and

successes in ways reflected in the current study. Most prevailing research supports the

current findings by referring in some form or other to the social network extension that is

derived from participation in support-groups (Anderson-Butcher et al., 2004; Davidson

et al., 1999; Solomon et al., 2001). In their recent study of self-injury support-groups,

Smith and Clarke (2003) similarly identified ‘friendship’ as one of the main benefits

received. Acknowledging the secrecy, shame and isolation often associated with self-injury

(e.g. Babiker & Arnold, 1997), it is perhaps not surprising that current literature and the

present study alike indicate the importance of friendships in support-group participation.

Change

Experiences of change were reported by all participants in the current study. Certainly, change

as an outcome is integral to the majority of support-group studies. Anderson-Butcher et al.

(2004, p. 135) reported that group-members attributed increased interpersonal skills to

empowerment through an ‘enhanced sense of responsibility and self-esteem’. Similarly,

Solomon et al. (2001, p. 125) described ‘identity change’ as group-membership outcome,

encompassing assertiveness, focus, inner strength, self-acceptance and improved relationships

with their children. Stewart (1990, p. 1062) argues that ‘vicariously derived information from

[role] models can alter perceived self-efficacy’ which impacts on ability to make desired

changes. Comparable to Rogers’ (1961) concept of ‘self-actualization’, Kurtz (1997, p. 26)

proposes that in support-group contexts, ‘empowerment occurs when one becomes able to

take action for oneself and on behalf of others’, which manifests as self-confidence arising

from resolution of group-members’ common issues. Nelson et al. (1998) liken support-groups

to ‘learning organizations’ (Senge, 1990a) in constituting cultures committed to ‘learning,

change, growth and community building’. They emphasize that such learning and change can

occur at both individual and group levels.

The current study explored individual-level empowerment within a group context.

Drawing upon Gilligan (1982), Andrews, Guadalupe, and Bolden (2003, p. 8) assert that

for women, ‘a sense of connectedness is an integral part of their perceived empowerment’

which is corroborated by the recent Women’s Mental Health Strategy (DOH, 2003). Since

most empowerment literature focuses on individual-level rather than group-level

empowerment (Nelson et al., 1998) future research involving focus-groups might

investigate group-level and/or community-level empowerment processes within self-injury

support-groups, using more social-constructionist approaches such as discourse analysis

(Potter & Wetherell, 1987) or narrative analysis (Hollway & Jefferson, 2000).

Critical evaluation

Guidelines for evaluating qualitative research (Elliott, Fischer, & Rennie, 1999) were

respected throughout the research process7 although time/resource restrictions obliged the

author to reduce the complex, dynamic findings to an inevitably simplified model. Due to

7These comprise (a) owning one’s perspective, (b) situating sample, (c) grounding analysis in data, (d) providingcredibility checks, (e) offering a coherent account, (f) accomplishing general versus specific tasks and (g)resonating with readers (Elliott, Fischer, & Rennie, 1999)



recruitment difficulties, sample size was small and debatably self-selecting and ‘negative

cases’ (e.g. those leaving the group or having negative support-group experiences) to

challenge and/or enrich emerging theory were lacking. Nonetheless, interviews

incorporated questions regarding limitations and unhelpful experiences of group-

membership.

Given time restrictions, saturation predictably did not occur in all categories (Henwood

& Pidgeon, 1995) and the relatively constructivist epistemology of GT methodology

implies that the model represents one of many possible perspectives on the data. The

model’s transferability to other contexts/individuals should, accordingly, be provisional,

while further research using wider sampling procedures may expand transferability.

Nonetheless, given the model’s corroboration by participants, relevant professionals8 and

existing literature, the salient functions of support-groups have arguably been captured

sufficiently to render findings ‘trustworthy’/valid (Miles & Huberman, 1994).

Clinical and theoretical implications

Both UK Government and official guidelines are advocating increased access and referral

to support-groups (DOH, 1994; National Institute of Clinical Excellence, 2004).

Incorporating support-groups into self-injury services in accordance with RCP (1994)

guidelines could reduce self-injury A&E admissions and, ultimately, pressure on NHS

finance, time and resources. A proposed A&E risk-assessment (McElroy & Sheppard,

1999) could refer women to support-groups as a first point of call in contrast to the usual

automatic referral to medically-trained staff (Currie & Blennerhassett, 1999), often

creating further distress for women and escalating the possibility of repeated self-injury

(Pembroke, 1994). Indeed, it has been argued that a misapplication of the medical model of

‘illness’ to self-injury has accounted for much of the problem, as articulated by Johnstone

(1997, p. 425) who asserted that:

‘The underlying philosophy of the medically-based psychiatric approach can be summarized astending to remove power and control from the person who self-injures, to deny her feelings and toignore the meanings behind her actions. These are the very circumstances that are likely to haveled to the need to self-injure in the first place.’

The possibility of support-group referral may equally empower staff and reduce the

negative feelings stemming from their reported sense of powerlessness (Frost, 1995).

Participants’ narratives suggest that support-groups afford exploration of their difficulties

in the relatively empowered context of mutual belonging, sharing and autonomy. Indeed

self-injury support-groups espouse principles quite opposed to those of the medical model,

in which self-injury is conceptualised as ‘illness’ within the individual9. Acknowledging

notions of power/equality (e.g. Ng, 1980) inherently incompatible with the hierarchy in

professional contexts (Smith & Clarke, 2003), this mutual empowerment may therefore

constitute support-groups’ unique potential within self-injury service-provision. Support-

groups might also provide suitable training to service-providers in accordance with official

recommendations (NICE, 2004).

8These professionals included a Consultant Clinical Psychologist specializing in self-injury and the Co-ordinatorof the Bristol Crisis Service for Women.9This approach usually results in a focus on reducing the self-injury (Tantum & Whittaker, 1992) while literature(Lindsay, 1995) and participants in this study emphasized that reduction in self-injury was explicitly not the aim ofsuch groups.



The experiential knowledge (Borkman, 1976) shared within support-groups could,

where appropriate, be applied in both enhancing professionals’ self-injury awareness and

establishing further groups. Indeed, the BCSW co-ordinator has suggested employing this

study’s model as a referential framework for existing and future support-groups. Support-

group funding, although typically minimal, is often impeded by views that they compete

with, rather than complement, existing services (Lindsay, 1995). Paradoxically, Richards

(2004, p. 122) reports a view of support-groups as ‘a beguiling answer’ to the struggles

inherent in service-provision while maintaining that support-group integration, rather than

marginalization, would advance their ‘valued place’ in service-provision. Given

participants’ negative reports regarding professional services, however, the extent to

which integration would compromise support-groups’ empowering elements remains to be

seen.

Overall, this study suggests that self-injury support groups are valued by women who

attend them. Setting-up/facilitating secondary-service groups as longer-term, potentially

self-sustaining initiatives would afford group-members an alternative perspective on their

self-injury. Sharing self-injury experiences apparently reduces its associated secrecy,

isolation, guilt, shame and perhaps, consequently, the perceived need to self-injure.

Support-groups appear to facilitate change in contextualizing self-injury as common to

many women (Babiker, 2002, personal communication); this relational dimension of

change is extremely important to women with various mental-health issues (DOH, 2003).

In line with community psychology principles (e.g. Reinharz, 1988), exploring self-injury

within support-groups may aid deeper, symbolic understanding of how experiences

precipitating self-injury perhaps reflect, or are located within, culture as opposed to

individuals. Wider dissemination of findings could contribute to deconstructing the taboo

around self-injury (Hyman, 1996) which, in turn, might alter professionals’ responses at a

deeper, more cultural, level resulting in reappraisal of attitude and approach.

CONCLUSION

Grounded in participants’ experiences, this study provides a substantive conceptual model

of the potential role of self-injury support-groups in women’s self-injury management. In

the advent of the Women’s Mental Health Strategy (DOH, 2003), it is hoped that the model

will stimulate debate about self-injury service development and offer a provisional

framework upon which future research may expand.

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