Abstract
In modern mental health care, ‘recovery’ does not necessarily mean the same thing for clinicians, service users, and survivor groups. This divergence is especially stark where self-injury is concerned. For clinicians, recovery often refers to cessation of self-injury; for those with lived experience, self-harm may be a temporary or long-term method of navigating trauma and distress. This article explores how the survivor-led model, which regards self-injury as an understandable reaction to distress, poverty, abuse, and discrimination emerged from second-wave feminism, the survivor movement, and the growth of grassroots mental health groups in the 1980s. We focus on Bristol Crisis Service for Women (BCSW), a peer-led listening service for women who self-injure, founded in 1986. We begin with the history of BCSW and how experiences of their founders and users caused them to advocate for a different model of self-injury. We then situate BCSW’s approach to self-harm and recovery within the frame of women’s mental health activism. Finally, we explore how BCSW and its allies criticised existing psychiatric paradigms of self-harm, showing how the individualised medical model was rooted in gendered stereotypes that failed to recognise the real-world concerns of many women. We argue that it remains important to see self-harm not as an individual health concern, but in relation to the structural and practical issues affecting users and survivors. Within BCSW, a peer-led service, experience of self-injury became not a deficit but a useful asset in supporting other women, indicating that recovery itself could be both collective and non-linear.
Introduction
Recovery is an emotive term in modern mental health. Today, the ‘recovery model’ generally refers to the idea that recovery may not mean a cessation in symptoms but can be a relative concept, associated with quality of life. This notion originally emerged from the user movement in the late 1980s, but by the early 2010s was being widely discussed as a potential alternative to a biomedical model of mental illness (Thornton and Lucas, 2011). Simultaneously, service users and survivors began to express concern about the co-option of this model to deny people access to services, benefits, and essential living support as well as to promote a very narrow set of expectations that everyone, no matter what their situation, was supposed to live up to. Recovery in the Bin, an activist group formed in 2016, has called for a social model of ‘madness, distress and confusion’ to address their concern that ‘“recovery” is being used to discipline and control those … trying to deal with the very real mental distress they encounter on a daily basis’ (‘About’, 2016). The recovery agenda, activists and researchers have complained, can have a very narrow perspective on wellness that emphasises the goals of middle-class professionals while utterly failing to take into account the detrimental effect social, environmental and political factors have on the lives of those in mental distress (Rose, 2018; Russo and Beresford, 2015). ‘Maybe we don’t have mental health difficulties’, artist and activist Dolly Sen suggests, ‘Maybe we have living in a selfish, unfair and judgmental world difficulties’ (Sen, 2016: 38).
While the material in this article pre-dates the so-called ‘recovery agenda’, it addresses an equally charged notion of recovery – in response to self-injury – which offers up some precursors to more recent thinking about recovery. In psychiatric circles, recovery has tended to mean cessation of self-injury: however, this is not how survivors and advocacy groups have understood it. The survivor-led model of self-harm recovery, which regards self-injury as an understandable reaction to distress, poverty, abuse, and discrimination, was rooted in second-wave feminism, the survivor movement, and the growth of grassroots mental health groups in the 1970s and 1980s. This article argues that it is important to see self-harm not as an individual health concern, but in relation to the social and political context of women’s status. Exploring the history of self-harm highlights the structures that disadvantage women and the pathologisation of difficult life experiences such as poverty, sexual violence, and abuse. We argue that while this contextual view of self-harm was formed within a specific historical and activist context it remains relevant today. Activist groups can and should interrogate and redefine recovery as BCSW did and other groups continue to do. This redefinition emerged within a collective approach to understanding and support that in itself rejected a purely individual view of self-harm.
This article charts this history by focusing on one central group – Bristol Crisis Service for Women (BCSW) – now Self Injury Support – a peer-led listening service based in Bristol, UK. We begin with the history of BCSW as a group: exploring their aims and activities, and how the experiences of their founders and users caused them to develop and advocate for a very different model of self-injury from that used in biomedical circles. We then go on to situate BCSW’s efforts within a wider frame of women’s mental health activism in the 1970s, 1980s, and 1990s. Finally, we address the way feminist survivor and user groups like BCSW challenged the biomedical model, claiming that an individualised model of self-harm was rooted in gendered stereotypes and a patriarchal attitude that failed to recognise the real-world concerns of women. Our time period begins in 1986 with the founding of BCSW, a year that Cresswell and Brock also highlight as the moment that self-harm activism began (Cresswell and Brock, 2017: 14). We continue beyond the year 2000, when a politics of self-harm was fully established, according to Cresswell and Brock, to explore the impact of this feminist politics on mainstream services, ending in 2002 with the publication of the Department of Health’s report on turning activism into policy in women’s mental health. This was also the year that BCSW changed from a collective to a community interest company and charity, arguably shifting the politics of self-harm away from activism to more mainstream approaches.
Within mental health services, definitions and descriptions of self-injury or self-harm have not remained constant. Today, these two terms may refer to a slightly different set of acts (with self-harm generally being broader, including overdosing and sometimes eating disorders). Definitions may also vary across national borders. Armando Favazza, the influential psychiatrist author of Bodies Under Siege, an early psychiatric text on self-injury, noted these discrepancies even between statistics relating to NSSI (non-suicidal self-injury) between countries in the 2010s: ‘The Brits include overdoses but the Americans don’t’ (quoted in Chaney, 2017: 181). Throughout its history, BCSW has often used the terms self-injury and self-harm interchangeably, sometimes to draw attention to the way helpline callers and staff understood self-harm as a very broad and varied practice. As their 1998 guide to self-help groups explained, ‘We do not adhere to a rigid definition, distinguishing self-injury from self-harm and the terms are used flexibly in this booklet’ (Lindsay and Parker, 1998: 3). This article takes a similar approach. When quoting or providing historical examples, we use the terminology of the historical actors. In our own writing, we recognise that terminology is changeable, and may mean different things to different groups or even individuals. However, we too use the terms self-harm and self-injury flexibly to better reflect the history of BCSW and its users throughout this article. We tend to use biomedical or psychiatric to refer to mainstream approaches within mental health services, while recognising that not all mainstream practice was or is biomedical. However, this approach to self-injury tended to be what BCSW and its allies regarded as the dominant model, which they opposed. We use the term mental health more loosely, to refer to any type of mental health intervention, whether within clinical services or the type of grassroots, peer-led interventions practised by BCSW. This acknowledges that there was and is overlap between these approaches, even when critical of each other.
Bristol Crisis Service for Women: Self-harm and recovery
Bristol Crisis Service for Women was founded in 1986 as a feminist collective. Wilton (1995) describes how it developed from the Bristol Women and Mental Health Network, devised by ‘three lesbians in a locked ward of a Bristol mental hospital’ to offer ‘woman-centred alternatives to the “mental health” services’ (Wilton, 1995: 34). In 1988, the collective set up its first telephone helpline for women in crisis staffed by volunteers, and in 1989 two of the founders, Maggy Ross and Diane Harrison, participated in the first Self-Harm Conference organised by Survivors Speak Out (Pembroke, 2009). By 1995, half the helpline calls received by BCSW concerned self-injury, and the collective aimed to offer support and a non-judgemental listening service for women’s experiences (Lindsay, 1995: 1). The same year, BCSW organised their own conference, Cutting Out the Pain, bringing together 150 delegates from across the UK. BCSW was also involved in the National Self Harm Network in the 1990s, including the risk reduction conferences that the network held (National Self Harm Network, 2000). BCSW continued to provide peer-to-peer services over subsequent decades, although its structure changed in 2002 (to become a charity and limited company, rather than a collective), and in 2014 the name was changed to Self Injury Support (Wild, 2022).
A recent National Lottery Heritage Fund project, Women Listening to Women, led by historian Rosie Wild and completed in 2022, has gathered the BCSW archive, digitising its publications and reports alongside newspaper articles. With the help of volunteer interviewers, the project carried out 22 oral histories with former and current staff and volunteers. Interviewers were trained in oral history interviewing and also went through BCSW’s standard helpline training, ensuring that they were supported to manage the emotive and often challenging nature of the project. Ethics approval for the project was gained from the Open University. It was not possible to cover the entire history of BCSW through oral histories – despite widespread advertising, none of the founder members of BCSW came forward, and their work and ideas remain accessible only through their publications and reports of BCSW activities. This article thus draws on both the reports and oral histories, alongside published articles and books by founder members of BCSW, to ensure that the early aims of BCSW are represented and explored. The project led to the creation of three podcasts, two exhibitions, and a booklet. The interviews and reports, along with a more extensive history of BCSW, can be found on the project website (https://www.womenlisteningtowomen.org.uk). The archive has been deposited at the Bishopsgate Institute.
The founders of BCSW saw themselves as survivors of the mental health system. They had had negative experiences of treatment for self-inflicted injury and saw this as a key reason why BCSW should be user-led. From the outset they insisted that stopping self-harm was not an essential goal and that recovery did not necessarily mean immediate (or even eventual) cessation of self-injury, even if for some women it might. As founder member Diane Harrison put it at BCSW’s National Conference on Self-Injury, held in 1995, I am often asked whether women stop harming when attending the FACES group [a peer support group she founded]. I reply that a woman’s success isn’t measured by the presence or absence of injury.… What is more important is that a woman’s struggles are heard and her strengths and creativity are nurtured and explored. (Bristol Crisis Service for Women, 1995: 7)
Over its nearly four decades of existence, BCSW and Self Injury Support remained a support service for all women with experience of self-harm, whether they continued to injure themselves or not. Catherine, a helpline volunteer from 2008 to 2009, captured this approach evocatively in her oral history: I suppose the image that I kind of always come back to, which is, um, if someone is kind of, if someone’s floating down a river on a log, really fast river and you kind of, and the log is their safety mechanism and you tell someone to kind of let go of that log and that you’re going to catch them on the other side or whatever. Like, I don’t know, it’s just like by telling someone to kind of jump off if they’re not ready or they don’t feel safe enough to do that, whatever, is just really wrong. I think it’s, it’s about that person kind of, when, you know, if they want to give it up, if they want to stop or if they can kind of find other things that kind of help relieve that pain, then, then that’s kind of up to them. It’s not up to us to tell somebody to kind of jump off when they’re not ready. ([Interview With Catherine S.], 2021)
Within BCSW, their view of self-harm as a way of managing life experiences seemed like common sense, because it was based on what service users were repeatedly telling staff and volunteers. One of the first evaluations of BCSW’s services, completed in 1995, noted that women ‘want their experiences and needs taken seriously, and want to feel accepted, and supported in their struggles’ (Lindsay, 1995: 3). This meant that BCSW was ‘meeting people where they were at’, as staff member Jenny put it ([Interview With Jenny S.], 2021). Sal, a collective member, volunteer, and freelance trainer from 1996 onwards, reflected in 2021 on this ongoing disconnect between mainstream mental health services and the work of Self Injury Support in relation to training she had recently carried out for the University of the West of England: And the guy who was the head of the course said, ‘gosh, your way of approaching things is so radical’, and I’m like, ‘is it? I just think we’re sensible’, but apparently, you know, not stopping people from hurting themselves and trying to understand why people hurt themselves and being more concerned about the emotional distress than the acts themselves apparently is quite radical. ([Interview With Sal B.], 2021)
BCSW set out to change attitudes in mainstream services and wider society, drawing on the experiences of their volunteers and users to raise awareness of the range of reasons why women might self-harm. Their Women and Self-Injury booklet of 1990 set out this approach as a feminist manifesto, rooted in patriarchal attitudes to and expectations on women that, the authors believed, led them to turn their anger or pain inward. The authors further suggested that witnesses (friends, family members, medical professionals) should examine their own attitudes to self-injury and recognise that their responses to self-harm were rooted in social experiences as much as the act itself: If we view self injury as a deep expression of inner hurt, and not think of it as being ‘attention seeking’ (for everyone needs attention) then perhaps if we feel disturbed or angry, we should look at our own fears. Maybe it reflects our own inner anger? maybe we too would like more attention? who’s listening to us? perhaps we feel in some way responsible for their actions, past, present or future? (Bristol Crisis Service for Women, 1990: 6)
In 1994, BCSW started a newsletter, SHOUT (Self Harm Overcome by Understanding and Tolerance; Bristol Crisis Service for Women, 1994), aimed at reducing the isolation felt by many women who injured themselves, and commissioned its first piece of research, carried out by Lois Arnold, a paid member of BCSW staff (Arnold, 1995). Arnold interviewed 76 women with experience of self-harm to better understand their views. This was a radical new model of self-harm research. As Arnold herself noted, most prior studies had been ‘based on the theories of academics and clinicians … drawing their own conclusions about which factors may be relevant and how’ (Arnold, 1995: 1). The women Arnold interviewed often interpreted their self-injury quite differently from academic researchers. Many drew a thread from superficial knocks and grazes in childhood to later deliberate self-injury, as well as linking self-harm to other aspects of their lives, for example remaining in abusive relationships and overwork or exercise (ibid.: 8). This, Arnold concluded, served as a warning to clinicians that, if self-injury was treated ‘as a behaviour to be “extinguished”, other forms of self-harm may be instituted or increased to take its place’ (ibid.: 9). This broad definition of self-injury encouraged flexibility about terminology: for BCSW there was less of a distinction between self-inflicted damage to the surface of the body and wider harming behaviours, like excessive exercise, than within a medical model of self-injurious behaviour (Lindsay and Parker, 1998: 3).
Arnold found that most of the women she interviewed had ‘a very clear understanding of the links between their experiences and their self-injury’ (Arnold, 1995: 12). This included an awareness of the function self-injury played for them and clarity about their motives for using it. Indeed, the depth of understanding was, Arnold felt, the thing that ‘emerged most strongly from this survey’ (ibid.: 16). Self-harm helped women to cope, to manage their emotions, to get through experiences that were otherwise hard or impossible to bear. The fact that these women’s experiences of self-harm were rooted in their lives, including practical problems such as poor and unsafe housing or violent relationships, meant that treatment often failed or was regarded as unhelpful: the only treatments deemed useful by Arnold’s participants were talking therapies and creative arts. Recovery, for these women, meant changing the conditions that had led to their self-injury, and not necessarily stopping the behaviour itself.
This view of recovery was reflected across the work of BCSW and its activists. Self-help guides suggested a need to develop other ways of coping and expressing feelings in order to stop or reduce self-injury (Arnold, 2002: 42), while those for friends and family emphasised that stopping self-harm was not a decision to be made by others: ‘When she is ready and no longer needs this way of coping, she will be able to make her own decision to stop’ (Bristol Crisis Service for Women, 1994: 3). Diane Harrison emphasised that stopping harming was not a measure of ‘a woman’s success’ in recovery (Bristol Crisis Service for Women, 1995: 7). But where did this contextual view of self-injury come from? BCSW’s founders were undoubtedly – and explicitly – inspired by second-wave feminism. In the 1980s mental health became for the first time an important area of activism, situating women’s struggles in sexism, gender stereotypes, and an unequal society.
Putting BCSW in context: Feminism and mental health activism
BCSW emerged in the context of a wide range of feminist groups and practitioners becoming engaged in women’s mental health activism, beginning in the later 1970s (Crook, 2018, 2022). Broadly these groups argued for a more political understanding of mental distress rather than the individualised pathologised approach popular in medical circles, and in giving primacy to women’s own voices. Groups and campaigns set up in the 1970s, 1980s, and 1990s in the UK included the Women’s Therapy Centre in 1976, Southall Black Sisters in 1979, the Newham Asian Women’s Project (now the London Black Women’s Project) in 1981, Women in Special Hospitals in 1987, MIND’s Stress on Women year in 1994, and the UK National Women and Mental Health Network in 1996. These groups developed from publications like Our Bodies Ourselves, published in 1973, which saw women coming together to redefine knowledge about their own bodies, and created a sense that with collective action it was possible to challenge dominant ways of seeing and treating women’s bodies and minds. This was important context to the new meanings given to self-harm recovery within BCSW. As Cresswell and Brock argue ‘the politics of self harm emerged between the years 1986 to 1989 at the confluence of survivor and feminist activism’ (Cresswell and Brock, 2017: 9). For example, self-harm was first indexed in Our Bodies Ourselves in 1989. BCSW emerged from this context of resistance to the medicalisation of the female body and challenges to medical dominance made by the mental health survivor movement. The emphasis was on self-knowledge and developing collective approaches to understanding, advocating, and providing support grounded in women’s own experience of mental distress. From experience of self-injury being seen as negative, an experience that had evoked internalised shame and stigma and was largely hidden, it became an asset in supporting other women, for example at the BCSW helpline.
The emergence of women’s organisations that offered advocacy, and mental health support to women outside mainstream services was underpinned by feminist critiques of the mental health system. Psychotherapist and writer Phyllis Chesler demanded ‘a million dollars in reparations for those women who had never been helped by the mental health professions but who had been instead … further abused, punitively labelled, overly tranquilized, sexually seduced whilst in treatment’ (Chesler, 1972: xvii). The 1970s marked the beginning of an era of activism fuelled by a rapid growth in women’s shared awareness that sex inequality was a significant determinant of their mental health (Showalter, 1987). The idea that the mental health system reinforced patriarchal attitudes and practices towards women outlined by Chesler formed a powerful rallying cry: Chesler was cited by BCSW founders (Harrison, 1994: 9–10). This was a time when personal experience was validated by second-wave feminism, the growth of women’s groups, and writings from North America (Baker-Miller and Mothner, 1971; Chesler, 1972; Millett, 1970). National networks emerged that had an important role in linking local and regional women’s activism, and in campaigning. London-based women’s mental health activism was also funded by the Women’s Committee of the Greater London Council between 1982 and 1986. However, self-harm did not feature in their activism (Cresswell and Brock, 2017: 13).
Until this point women’s inequality and the mental health consequences of violence against women had largely been ignored by mainstream theory and practice in the field of mental health. Critiques of this neglect began to emerge from academia, accompanied by alternative understandings of women’s distress. Feminists reframed child abuse and domestic violence from private and hidden concerns to issues requiring public attention and community action (Tseris, 2019). Post-traumatic stress disorder was fought for by feminists as a diagnosis for women who had suffered abuse and violence (Kutchins and Kirk, 1999). The invisibility of the widespread violence that women suffered from in the domestic sphere and its mental health consequences were articulated in Judith Herman’s groundbreaking 1992 book Trauma and Recovery, which connected these private domestic terrors to the more public and widely recognised consequences of men taking part in warfare. Herman located her work firmly within the women’s liberation movement, of which she wrote, ‘In the 1970s, the speakouts of the women’s liberation movement brought public awareness to the widespread crimes of violence against women.… As a psychiatric resident I heard numerous stories of sexual and domestic violence from my patients’ (Herman, 1992: 2). These stories, she said, had previously been deemed ‘unspeakable’ and women’s victimisation had been ignored in spite of multiple diagnoses.
Herman viewed ‘recovery’ as having three stages: ‘establishing safety, reconstructing the trauma story, and restoring the connection between survivors and their community’ (Herman, 1992: 3). She suggested that central to trauma was the sense of disconnection from others and disempowerment. This meant that recovery had to be based on tackling these issues, and it could only take place ‘within the context of relationships’ (ibid.: 133). By putting women’s experiences at the centre and seeing self-harm in the context of their experience, BCSW aimed to offer the recognition and community that Herman’s feminist analysis highlighted. Herman discussed the multiple diagnoses that women who have experienced childhood sexual abuse, rape, and violence were subjected to within psychiatric services. For Herman, it was not the diagnosis or the manifestation of the distress that was central but listening to what women have to say about the context of their lives. This links to the findings in Arnold’s 1995 study and the BCSW interviews: if the focus of services is mainly on stopping women from self-harming, then another manifestation of the underlying distress may take its place, for example eating disorders or addiction.
Within the feminist movement, the dominant and interconnected concerns were women speaking for themselves about their mental health difficulties, an increased understanding and spotlight on the relationship between sexual violence and mental distress, the safety of women using services, redefining women’s mental health, developing more effective responses to women in distress, consciousness raising – ‘the personal is political’ – and the diversity of women’s experiences. The vast majority of these concerns were picked up by BCSW. Women’s voices also emerged against the backdrop of the anti-psychiatry movement and the differing commentaries of writers such as Laing (1965), Goffman (1961), and Szasz (1961). An organised mental health survivor movement, inspired by civil rights campaigns as well as by anti-psychiatry, began in the 1970s (Blayney, 2022; Campbell, 1996; Rashed, 2019). In the UK, People Not Psychiatry was founded in 1969, while a range of groups were set up across North America in the early 1970s. The Mental Patients Union (MPU), founded in London in 1972, had activists across the UK by the mid 1970s (Roberts, 2005–18; Spandler, 2006: 59). The MPU rooted its understanding of mental ill health in the class struggle (ibid.: 60). Its founding manifesto outlined a Marxist perspective that highlighted the sufferings of working-class women: ‘Not only do some women suffer the same work conditions as male manual workers, often for lower pay, but they are expected to act as slaves to their children and husbands’ (Irwin et al., 1972: 25). This reflected elements of feminist ideology, albeit within a Marxist frame that saw class as significantly more important to mental health than gender.
Outside these groups – and within mainstream medicine – there was little acknowledgement that gender and other social inequalities had any relevance to the psychiatric enterprise (Sayce and Copperman, 1997). These issues were reflected on in discussion in a 2014 workshop held with women activists at the Open University to scope the creation of a digital archive of women’s mental health activism: We could see that women weren't listened to, they weren’t believed, they were judged, they were mad, bad, they were not respected. Their experiences weren’t validated at all. (OU workshop participant, quoted in Carr and Copperman, 2014: 10)
While early survivor-led groups, like the MPU, often excluded those who were not survivors from full membership, by the 1980s when BCSW was founded some groups had begun to take a broadly collaborative approach to demanding a voice within mainstream services (Rashed, 2019: 13). For women’s activist groups, who shared a basis in gendered inequalities whether women were staff or service users, this was perhaps more successful than in other areas – one of the factors behind BCSW’s longevity. Women mental health professionals, survivors, activists, and researchers found commonalities in experiences that undermined professional divisions (Jamison, 1996). This supported the involvement of non-medical professions in which women were over-represented within activism: nurses, social workers, and occupational therapists. The network that developed the MPU’s founding principles, for example, included junior occupational therapist Lesley Mitchell and social work student Liz Durkin (Spandler, 2006: 53). Clare Shaw, meanwhile, found that the only practitioners interested in and supportive of their women and self-harm group in the 1990s were nurses. 1 These women attached importance to finding equitable and respectful ways of working together, which found echoes in other collective struggles for change. For example, the mental health survivor movement challenged the assumption that professionals and service users belonged to discrete groups (Perkins, 2005), and the stigmatisation and subordination of those who used services.
This was a time of challenge to hierarchies of power, within the activist movement as well as because of it. Some groups felt that their voices were not sufficiently heard and that white middle-class and heterosexual women were privileged. For example some lesbians suggested that the failure to establish a psychology of lesbianism section within the British Psychological Society was due to a marginalisation of lesbian concerns by feminists (Comely et al., 1992). Efforts were made by feminists active on mental health issues in the 1990s to establish a more inclusive approach, which included documenting good practice in meeting the mental health needs of marginalised women, for example in the publication Women in Context (Perkins et al., 1996). This good-practice review revealed that the mental health of Black and global majority women had been seriously overlooked. Yvonne Christie, who came to women’s mental health activism through her work on race and mental health, described her shock when, as a trainee mental health practitioner, she found out how Black women were treated in day centres: ‘Even though there was a dire situation for white people, I thought “Oh my God, what's happening to black people?”’ (Carr and Copperman, 2014: 10).
Some participants at the Open University workshop reflected on the integration of research and practice in activism: ‘There was activism in the academy in research for South Asian women who self-harm’ (Carr and Copperman, 2014: 13). Another participant described how reading research about the ways that mental health service responses to South Asian women were affected by traditional psychiatric labelling and barriers (Bhardwaj, 2001) had been a key influence on her development as a feminist activist. Mental health activism for Black and global majority women also originated in grassroots projects established to deal with violence within communities. This included the Newham Asian Women’s Project (NAWP), which highlighted the challenges associated with growing up young, Asian, and female in Britain (Yazdani, 1998), and Southall Black Sisters (Siddiqui and Patel, 2010). Particular attention was paid by NAWP in the 1990s to researching self-harm and suicide among Asian women and young people (Bhardwaj, 2001). The research was used to influence mainstream services to respond appropriately and establish refuges, support groups, and schools outreach programmes, among other interventions (Bhardwaj, 2001; Carr and Copperman, 2014). Responding to different women’s needs was both a challenge and an opportunity for the small, largely unfunded BCSW. In order to reach new audiences, for example younger women, BCSW produced publications, set up a text service and support groups, and at one point went into schools. It did outreach to women in prison, and specific work on self-injury among women with learning disabilities, which had been previously ignored. Some interviewees commented, however, that it was less successful in involving Black and ethnic minority women in its work, despite a specific outreach project ([Interview With Fiona M.], 2021).
Groups and networks were also created outside existing structures. The great attraction of this was that it offered women the opportunity to speak freely and make decisions without compromise. This is typified by the National Women and Mental Health Network (NWMHN), established in 1996, which protected its independence by not accepting external funding. NWMHN attracted a diverse membership including the lead for women’s mental health at the Department of Health and women incarcerated in secure psychiatric hospitals and prisons who received the newsletter free of charge. The network, organised by women volunteers, held conferences and produced publications on issues around violence, survivor perspectives, mothering and reproduction, race, and sexuality, and campaigned about specific issues such as electroconvulsive therapy, service responses to older women, and safety in mental health settings. Another example was Threshold, a Brighton-based service that provided leaflets and counselling for local women with mental health needs, along with national conferences and a telephone helpline. Significantly, neither of these organisations has any online trace today. While these types of groups were impactful and valued, their lack of reliable funding and organisational anchors meant they often had a short life span.
Women activists situated within established social organisations and institutions used a range of strategies to mobilise their own organisation to good effect. Grassroots groups across the UK were instrumental to the success of MIND’s influential ‘Stress on Women’ campaign (Darton, Gorman, and Sayce, 1994; MIND, 1992; Wood and Williams, 1992), run by the national mental health charity. Key demands of the Stress on Women year included (a) an end to sexual harassment and abuse in mental health settings, (b) the right for women to choose a woman care manager or key worker, (c) childcare for people who use mental health services, and (d) service provision monitored by gender and action to end unfair treatment. Local organisations took action all over the country: 1370 campaign packs and 39,000 leaflets addressing sexual violence within mental health settings were sent out. Politicians were challenged to support the creation of women-only wards within mental health settings and the campaign received media attention. Self-harm was discussed as a policy issue within MIND’s Stress on Women policy paper (MIND, 1992), which accompanied the year-long campaign. BCSW, Women in Special Hospitals, and the feminist networks around these organisations influenced the policy paper, which suggested that ‘self harm is often linked to earlier experiences of abuse and current experiences of powerlessness, particularly in prisons, special hospitals and psychiatric hospitals’ (ibid.: 17). Similarly, Women in Context, written in 1996 by women active within both the MIND Stress on Women year and the NWMHN, contained a chapter by Lindsay and Arnold on ‘Self Injury’ that outlined the groundbreaking work of BCSW (Perkins et al., 1996). The development of feminist and survivor networks active on mental health issues during the 1990s enabled self-harm to be actively discussed despite, as Wilton claimed, the reluctance of the mainstream second-wave feminist movement to consider it (Wilton, 1995: 35).
A gendered view of recovery in self-injury
It was in bringing together politics, feminism, and self-injury, then, that BCSW offered a specific contribution to women’s mental health activism. As Chaney elsewhere describes, the history of self-harm indicates that, prior to the 20th century, self-injurious behaviour was not specifically gendered as a female behaviour. Indeed, in the late 19th century, the paradigm for ‘self-mutilation’ across Europe and North America was genital injury in men (Chaney, 2017: 64–6). It was in the early 20th century that self-injury became associated with women, particularly the ‘hysterical malingerer’, whose behaviour was explained by the fact that they were female, and therefore ‘naturally’ manipulative (Weber, 1911: 1542). Meanwhile, in the 1960s, as Chris Millard and Barbara Brickman have shown, a small number of clinicians writing about cases in private psychoanalytic institutions on the East Coast of the US promoted cutting as the primary form of self-injury and women as ‘typical cutters’ by a process of exclusion and emphasis (Brickman, 2004; Millard, 2013, 2015). These definitions shared the assumption that self-injurious behaviour was rooted in the ‘natural’ traits of women: a desire for sympathy and attention, a tendency to be deceptive, and a passivity that manifested in masochistic behaviour. Both medical frameworks also supported the repeated claim that recovery required women to change their behaviour to accept the limitations imposed upon them within a patriarchal society, and not the other way around (Graff and Mallin, 1967: 36–7; Pao, 1969: 201–2). Even those who acknowledged the lack of opportunities available to women nonetheless concluded that marriage and children was an appropriate cure (Weber, 1911).
It is perhaps unsurprising given this history that BCSW perceived psychiatry as a direct corollary of the social limitations imposed on women by a patriarchal society. ‘But what is “normal”?’ founder Diane Harrison asked at the 1995 Cutting Out the Pain conference. ‘Merely an illusion which is imposed on us by patriarchal powers. It sets out to define social and moral order, so that any attempt at individuality will be seen as deviant’ (Bristol Crisis Service for Women, 1995: 2). Harrison viewed self-injury as a rational feminist response: Self-inflicted injury could be described as a radical response to feelings of total powerlessness and loss of self, a symbolic resistance to the power structures found within society which negate and silence women. (Harrison, 1994: 19)
For Harrison and Pembroke, this was reinforced by attitudes towards recovery focused on cessation and behaviour modification. The idea that self-injury was attention-seeking meant that ‘withholding attention’ might be classed by medical staff as a treatment for self-injury, with an intentional reduction in empathy and care. Arnold’s participants found this deeply traumatising (Arnold, 1995: 4). Pembroke spoke of being sutured without anaesthetic ‘to teach me a lesson’: the ultimate ‘lesson’ was that she stopped using mental health services at all (Pembroke, 1991: 32). In a recent interview, Arnold reflected on this individualised model of mental health, which depicted self-injury as a manipulative act to be ignored or stamped out: [Psychiatrists were] telling them why they were doing it and also telling them that they had to stop it.… I mean I know it seems so self-evident that you should ask people why they’re doing it and what they need, but, you know, often it was seen as, well, you’ve got to stop this … and that talking about it is only going to feed your, you know, giving you attention, because of course they often saw it as attention seeking, so there was this kind of theory that giving you attention will only reinforce that bad behaviour. ([Interview With Lois A.], 2021)
The key issue highlighted by Arnold, Harrison, and Pembroke was one of powerlessness. ‘Women are further damaged by services’, Arnold claimed, ‘when they find they have (yet again in their lives) no power or control’ (Bristol Crisis Service for Women, 1995: 22). The underlying philosophy of the medically-based psychiatric approach can be summarised as tending to remove power and control from the person who self-injures, to deny her feelings, and to ignore the meanings behind her actions. These are the very circumstances that are likely to have led to the need to self-injure in the first place. (ibid.: 11; original emphasis)
This approach led BCSW to emphasise quite different practices from those of mainstream psychiatry, such as peer support and self-help groups. Some activists, like Pembroke, rejected medication. ‘Psychiatric drugs make it easier to hurt yourself’, Pembroke explained. ‘Their effects, such as emotional blunting, merely help to dull pain and fear’ (Pembroke, 1991: 32). Rather than supporting recovery, medication might make self-injury worse. Yet it was peer support, not medication, that made professionals suspicious. BCSW’s 1998 pamphlet on self-help groups acknowledged that ‘some professionals’ were reluctant to support self-help groups, fearing that sharing experiences would worsen individuals’ self-injury by encouraging copycat behaviour. They concluded, however, that ‘in our experience, the opposite is true’ (Lindsay and Parker, 1998: 24). Similarly, Pembroke wrote about the guilt and shame provoked by the psychiatric model of recovery as cessation. It was only when a friend who was a nurse taught her how to prevent infection and look after her wounds in a ‘non-judgemental atmosphere’ that things began to change. ‘This was liberating and I began to harm myself less’ (Pembroke, 1991: 32). Activist groups including BCSW and the National Self Harm Network in the 1990s promoted the idea of harm minimisation or reduction (National Self Harm Network, 1998). While this type of safer self-harm described by Pembroke has received some attention in mental health services – often promoted by nurses like Chris Holley and Jane Bunclark – it has never been incorporated fully into mainstream practice, despite the efforts of BCSW and other activists (Chaney, 2017: 224–5).
In 2002, the publication of the Department of Health’s Women’s Mental Health: Into the Mainstream (Department of Health, 2002, 2003) showed to what extent activist groups had been absorbed into mainstream activity. Insights from BCSW and the National Self Harm Network were integrated into Department of Health service development recommendations, which began by emphasising that ‘policies, training and staff support’ must acknowledge the woman’s own view of an event as important, as well as understanding that staff’s dismissive or punitive responses had consequences. The policy also acknowledged that ‘staff may find dealing with repeated or serious episodes of self-harm frightening and/or rejecting’ (Department of Health, 2002: 78). The discussion of staff attitudes as impacting on patient recovery and the reference to the need for support for staff to act empathically echo the way in which BCSW made the support for helpline volunteers integral to its services, offering a ‘gold standard’ of support. The impact of feminist and survivor approaches and their critique of the harmful impact of punitive treatment is evident: BCSW and the National Self Harm Network were both cited as good-practice examples.
By the mid 2000s, however, many activist groups were disappearing from public view, and even much of the work on women’s mental health carried out by major health and mental health charities and networks had been forgotten. Others, like BCSW, managed to survive, including the Southwark Women and Mental Health Forum. This coalition of professionals and service users was originally funded by Southwark Council and intervened effectively on the safety of women inpatients, assisting a local mental health hospital to establish the first set of guidelines in the UK that recognised women’s experiences of sexual violence within mental health settings and contributed to the establishment of a women-only ward (Copperman and Knowles, 2006). Another notable exception is Women in Secure Hospitals (WISH), a national charity founded in 1987 by Prue Stevenson in collaboration with two former patients. Sleep problems, anxiety attacks, alcohol and drug abuse, and self-harm have been noted as particular issues among women in prisons and high secure settings (Barnes and Stevenson, 1996; Department of Health, 2002). Potier, a clinical psychologist giving evidence to the 1992 public inquiry about conditions for women at Ashworth Hospital (a high secure setting), detailed the powerlessness that women experienced being detained within the institution. The lack of a therapeutic regime for women and the infantilising, punitive, and sometimes abusive treatment that women, who had themselves often experienced disrupted and abusive childhoods, received were highlighted (Potier, 1993). High rates of self-harm in Ashworth were identified and studied, and a sense of the powerlessness that women felt was exposed. Women were actively prevented from leaving the special hospitals unless they had stopped self-harming first. The women identified ‘being in a less secure environment’, ‘living with family or friends’, and being in a ‘more caring environment’ as necessary to reduce their self-harming and increase their well-being. They also wanted to be in segregated wards. These themes link back to BCSW’s overall philosophy and their project with women in prisons in particular.
The WISH campaign was successful in making it known that many of these women were receiving very poor care, at levels of security that were unwarranted (Parry-Crooke, Oliver, and Newton, 2000). The charity was instrumental in changing high secure services: women are no longer housed in Broadmoor and Ashworth hospitals, and specialist provision has been developed for a smaller number of women in Rampton hospital and in medium secure units (Aiken, 2006). WISH’s campaign to provide medium and high secure settings that met the needs of the women in them were linked to feminist and survivor ideas of recovery and the relational care that is needed to support women who have experienced trauma. The NAWP (now the London Black Women’s Project) and Southall Black Sisters have also survived funding crises, and at the time of writing continue to offer services to girls and women. Both of these organisations address the mental health implications of violence against women and girls, offering critiques of racial discrimination within mainstream services and violence and abuse within communities.
BCSW, of course, made a specific contribution to women’s mental health activism by focusing attention on the ways in which self-injury had been misrepresented and misunderstood within psychiatric services and in pioneering a practical alternative through a women-only peer support model. This approach was to prove nationally influential in reconceptualising support for women who self-injured and offering a powerful critique of the pathologised and individualised approaches that predominate in psychiatric services (Wild, 2022). BCSW were notable in terms of a specific model of recovery (‘Our Impact’, 2022): the service was developed for women by women, it emphasised women’s own agency in self-injury, and self-injury was seen within BCSW in the context of women’s lives. This turned the experience of self-injury within BCSW from being an individual deficit into an asset in helping other women on the helpline and with other activities. While volunteers themselves might have experienced their self-harm as negative – and had often been told by doctors that it was – sharing their experiences gave them meaning, while simultaneously enabling others to feel supported and understood. It also demonstrated what could be achieved by a small organisation that put listening to women and community at its heart.
Conclusion
BCSW is rare among women’s mental health activist groups, in that its history has recently been collected and recorded, with the organisation’s archive and new oral histories with staff and volunteers added to the collection of the Bishopsgate Institute. Many of the other small activist groups mentioned above have not been well documented: their archives remain scattered among members and collaborators and, as memberships change and groups disappear, their work and influence risk being lost to history. Yet, as this article has shown, activist groups like BCSW played a key part in shaping views of mental health recovery alternative to the biomedical model. When BCSW was founded in 1986, self-harm was noticeably absent from the survivor and service user agenda and, within mainstream mental health circles, recovery was synonymous with cessation of injury (Cresswell and Brock, 2017: 14). Self-injury was also largely absent from feminist literature on mental health (Wilton, 1995: 35). BCSW developed a collective model of women’s mental health and self-injury, emphasising the social and political factors impacting on women’s lives and mental health. This context shaped the way in which staff and volunteers (who often had lived experience of self-injury) approached BCSW’s users, listening to the way in which self-harm was located within the circumstances of their lives, and acknowledging how these circumstances might need to be changed before self-injury would no longer seem necessary.
The medical model of self-injury (and mental health) has historically been rooted in an individualist approach. In the early 20th century, this model was gendered female, and rooted in stereotypes about women’s behaviour and experiences – the idea that self-harm is ‘attention-seeking’, which remains widespread today, emerged from the notion that so-called hysterics (and, by extension, all women) craved sympathy. Recovery from self-injury within the medical framework has also been primarily about changes within an individual, which enable them to fit into social expectation – often by the reinforcement of gender stereotypes. The collectivist model of recovery espoused by BCSW not only rejected these stereotypes as harmful, but also advocated for social change, acknowledging the positive role of lived experience in peer support and advocacy networks, through which experience of self-injury became a positive asset rather than a negative trait to be ‘fixed’.
Volunteers across women’s mental health groups recognised that, in the words of BCSW worker Sal, ‘women were being doubly hurt, firstly by their experiences that led them to self-harm and then from the responses that they got when they tried to get some help for themselves’ ([Interview With Sal B.], 2021). Re-traumatising practices within mainstream services had been identified early on as an issue for women attempting to heal from sexual violence (Chesler, 1972; Darton, Gorman, and Sayce, 1994; Herman, 1992). The lack of acknowledgement and respect within mainstream services for women who had experienced sexual violence was a theme that ran through women’s mental health activism; BCSW were explicit in challenging this disregard (Arnold, 1995; Darton, Gorman, and Sayce, 1994; Department of Health, 2002). By 2002, some of the lessons from BCSW’s work had been incorporated into mainstream practice, through Department of Health service development recommendations and input into NICE guidance on self-injury. Psychiatric services had begun to explore the concept of ‘harm minimization’ or reduction, rather than complete cessation (Chaney, 2017: 224–5). More generally, the concept of self-injury as a social phenomenon and a coping mechanism (rather than a pathology in itself) had become widely discussed, if not universally recognised. While BCSW was not the only group advocating for such changes, it was central to these demands, working alongside other survivor and user groups like London-based Survivors Speak Out. Meanwhile, the user research that supported this advocacy was led by BCSW.
Yet despite this entry into mainstream mental health care and practice, this activism was – and often still is – radical. BCSW and mental health activist groups showed that listening to and understanding their female users was central to recovery. BCSW also rejected one of the biggest assumptions behind the so-called recovery model of mental health and self-injury: that recovery is a fixed and linear process. As mental health activist Clare S. recognised in their oral history, When I look at the, the histories of the women that I met through the, the self-help group and, and the, all the people that I’ve met along the way through Bristol Crisis Service and the National Self-Harm Network and, that for some of us it can feel about, it can feel like recovery is chronological or that you leave the bad times behind, for some of us it can feel like you never leave them behind and, you know, it can feel really frustrating because you’re running through the same circles and I’ve lost people, you know, people have died and, and, and killed themselves or, or died accidentally and I guess for me it feels really important, I don’t know why, j-just to say I’m still vulnerable, it’s still a struggle, self-injury is still there and it’s, it, it’s not that you pass through the kind of, that you pass through some sort of test and emerge from it. I don’t actively self-injure but I’ve learnt to live with those urges in different ways. It’s still part of my story and it’s still part of my identity and I guess I’ve kind of reached that point in my career as well as my journey of going, I don’t think I want to leave it behind, you know, I th- I think I accept that this is, this is, I’m not trying to leave it behind anymore, I’m going, this is maybe, maybe this is as good as it gets. ([Interview With Clare S.], 2021)
Footnotes
Acknowledgements
The authors would like to acknowledge the work of Rosie Wild, Marnie Woodmeade, and the volunteers who carried out the Women Listening to Women project, archiving Bristol Crisis Service for Women, without which the research for this article would not have been possible. More information can be found on the project’s website (
). We would also like to thank Hannah Blythe, Sarah Marks, and all the contributors to the Recovery, Rehabilitation and Remission Conference, held at Birkbeck Centre for Interdisciplinary Research on Mental Health in November 2022, for questions and discussion. We would also like to thank all the women who took part in the 2014 Open University Workshop, Jennie Williams for her research and writing on inequality and mental health and her contribution to this article, and the Open University for all their support for the project. Women Listening to Women was approved by the Open University Ethics Committee on 18 December 2020 (HREC/3786).
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.