Key learning points:
- For many young people, the function of self-harm is to escape an unbearable emotional state
- Relief and negative feelings experienced following self-harm can result in a cycle of self-harming behaviour
- Safety planning is an essential intervention to help young people and their families manage and reduce self-harm
Self-harm is defined as ‘any act of self-poisoning or self-injury carried out by an individual irrespective of motivation’.[1] It is increasingly common in the UK, with estimates that 10 to 15% of young people have self-harmed at some point [2,3] and recent headlines indicating a 14% rise in hospital presentations following self-harm over the last three years.[4] Self-harm is one of the most common reasons for calls to Childline,[4] demonstrating that self-harm is a prolific and growing concern. Although self-harm can occur in the context of suicidal ideation, non-suicidal self-harm should primarily be viewed as a means to manage emotional distress. However, it is clear that self-harm, particularly repeated self-harm, is a significant risk factor for suicide.[2]
At risk of self-harm
There is no ‘type’ of young person who self-harms. Risk results from a multifaceted interaction between genetic, biological, psychiatric, psychological, social and cultural factors.[2] Self-harm affects both genders, although is more common in girls,[2] with late puberty having some influence.[5] However, it is important to remember that not everyone who self-harms will exhibit common vulnerability factors and not everyone who presents with common vulnerability factors will self-harm.
Why young people self-harm
Self-harm is a coping strategy; an attempt to manage unbearable emotional pain by channelling it into physical pain, which can feel more tolerable and provide emotional relief.[6] Emotional states experienced prior to self-harm are often anger, depression, loneliness and frustration.[3] Other functions of self-harm include punishing oneself or someone else, communicating emotional pain, generating an interpersonal response, regaining a sense of control, stopping feelings of numbness or detachment, to escape, to die and to prevent a suicidal act.[2,3,7]
Cutting is the most frequent method of self-harm,[6,7] but additional methods include burning, hitting, head banging, hair pulling, poisoning and misusing substances. The function of self-harm can have an influence on the method; cutting is associated with self-punishment and gaining a sense of relief whereas overdosing more frequently derives from a need to escape or a want to die.[8]
Individuals who engage in methods such as cutting may have low levels of endogenous opioids [9] that, in the context of stress, can be increased by self-harming, hence the feeling of relief. A risk of repetition is due to the addictive qualities associated with restoring opioids. This cycle can be perpetuated psychologically by negative feelings of shame, disgust and guilt often experienced after self-harm[3] that can engender further emotional pain. Thus, young people can become embroiled in a cycle of self-harm as a way of dealing with emotional distress.
Identifying a young person who is self-harming
As well as the appearance of bruises or cuts that look as though they might have been self-inflicted and are otherwise unexplained, behavioural and mood changes such as social withdrawal and isolation, angry outbursts, expressions of self-blame or self-hatred, low mood and covering up arms or legs or avoiding sports can be warning signs that a young person may be self-harming and certainly indicate unhappiness and possibly depression. The only way to be sure a young person is self-harming is to ask. Asking about self-harm does not increase the likelihood of the behaviour, and it is important that all healthcare professionals become confident in asking about it.[10]
Treatment
There is a lack of unequivocal evidence for effective clinical interventions for adolescent self-harm,[2] but approaches include Cognitive Behaviour Therapy, problem-solving therapy, psychodynamic treatment and family therapy.[1,11] The most encouraging evidence is for Dialectical Behaviour Therapy, which places an emphasis on behavioural methods to learn and practise new skills to manage emotions more effectively.[12]
Given the community prevalence of self-harm, school based approaches are essential, particularly as school connectedness and peer attachment can be protective factors. Recent research has demonstrated promise for a universal school awareness-raising intervention involving provision of an information booklet and posters and follow-up interactive lessons including roleplay.[13]
Voluntary sector organisations provide excellent services and resources to young people and educational and self-help information is readily accessible online (see Resources).
The importance of the nurse’s role
Primary care and school nurses might be the first professional a young person encounters following self-harm or the first person they disclose self-harming behaviour to. This first contact with healthcare services could be the last if it is perceived to be unhelpful.[14] Young people may fear the stigma associated with self-harm, worry that their peers might find out and ridicule them or feel embarrassed about seeking help. Our responses to young people who self-harm can be pivotal in facilitating ongoing engagement with health or support services.
Self-harm can nevertheless be a difficult issue for nurses to digest and we can experience a vast range of feelings when faced with an individual who has engaged in self-harm. It is important to seek out support and supervision if we experience discomfort when working with self-harm to help us understand our psychological responses and ensure they don’t inhibit the quality of our care.
Responding when a young person has self-harmed
A calm demeanour is essential in order to instil security and confidence and optimise engagement. Fresh wounds should be attended to gently and respectfully. Always offer pain relief – while the young person may have needed physical pain to reduce their emotional distress, it doesn’t mean they don’t feel pain afterwards, or that they want pain once they have achieved some relief.
The most important thing we can do is validate their distress and provide a safe space to talk.[1] Whatever the function of the self-harm, the young person’s self-esteem will be low and a caring, empathetic attitude is essential in order not to dent this further.
In order to gain an understanding of the function of the self-harm and the preceding emotional state, it is important to directly, but gently, ask about the young person’s circumstances and feelings leading up to, during and following their self-harm.
For most young people, family involvement will be protective and an important part of recovery. It is advisable, once the young person has been seen individually, to try and secure consent to talk to them and their parent/s or carer together to assess and support their communication. Parents may feel overwhelmed and frightened by their child’s self-harm and they will need support, education and guidance.
Safety planning
Once an understanding of the young person’s self-harming behaviour has been established, a collaborative safety plan should be developed to try to reduce the likelihood of ongoing self-harm by promoting alternative ways of managing emotional distress and identifying help-seeking strategies. A safety plan should identify triggers, warning signs, distraction techniques and who to contact for support, including contingencies.
It is important that distraction techniques are conducive to the underlying emotional state. If a young person is feeling angry, stroking their pet or wrapping themselves in a warm blanket and watching a film won’t help. They will need something that involves some form of exertion.
A ‘hope-box’ is a useful exercise for a young person to engage in as part of safety planning. This involves putting positive and protective things and memories in a box, eg photos of happy times or loved ones; ‘feelgood’ songs; letters from loved ones; favourite perfumes; soft toys or materials; evidence of achievements; reasons for not self-harming and promises for the future. The young person can be encouraged to distract themselves when they are feeling vulnerable by going through their hope box.
Not all young people will be motivated to try and reduce or stop self-harming and in such instances it is important to have a frank conversation about health risks associated with cutting with dirty blades or implements, taking prescribed or excessive medication, misusing substances and generally using self-harm as a coping strategy.
Such a dialogue should always promote help-seeking and aim to instil hope that behaviours can change and support is available. Specialist advice should be sought for such individuals.
Self-harm is a growing problem. If a young person has a positive experience when they first present to a healthcare professional, they are much more likely to continue to engage and seek help. Primary care and school nurses have a vital role in identifying and responding to self-harm and facilitating ongoing support.
Authors
- Karen Lascelles, nurse consultant for suicide prevention at Oxford Health NHS Foundation Trust
- Fiona Brand, psychiatric liaison and research nurse at University of Oxford Centre for Suicide Research
- Annya Alfoadari, psychiatric liaison nurse at Oxford Health NHS Foundation Trust
References
- National Institute for Health and Clinical Excellence (NICE). Self harm in over 8s: short-term management; 2004. [Online]. Available at: nice.org.uk/guidance/cg133 (accessed 30 November 2016)
- Hawton K, Saunders KEA, O’Connor R C. Self-harm and suicide in adolescents. The Lancet 2012;379:2373-82
- Laye-Gindhu A, Schonert-Reichl KA. Nonsuicidal self-harm among community adolescents: Understanding the “whats” and “whys” of self-harm. Journal of youth and Adolescence 2005;34:447-57
- National Society for Prevention of Cruelty to Children (NSPCC) (2016). zenopa.com/news/801829746/nspcc-report-highlights-rise-in-children-hospitalised-for-self-harm (Accessed 9 December 2016)
- Patton GC, Hemphill SA, Beyers JM e al. Pubertal stage and deliberate self-harm in adolescents. Journal of the American Academy of Child & Adolescent Psychiatry. 2007;46:508-14
- Madge N, Hewitt A, Hawton K et al. Deliberate self-harm within an international community sample of young people: comparative findings from the Child & Adolescent Self-harm in Europe (CASE) Study. Journal of child Psychology and Psychiatry. 2008;49:667-77
- Nock MK. Why do people hurt themselves? New insights into the nature and functions of self-injury. Current Directions In Psychological Science. 2009;18:78-83
- Rodham K, Hawton K, Evans E. Reasons for deliberate self-harm: Comparison of self-poisoners and self-cutters in a community sample of adolescents. Journal of the American Academy of Child & Adolescent Psychiatry. 2004;43:80-7
- Groschwitz RC, Plener PL. The Neurobiology of Non-suicidal Self-injury (NSSI): a review. Suicidology Online. 2012;3:24-32
- Royal College of Psychiatry. Managing Self-Harm in Young People. Royal College of Psychiatry, 2014
- National Institute for Health and Clinical Excellence (NICE) (2004) Self harm in over 8s: long-term management. [Online]. Available at: nice.org.uk/guidance/cg133 (accessed 30 November 2016)
- Linehan M M. DBT Skills Training Manual, 2nd Ed. Guildford Press, 2015
- Wasserman D, Carli V, Wasserman C et a;. Saving and empowering young lives in Europe (SEYLE): a randomized controlled trial. BMC public health. 2010;10:1
- Hawton K, Rodham K. By Their Own Young Hand. London: Jessica Knightley Publishers; 2006
Resources
- YoungMinds: youngminds.org.uk
- Coping with self-harm: A guide for parents and carers. Available atpsych.ox.ac.uk/research/csr/research-projects-1/coping-with-self-harm-a-guide-for-parents-and-carers
- MindEd module self-harm and risky behaviour: minded.org.uk/course/view.php?id=89
This article has been peer-reviewed.
