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The Royal College of Psychiatrists Improving the lives of people with mental illness

 

Self-harmself-harm

Introduction

This leaflet is for anyone who wants to know more about self-harm, particularly anyone who is harming themselves, or feels that they might. We hope it will also be helpful for friends and families.

The leaflet looks at the different sorts of self-harm and why someone might do it.

 It discusses:

  • some of the help available
  • what you can do to help yourself
  • what friends or family can do to help.

At the end of the leaflet is a list other publications which can give you more information.

What is self-harm?

Self-harm happens when you hurt or harm yourself. You may:

  • take too many tablets – an overdose
  • cut yourself
  • burn yourself
  • bang your head or throw yourself against something hard
  • punch yourself
  • stick things in your body
  • swallow things.

It can feel to other people that these things are done calmly and deliberately – almost cynically.  But we know that someone who self-harms is usually in a state of high emotion, distress and unbearable inner turmoil. Some people plan it in advance, for others, it happens on the spur of the moment. Some people self-harm only once or twice, but others do it regularly - it can be hard to stop.

Some of us harm ourselves in less obvious, but still serious ways. We may behave in ways that suggest we don't care whether we live or die – we may take drugs recklessly, have unsafe sex, or binge drink. Some people simply starve themselves.

Other words that are used to describe self-harm

These terms were previously used to describe self-harm, but are now going out of use:

  • Deliberate self-harm (DSH): the word 'deliberate' tended to blame people for their self-harm.
  • Suicide/Parasuicide: these suggested that harming yourself is the same as wanting to kill yourself - which is often not the case.

How common is self-harm?

  • About 1 in 10 young people will self-harm at some point, but it can happen at any age.
  • The research probably under-estimates how common self-harm is. It is usually based on surveys of people who go to hospital or their GP after harming themselves. However, we know that a lot of people do not seek help after self-harm. Some types of self-harm, like cutting, may be more secret and so less likely to be noticed.
  • In a study of over 4000 self-harming adults in hospital, 80% had overdosed and around 15% had cut themselves. In the community, it is likely that cutting is a more common way of self-harming than taking an overdose.

Who self-harms?

It happens more often in:

  • young women
  • prisoners, asylum seekers, and veterans of the armed forces
  • gay, lesbian and bisexual people: this seems, at least in part, due to the stress of prejudice and discrimination
  • a group of young people who self-harm together: having a friend who self-harms may increase your chances of doing it as well
  • people who have  experienced physical, emotional or sexual abuse during childhood.

What makes people self-harm?

Research has shown that many people who harm themselves are struggling with intolerable distress or unbearable situations. A person will often struggle with difficulties for some time before they self-harm. 

Common problems include:

  • physical or sexual abuse
  • feeling depressed
  • feeling bad about yourself
  • relationship problems with partners, friends, and family
  • being unemployed, or having difficulties at work

You may be more likely to harm yourself if you feel:

  • that people don’t listen to you
  • hopeless
  • isolated, alone
  • out of control
  • powerless – it feels as though there's nothing you can do to change anything.

It's more likely to happen if you are using alcohol or drugs – it may feel that these are as out of control as the rest of your life.

You may feel like harming yourself if you want to show someone else how distressed you are or to get back at them or to punish them. This is not common – most people suffer in silence and self-harm in private.

How does it make you feel?

Self-harm can help you to feel in control, and reduce uncomfortable feelings of tension and distress. If you feel guilty, it can be a way of punishing yourself and relieving your guilt. Either way, it can become a 'quick fix' for feeling bad.

Does this mean I'm mentally ill?

Probably not. However, you may be depressed, have personality difficulties, find it difficult to get on with other people or have problems with alcohol and/or drugs. You could still do with some help.

Is self-harm the same as attempted suicide

Usually not. But if you start to harm yourself, the risk of killing yourself is greater than for people who don't self-harm. So anyone who self-harms should be taken seriously and offered help.

Getting help

A lot of people who self-harm don't ask for help. Why not? You might be aware that you have some serious problems, but don't feel that you can tell anyone – so you don’t talk about it. You may not feel that you do have a serious problem, but see self-harm as a way to cope with life. Unfortunately, at the moment, if you do go to hospital after self-harming, you've only got a 50:50 chance of being seen by a specialist in this area.

Danger signs

You are most likely to harm yourself badly if you:

  • use a dangerous or violent method
  • self-harm regularly
  • don't see many people
  • have a mental illness.

You should really see someone who has a lot of experience of helping people who self-harm, and who knows about mental health problems.

What help is there?

  • Talking with a non-professional

You may find it helpful just to talk anonymously to someone else about what is happening to you. Knowing that someone else knows what you are going through can help you to feel less alone with your problems. It can also help you to think about your difficulties more clearly – maybe even see ways of solving them that you wouldn't think of on your own. You can do this on the internet or by telephone. Some helplines are listed at the end of this leaflet.

  • Self-help groups

A group of people, who all self-harm, meet regularly to give each other emotional support and practical advice. Just sharing your problems in a group can help you to feel less alone - others in the group will almost certainly have had similar experiences.

  • Help with relationships

Self-harm is often the result of a crisis in a close relationship. If this is the case, get some help with sorting out the relationship - it may be more difficult in the short-term, but it will be better for you (certainly less dangerous) in the long-term. 

  • Talking with a professional

One-to-one talking treatments can help, such as:

If you are still living with your family, it may help to have a family meeting with a therapist. This can help to relieve the tiring, daily stress for everyone in the family. It is not always appropriate, for instance, if you are the victim of physical or sexual abuse within your family.

  • Group therapy

This is different from a self-help group.  A professional will lead (or facilitate) the group to help the members to deal with problems they share, for example, in getting on with other people.

What works best?

There isn't much good evidence yet of which therapies work well for people who have harmed themselves. However, what evidence there is, suggests that problem-solving therapy and cognitive-behavioural therapy are useful. A health professional will make suggestions based on your individual problems and on what is available locally.

What if I don't get help?

  • About 1 in 3 people who self-harm for the first time will do it again during the following year.
  • About 3 in 100 people who self-harm over 15 years will actually kill themselves. This is more than 50 times the rate for people who don't self-harm. The risk increases with age and is much greater for men.
  • Cutting can give you permanent scarring. If nerves or tendons are damaged by cutting, this can lead to numbness or weakness.

How can I help myself?

When you want to harm yourself

The feelings of self-harm will go away after a while. If you can cope with your distress without self-harming for a time, it will get easier over the next few hours. You can:

  • Talk to someone – if you are on your own perhaps you could phone a friend. Some helplines are listed at the end of this leaflet.
  • If the person you are with is making you feel worse, go out.
  • Distract yourself by going out, listening to music, or by doing something harmless that interests you.
  • Relax and focus your mind on something pleasant – your very own personal comforting place.
  • Find another way to express your feelings such as squeezing ice cubes (which you can make with red juice to mimic blood if the sight of blood is important), or just drawing red lines on your skin.
  • Give yourself some 'harmless pain' - eat a hot chilli, or have a cold shower.
  • Focus your mind on positive things.
  • Be kind to yourself – allow yourself to do something harmless that you enjoy.
  • Write a diary or a letter, to explain what is happening to you – no one else needs to see it.

When you don't feel like harming yourself

When the urge has gone, and you feel safe, think about the times that you have self-harmed and what (if anything) has been helpful.

  • Go back in your mind to the last time when you did not want to self-harm, and move forward in your memory from there.
  • Think about where you were, who you were with, and what you were feeling?
  • Try to work out why you began feeling like you did.
  • Did your self-harm give you a sense of escape, or relief, or control? Try to work out something to do that might give you the same result, but that doesn't damage you.
  • How did other people react?
  • Could you have done anything else?
  • Make an audio recording. Talk about your good points and why you don't want to self-harm. Or, ask someone you trust to do this. When you start to feel bad, you can play this back to remind yourself of the parts of you that are good and worthwhile.
  • Make a 'crisis plan' so you can talk to someone instead of self-harming.  Being able to get in touch with someone quickly can help you control your urge to self-harm. While you are talking, your wish to harm yourself may start to go away.

What if you don't want to stop self-harming?

If you decide that you don't want to stop self-harming, you can still:

  • reduce the damage to your body (for example, by using clean blades if you cut yourself)
  • keep thinking about possible answers to the things that make you harm yourself
  • every so often, re-consider your decision not to stop.

Self-harm can be very damaging physically and psychologically –  in the end, you'll do better by stopping.

There are a number of questions to ask yourself to see if you are ready to stop. If you can honestly say YES to half of the questions below, or more, then why not try stopping?

  • Are there at least two people who are willing to help me stop?
  • Do I have friends that know about my self-harming who I can go to if I get desperate?
  • Have I found at least two alternative safe ways that reduce the feelings that lead me to self-harm?
  • Am I able to tell myself, and to believe, that I want to stop hurting myself?
  • Can I tell myself that I WILL tolerate feelings of frustration, desperation, and fear?
  • If necessary, is there a professional who will also give me support and help in a crisis?

If I harm myself and need treatment?

You have the right to be treated with courtesy and respect by the doctors and nurses in the  Emergency Department. Many Emergency Departments now have easy access to a health professional who knows about self-harm, such as a psychiatric nurse, a doctor, or a social worker. They will be able to talk with you about how you are feeling, and to see if there are any ways of helping you. They should be able to properly assess all your needs, whatever they may be. You should be able to go through your assessment with them. Staff may want to go through a questionnaire with you, to try to judge how at risk you are.

What can I do if I know someone who self-harms?

It can be very upsetting to be close to someone who self-harms - but there are things you can do. The most important is to listen to them without judging them or being critical. This can be very hard if you are upset yourself - and perhaps angry - about what they are doing. Try to concentrate on them rather than your own feelings – although this can be hard.

Do

  • Talk to them when they feel like self-harming. Try to understand their feelings, and then move the conversation onto other things.
  • Take some of the mystery out of self-harm by helping them find out about self-harm, perhaps by showing them this leaflet, or by using the internet or the local library.
  • Find out about getting help - maybe go with them to see someone, such as their GP.
  •  Help them to think about their self-harm not as a shameful secret, but as a problem to be sorted out.

Don't

  • Try to be their therapist – therapy is complicated and you have enough to deal with as their friend, partner or relative.
  • Expect them to stop overnight – it's difficult and takes time and effort.
  • React strongly, with anger, hurt, or upset - this is likely to make them feel worse. Talk honestly about the effect it has on you, but do this calmly and in a way that shows how much you care for them.
  • Struggle with them when they are about to self-harm – it's better to walk away and to suggest they come and talk about it rather than do it.
  • Make them promise not to do it again.
  • Say that you won't see them unless they stop self-harming. 
  • Feel responsible for their self-harm or become the person who is supposed to stop them. You must get on with your own life as well. Make sure you talk to someone close to you, so you get some support.

Self-help and support

Childline: Free national helpline for young people, free confidential advice on all sorts of problems: 0800 1111.

Samaritans: Telephone and email support for anyone who is worried, upset, or suicidal; 08457 90 90 90; ROI 1850 60 90 90; email: jo@samaritans.org.

PAPYRUS HOPELine UK: a professionally staffed helpline providing support, practical advice and information to young people worried about themselves, and to anyone concerned that a young person may harm themselves. Tel: 0800 068 41 41.

Get Connected: offers help by telephone and email for people under 25 who self-harm. Tel: 0808 808 4994; text: 80849.

Selfharm.co.uk: a project dedicated to supporting young people who are affected by self-harm.

 

Further Reading

The Royal College of Psychiatrists publishes a range of leaflets on mental health problems and their treatment. A leaflet 'Feeling on the edge? Helping you get through it' has advice for someone who is in crisis and thinking about harming themselves.

The Scarred Soul: Understanding and Ending Self-inflicted Violence by Tracy Alderman: New Harbinger Publications.

Healing the Hurt Within: understand self-injury and self-harm, and heal the emotional wounds by Jan Sutton: How To Books Ltd.

 

References

Effectiveness of interventions to prevent suicide and suicidal behaviour: a systematic review. (2008). Leitner,M.,Barr,W.,& Hobby, L. Health and Community Care Research Unit, Liverpool University and Scottish Government Social Research.

The epidemiology and management of self-harm among adults in England (2005).Gunnell, D. & Bennewith, O., Journal of Public Health; 27, p.67-73.

In what way are adolescents who engage in self-harm, or experience thoughts of self-harm, different in terms of help-seeking, communications and coping strategies? (2005). Evans, E., Hawton, K. & Rodham, K., Journal of Adolescence, 28, p.573-587.

Mental disorders, suicide and deliberate self-harm in lesbian, gay and bisexual people, a systematic review (2008) BMC Psychiatry, 8, 70.

National Institute for Health and Care Excellence. Self-harm: longer-term management. (Clinical guideline CG133.) 2011.

Royal College of Psychiatrists College Report CR 158: Self-harm, suicide and risk: helping people who self-harm (2010)

Suicide and deliberate self-harm in young people (2005).  Hawton, K. & James, A., BMJ, 330, p.891-894.

Suicide following deliberate self-harm: long-term follow-up of patients who presented to a general hospital (2003)  Hawton, K., Zahl, D. & Weatherall, R., British Journal of Psychiatry, 182, p.537 - 542.

Understanding resolutions of deliberate self-harm: qualitative study of patients' experiences (2005). Sinclair, J. & Green, J. BMJ, 330, p.1112 – 1115.

This leaflet was produced by the Royal College of Psychiatrists’ Public Education Editorial Board.

Series Editor: Dr Philip Timms

 

  • Original author: Professor Anthony Bateman
  • Expert Review: Dr Jim Bolton and Dr Philip Timms
  • User and Carer input: members of the RCPsych Service User and Carers’ Forum

Illustration by Lo Cole: www.locole.co.uk

This leaflet reflects the best available evidence available at the time of writing.

© Updated: July 2014. Due for review: July 2016. Royal College of Psychiatrists. This leaflet may be downloaded, printed out, photocopied and distributed free of charge as long as the Royal College of Psychiatrists is properly credited and no profit is gained from its use. Permission to reproduce it in any other way must be obtained from permissions@rcpsych.ac.uk. The College does not allow reposting of its leaflets on other sites, but allows them to be linked to directly.

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