Self-harm

Self-harm is a term used when someone injures or harms themselves on purpose rather than by accident. Common examples include 'overdosing' (self-poisoning), hitting, cutting or burning oneself, pulling hair or picking skin, or self-strangulation. Self-harm is always a sign of something being seriously wrong.

Unfortunately some young people use self-harm as a way of trying to deal with very difficult feelings that build up inside. This is clearly very serious and can be life threatening. People say different things about why they do it.

• Some say that they have been feeling desperate about a problem and don't know where to turn for help. They feel trapped and helpless. Self-injury helps them to feel more in control.
• Some people talk of feelings of anger or tension that get bottled up inside, until they feel like exploding. Self-injury helps to relieve the tension that they feel.
• Feelings of guilt or shame may also become unbearable. Self-harm is a way of punishing oneself.
• Some people try to cope with very upsetting experiences, such as trauma or abuse, by convincing themselves that the upsetting event(s) never happened. These people sometimes feel 'numb' or 'dead'. They say that they feel detached from the world and their bodies, and that self-injury is a way of feeling more connected and alive.
• A proportion of young people who self-harm do so because they feel so upset and overwhelmed that they wish to die by suicide. At the time, many people just want their problems to disappear, and have no idea how to get help. They feel as if the only way out is to kill themselves.

An episode of self-harm is most commonly triggered by an argument with a parent or close friend. When family life involves a lot of abuse, neglect or rejection, people are more likely to harm themselves. Young people who are depressed, or have an eating disorder, or another serious mental health problem, are more likely to self-harm. So are people who take illegal drugs or drink too much alcohol.

Many young people who self-harm with a wish to die also have mental health or personality difficulties; often the suicide attempt follows a stressful event in the young person’s life, but in other cases, the young person may not have shown any previous signs of difficulty.

Sometimes the young person is known to have long standing difficulties at school, home or with the police. Some will already be seeing a counsellor, psychiatrist, or social worker. There has been an increase in the suicide rate in young men over recent years.

The risk of suicide is higher if the young person:

• is depressed, or has a serious mental illness
• is using drugs or alcohol when they are upset
• has previously tried to kill themselves, or has planned for a while about how to die without being saved
• has a relative or friend who tried to kill themselves.

• Notice when the young person seems upset, withdrawn or irritable. Self-injury is often kept secret but there may be clues, such as refusing to wear short sleeves or to take off clothing for sports.
• Encourage them to talk about their worries and take them seriously. Show them you care by listening, offer sympathy and understanding, and help them to solve any problems.
• Buy blister packs of medicine in small amounts. This helps prevent impulsive overdoses. Getting pills out of a blister pack takes longer than swallowing them straight from a bottle. It may be long enough to make someone stop and think about what they are doing.
• Keep medicines locked away.
• Get help if family problems or arguments keep upsetting you or the young person.
• If a young person has injured themselves, you can help practically by checking to see if injuries (cuts or burns for example) need hospital treatment and if not, by providing them with clean dressings to cover their wounds.

As a parent, it's really hard to cope with a child/young person with self-harming behaviour or who attempts suicide. It's natural to feel angry, frightened or guilty. It may also be difficult to take it seriously or know what to do for the best. Try to keep calm and caring, even if you feel cross or frightened; this will help your child/young person know you can manage their distress and they can come to you for help and support.

This may be difficult if there are a lot of problems or arguments at home. Or, you may simply feel too upset, angry or overwhelmed to effectively help your child/young person. If so, you should seek advice from your GP.

If you are a teacher, it is important to encourage students to let you know if one of their friends is in trouble, upset, or shows signs of harming themselves. Friends often worry about betraying a confidence and you may need to explain that self-harm is very serious and can be life threatening. For this reason, it should never be kept secret.

Everyone who has taken an overdose, or tried to kill themselves, needs an urgent assessment by a doctor as soon as possible even if they look OK.

Usually, this means an examination at the nearest Emergency Department (also known as A&E). If you are unsure whether the young person was suicidal or not, it is best to act cautiously and take them to hospital. With overdose, the harmful effects can sometimes be delayed, and treatment with medication may be needed. Paracetamol is the most common medicine taken as an overdose in Britain. It can cause serious liver damage, and each year this leads to many deaths. Even small overdoses can sometimes be fatal.

If the young person is self harming by cutting themselves or other ways, it is still important that they have help. Do speak to your GP who can refer you to your local child and adolescent mental health services (CAMHS).

All young people who attend hospital following attempting suicide or harming themselves should also have a specialist mental health assessment before leaving.

It is often difficult to work out what prompted the young person to self-harm or whether they actually wished to attempt suicide or not; mental health professionals have the expertise to make sense of these complicated situations.

It is usual for parents or carers to be involved in the assessment and any treatment. This makes it easier to understand the background to what has happened, and to work out together whether more help is needed.

Assessments in Emergency Departments (also known as A&E) which include a short ‘talking therapy’ session have been shown to help young people come back for ongoing help and support.  A lot of young people self-harm or make another suicide attempt if they do not receive the help they need.

Usually, treatment for self-harm and attempted suicide, other than any immediate physical treatment, will involve individual or family 'talking therapy' work for a small number of sessions. They will need help with how to cope with the very difficult feelings that cause self-harm.

Clear plans on how to help and how to keep the young person safe will also be made. Some people who find it very difficult to stop self-harming behaviour in the short term will need help to think of less harmful ways of managing their distress.

Families often need help in working out how to make sure that the dangerous behaviour doesn't happen again, and how to give the support that is needed. This is something your local CAMHS should have on offer.

If depression or another serious mental health problem is part of the problem, it will need treatment. Some young people who self-harm may have suffered particularly damaging and traumatic experiences in their past. A very small number of young people who try to kill themselves really do still want to die. These two groups may need specialist help over a longer period of time.

I’ve always been the tallest girl in my class and my so-called friends regularly bitch about me behind my back and bully me. I hate being different, but the harder I try to fit in, the more they reject me.

My parents are divorced and I lived for many years with my mother but it was my grandmother who really looked after me. My mother was always busy at work or with her friends or boyfriend; she travelled a lot. I never felt that she was really there for me. My father remarried to a much younger woman who hated me and I hated her – I still do.

A couple of years ago, I was changing for PE and noticed that one of my friends has bright red lines all the way down her arms; she usually wore long sleeved tops, even in the summer, so I had never noticed them before. I was shocked and she confided in me that she regularly cut herself. I couldn’t understand why – she had everything, rich parents and wonderful holidays all over the world. She told me that her parents were never around and that she spent a lot of her time by herself. She felt that when she cut herself, she got rid of the pain and the loneliness.

I am now sixteen and have been regularly cutting myself for more than a year. I hide the knife or the scissors under the mattress and when my mother goes to bed, I cut my arms and the top of my thighs. Some days are worse than others, particularly when I get upset.

My mother noticed the marks on my body and took me to the GP who put me on antidepressants, but I never took them. I am now seeing a psychotherapist. I go every week, but I still have a lot of things to sort out and it’s taking time. I’m not doing it so often, only when I feel very stressed. I know it’s dangerous, but it’s a very difficult thing to stop doing.

Childline - Provides a free and confidential telephone service for children. Helpline: 0800 1111.

National Self-Harm Network - UK charity offering support, advice and advocacy services to people affected by self harm directly or in a care role.

The Samaritans - Provide a 24-hour service offering confidential emotional support to anyone who is in crisis. Helpline 08457 909090 (UK), 1850 609090 (ROI); e-mail: jo@samaritans.org

YoungMinds - Provides information and advice on child mental health issue and a Parents'Helpline:0800 802 5544.

• Watch the YoungMinds "No Harm Done" videos for young people, parents and professionals.

Further reading

Understanding NICE guidance: There are versions of all guidance for patients, carers and the public and they summarise, in plain English, the recommendations that the National Institute for Health and Clinical Excellence makes to health and other professionals.  

References

• National Institute for Health and Clinical Excellence: CG16 Self Harm: NICE Guideline (2004). 
• National Institute for Health and Clinical Excellence: CG133 Self-harm: Longer term management): of Self Harm: NICE Guideline 2011. 
• Hawton K, Harriss L. Deliberate self harm in young people: characteristics and subsequent mortality in a 20 year cohort of patients presenting to hospital. Journal of Clinical Psychiatry2007 68:1574-83
• Ougrin D et al. Trial of therapeutic assessment in London: randomised controlled trial of Therapeutic Assessment versus standard psychosocial assessment in adolescents presenting with self-harm. Archives of disease in childhood 2011 96 148-153

Credits

Revised by the Royal College of Psychiatrists’ Child and Family Public Education Editorial Board.

Series Editor: Dr Vasu Balaguru

With grateful thanks to Dr Vasu Balaguru and Dr Mona Freeman.

This information reflects the best possible evidence at the time of writing.