Self-harm

You hurt or harm yourself – on purpose. This can be for any reason, in any situation, and in a number of ways, such as:

• taking too many tablets – an overdose
• cutting yourself
• burning yourself
• banging your head or throwing yourself against something hard
• punching yourself
• sticking things in your body
• swallowing things that shouldn’t be swallowed.

When someone self-harms, they are usually feeling very emotional and distressed. Many describe their self-harm as a way to release overwhelming emotions. Some people plan it in advance, others act on the spur of the moment. Though some people self-harm only once or twice, others do it regularly – and it can become hard to stop.

There are indirect ways of harming yourself. This could be using alcohol or drugs too much and have accidents as a result, having unsafe sex, or the physical harm involved in the bingeing or vomiting of someone with eating disorder. These are not seen as self-harm in the same way.

Other words that are used to describe self-harm

Other words have been used to describe self-harm, but are now going out of use:

• Deliberate self-harm (DSH): we don’t use the word 'deliberate' any more. It makes it sound as though the individual is to blame, that their self-harm was a calmly planned action rather than the result of emotional anguish or intense distress.
• Attempted suicide/parasuicide: these phrases assume that harming yourself is the same as wanting to kill yourself - which is often not the case.

• About 1 in 10 young people will self-harm at some point, but it can happen at any age. 
  
• This is probably an under-estimate because the research is mostly based on people who go to hospital or their GP after harming themselves. And many do not (see below). 
• Many people do not seek help after self-harm. Some types, like cutting, are more secret and less likely to be noticed. 
• In a large study of self-harming adults in hospital, 80% had overdosed and around 15% had cut themselves. In the community, cutting is probably a more common way of self-harming than taking an overdose. 

It seems to happen more often in:

• young people
• prisoners, asylum seekers,  and veterans of the armed forces
• gay, lesbian, bisexual and transgender people - this may be 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 been neglected or experienced physical, emotional or sexual abuse during childhood.

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

You are more likely to harm yourself if you feel:

• That people don’t understand you or listen to you properly.
• Hopeless. 
• Isolated, alone.
• That you have no power or control over your life.

Many people who self-harm may also have alcohol or drug use problems, though this is not always the case. 

Self-harm can give you a sense of control and reduce uncomfortable feelings of tension and distress. If you feel guilty, it can feel like a way of punishing yourself. Either way, it can become a way to deal with negative feelings and distress.

This may – or may not be - not be the case. You can, however, find that you also feel depressed, have trouble with managing or controlling your emotions, difficulty connecting with others, and alcohol or drug problems. So it is still a good idea to get some help and support.

This is not usually so. But, if you do start to harm yourself, you are more likely than other people to die through suicide. Anyone who self-harms should be taken seriously and offered help.

A lot of people who self-harm don't ask for help. 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. It can sometimes feel as though self-harm is not a major problem – just a way to cope with life. 

Danger signs

You are most likely to harm yourself badly if you:

• use a dangerous or violent method.
• self-harm regularly. 
• have existing mental health problems. 

If you think you may harm yourself, don’t suffer in silence – tell someone about how you feel. The best place to start might be a health professional, like your GP.

What help is available? 

• Talking with a professional like your GP or a mental health professional

There are several one-to-one talking treatments can help, such as:

• Problem solving therapy 
• Cognitive behavioural therapy 
• Psychodynamic psychotherapy
• 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 new ways of approaching your problems. You can do this online or by telephone. Some helplines are listed at the end of this leaflet.

Self-help groups 

This is group of people who all might think about harming themselves from time to time, that meet regularly to give each other practical and emotional support. 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 can often happen during a crisis in a close relationship. It may be helpful to get some advice and support regarding the relationship. This may be a difficult process, but could be better in the long-term.

Family meetings

A family meeting with a therapist can help. This can help family members to talk to each other more clearly – and to listen better. This can help other family member to understand how you are feeling – and can help to tackle areas of stress and conflict. This may not be appropriate if, for instance, you have been the victim of abuse from a family member.

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.

What works best? 

There isn't much good evidence yet of which therapies work well for people who self-harm or are considering doing so. 

Cognitive behavioural therapy (CBT) seems to be useful, as is a combination of problem-solving therapy and CBT. A health professional will make suggestions based on your individual problems, your preference, and on what is available locally.

What if I don't get help?

• About 1 in 3 people who self-harm will do it again during the following year.
• Over a 15 year period, 3 people in every 100 people who self-harm (3%) will die by suicide.
• Cutting can result in 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

Remember that 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 may get easier over the next few hours. 

You can:

• Talk to someone – if you are on your own perhaps you could phone a friend or use a helpline. Some helplines are listed at the end of this leaflet. 
• If you are in an environment that is making you feel worse, try to find a way to distance yourself from it.
• Distract yourself by going out, listening to music, or by doing something that interests you. 
• Relax and focus your mind on pleasant and positive thoughts. 
• 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. 
• Be kind to yourself – allow yourself to do something 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 wanted 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 to want to harm yourself. 
• 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 which doesn’t harm you. 
• If other people knew about it, how did they react to your self-harm? 
• Could you have done anything differently? 
• 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, play this back to remind yourself of the parts of you that you know are good and worthwhile. 
• Make a 'crisis plan' so you can talk to someone instead of self-arming yourself. Make sure you can get in touch with someone quickly to help you control your urge to self-harm. You may find that, while you are talking, your wish to harm yourself starts to go away. 

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

• Reduce the damage to your body by using a method that is not so harmful.
• Keep thinking about how to tackle the problems that make you self- harm.
• Every so often, re-consider your decision not to stop. 

If you can say YES to half (or more) of the questions below, or more, then it might be time to try stopping.

• Is there someone who knows about my self-harm who I can contact if I get desperate?
• Have I found at least two alternative safe ways to 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 say to myself that I WILL tolerate feelings of frustration, desperation, and fear?
• Is there a professional who can also give me support and help in a crisis?
  

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 is familiar with self-harm. This could be a psychiatric nurse, a doctor, or a social worker. They will talk with you about how you are feeling and work out ways help you. Staff may want to do a risk assessment by going  through a questionnaire with you.

It can be very upsetting to be close to someone who self-harms - but there are things you can do. It’s The most important to listen without judgment and to not be critical. This can be very hard if you are upset yourself - and perhaps frightened and angry  about what they are doing. Try to concentrate on them rather than your own feelings – although this can be hard.

Do

• Talk to the person when they feel like self-harming. First, try to acknowledge and understand their feelings. You may then be able to talk about more positive things. 
• Help them find out more about self-harm.  You could show them this leaflet, or find resources online, or at the local library. 
• Find out about getting help - maybe offer to go with them to see someone, such as their GP. 

• Help them to see their self-harm as an ordinary problem that requires support and understanding, not as something secret and shameful. 

Don't

• Try to be their therapist – you can best help by being their friend, relative or partner. 
• Expect them to stop overnight – it usually takes time and effort. 
• React strongly, with anger, hurt, or upset. This will probably make them feel even worse – and this makes it harder to change.  
• You can, honestly and openly, tell your friend or relative about the effect their self-harm has on you.  But you have to be calm to do this , so that you can talk 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 to you about it rather harm themselves. 
• 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. Make sure that you have someone to talk to as well - so that you also get the support you need too. 

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 116 123; 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.

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

Self Injury Support: provides a young women's text and email service, any age helpline for women who self-harm, UK-wide listings for self-harm support and self-help tools. Email: info@selfinjurysupport.org.uk.

Further reading

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

Polk E, Liss M. Exploring the motivations behind self-injury. Couns Psychol Q 2009; 22: 233-41.

Rodham K, Hawton K, Evans E. Reasons for deliberate self-harm: Comparison of self-poisoners and self-cutters in a community sample of adolescents. J Am Acad Child Adolesc Psychiatry 2004; 43: 80-7.

Chapman AL, Gratz KL, Brown MZ. Solving the puzzle of deliberate self-harm: The experiential avoidance model. Behav Res Ther 2006; 44: 371-94.

Skegg K. Self-harm. Lancet 2005; 366: 22-8.

Hawton K, Saunders KEA, O’Connor RC. Self-harm and suicide in adolescents. Lancet 2012; 379: 23-9.

Fortune S, Sinclair J, Hawton K. Help-seeking before and after episodes of self-harm: A descriptive study in school pupils in England. BMC Public Health 2008; 8: 369.

Gunnell D, Bennewith O, Peters TJ, House A, Hawton K. The epidemiology and management of self-harm amongst adults in England. J Public Health (Oxf) 2005; 27: 67-73.

Hawton K, Linsell L, Adeniji T, Sariaslan A, Fazel S. Self-harm in prisons in England and Wales: An epidemiological study of prevalence, risk factors, clustering, and subsequent suicide. Lancet 2014; 383: 1147-54.

Cohen J. Safe in our hands? A study of suicide and self-harm in asylum seekers. J Forensic Leg Med 2008; 15; 235-44.

Bergman BP, Mackay DF, Smith DJ, Pell JP. Non-fatal self-harm in Scottish military veterans: a retrospective cohort study of 57,000 veterans and 173,000 matched non-veterans. Soc Psychiatry Psychiatr Epidemiol 2019; 54: 81-7.

King M, Semlyen J, Tai SS, Killaspy H, Osborn D, Popelyuk D, Nazareth I. A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay and bisexual people. BMC Psychiatry 2008; 8: 70.

Hawton K, Rodham K, Evans E, Weatherall R. Deliberate self harm in adolescents: Self report survey in schools in England. BMJ 2002; 325: 1207.

Serafini G, Canepa G, Adavastro G, Nebbia J, Murri MB, Erbuto D, et al. The relationship between childhood maltreatment and non-suicidal self-injury: A systematic review. Front Psychiatry 2017; 8: 149.

Edmondson AJ, Brennan CA, House AO. Non-suicidal reasons for self-harm: A systematic review of self-reported accounts. J Affect Disord 2016; 191: 109-17.

Hume M, Platt S. Appropriate interventions for the prevention and management of self-harm: A qualitative exploration of service-users’ views. BMC Public Health 2007; 7: 9.

Chan MKY, Bhatti H, Meader N, Stockton S, Evans J, O’Connor RC et al. Predicting suicide following self-harm: Systematic review of risk factors and risk scales. Br J Psychiatry 2016; 209: 277-83.

Milnes D, Owens D, Blenkiron P. Problems reported by self-harm patients: Perception, hopelessness, and suicidal intent. J Psychosom Res 2002; 53: 819-22.

Hawton K, Witt KG, Taylor Salisbury TL, Arensman E, Gunnell D, Hazell P et al. Psychosocial interventions following self-harm in adults: A systematic review and meta-analysis. Lancet 2016; 3: 740-50.

Evans J. Interventions to reduce repetition of deliberate self-harm. Int Rev Psychiatry 2000; 12: 44-7.

Hawton K, Zahl D, Weatherall R. Suicide following deliberate self-harm: Long-term follow-up of patients who presented to a general hospital. Br J Psychiatry 2003; 182: 537-42.

Credits

This information was produced by the Royal College of Psychiatrists’ Public Education Editorial Board. It reflects the best available evidence available at the time of writing.

• Expert review: Dr Hester Mannion
• Series Editor: Dr Phil Timms  
• Series Manager: Thomas Kennedy