Dr Dominique Thompson Provides 10 Top Tips on Recognising Self-Harm and How to Help Reduce the Risks of Further Self-Harm or Suicide
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It is hard to be sure exactly how prevalent self-harm may be in the general population as so much of it is hidden, but recent studies have demonstrated a sharp increase in such behaviours in young people in particular.1,2 Self-harm is much more common in females1,3 and can start at a young age, so the NICE guidelines cover the management of self-harm in people aged 8 years and above.4,5 However, the most common age for self-harm, according to NICE, is during adolescence and young adulthood. Only a small proportion of self-harm occurs in older people (aged over 65 years) but those who do are at substantially higher risk of further self-harm and suicide.6
Self-harm matters, not just as a condition in its own right with symptoms and risks requiring assessment and treatment, but because it is associated with a significantly increased risk of suicide.1,5 Therefore, if primary care teams see someone who has self-harmed they have a potentially life-changing opportunity to intervene compassionately and prevent further self-harm or a tragic outcome. Self-harm should always be taken seriously, as it may be the opportunity to save a life.7,8
In this article, ‘self-harm’ will encompass self-injury and self-poisoning but not broader self-harmful behaviours such as alcoholism or eating disorders, which many people might consider to be related.
1. Self-Harm is Strongly Associated with increased mortality
There are very few primary care specific guidelines around care or prevention of self-harm but a 2016 analysis of what guidance did exist found that people who attended primary care following self-harm then went on to repeat self-harm, with 1 in 5 doing so within a year.1,7
People who attended primary care for self-harm had an increased risk of mortality from all causes, also highest within the first year of follow up, and the strongest predictor of mortality was alcohol misuse or dependence.7 Alcohol misuse may also lower inhibitions to self-harm, and is often associated with self-harm in adults.9
In terms of guidance applicable to primary care, the NICE Pathways on Managing self-harm in primary care is particularly accessible and well laid out for quick reference; all the self-harm advice is in one place in a neat flowchart.10 It should however be noted that NICE has scheduled an update for 2022 to provide clearer guidance on the transition between short- and long-term care, and up-to-date, concise guidance that reflects current practice for self-harm.11
2. Think Prevention As Well As Treatment
Prevention of future self-harm may be as important as treatment of the acute episode.7 Having dealt with the immediate wound care or poisoning risk assessment, it is important to consider longer-term risk. To prevent future self-harm and reduce future risk it is therefore crucial to recognise a behaviour as self-harm, then gently address the issue with the patient. Prevention of self-harm requires healthcare professionals to understand the why behind the behaviour, not just to focus on the what (cutting/poisoning and so on).5
3. Recognise the Variety of Self-Harm
Self-harm can involve cutting, scratching, burning, and squeezing, but it can also be seen in the punching of a wall or banging a head against a hard object. It can include self-poisoning with over-the-counter or prescription medication, often not the patient’s own.12,13 Males and females may choose different methods, which may lead to under-recognition, for example in men punching walls and presenting with a ‘boxer’s fracture’.2 Awareness of this as a potential method of self-harm may allow a conversation to begin even if the patient is not ready to fully discuss the underlying issues yet. They will however know that you are ready to talk when they are.
4. Address the Underlying Issues—the ‘Why’ of Self-Harm
If we are to support our patients to stop self-harming, we need to ‘get alongside them’ and discover the reasons behind their behaviours. It is only by addressing and tackling underlying problems, distress, and trauma that any progress will be made on stopping acutely damaging behaviour. People self-harm for many reasons. For some it is to distract themselves from emotional pain, by replacing it with physical pain, for others it is self-punishment for their own (perceived) wrongdoing, and for some it is to demonstrate to others how awful they are feeling if they lack the words to communicate their distress. Self-harm is commonly associated with relationships difficulties,9 but also with depression, anxiety, or bipolar disorder,14 or following abuse5 or bereavement.9 Dealing with these issues will allow the person the space they need to find alternatives to self-harm.
5. Offer to Support Them to Stop Self-Harming
To understand self-harm it can help to use the ‘boiling pot’ analogy. When someone self-harms, it can be like lifting the lid off a boiling pot; there is a sudden release of pressure, a sense of relief, and a temporary feeling of calm.13 If we ask someone who self-harms to stop, without finding helpful alternatives for emotional relief, then it may be like pushing the lid back on to the boiling pot. The pressure may build and the consequences could be devastating. It is reasonable to ask if they feel able to stop but if they feel unable to do so, NICE CG133 recommends talking to the patient about harm minimisation, while they address the long-term underlying issues and find more healthy coping strategies through therapy.5 It is important to explain though that there is ‘no safe way to self-poison’.5
6. Support the Patient to Find Safe Alternatives to Self-Harm
Learning to tolerate the feelings of frustration and emotional despair are part of the approach to recovery, alongside finding safer ways to manage the feelings that lead to self-harm.15 The main aims of treatment for self-harm are to reduce or stop self-harm, reduce likelihood of escalation, reduce suicide risk, and address the factors driving the self-destructive behaviours.5 Improving quality of life and daily functioning, and addressing associated mental health conditions is also key.5 Psychological therapy is the recommended long-term approach for treatment of self-harm and the underlying causes.5
You may wish to suggest alternatives to self-harm, and the following are recommended by the free distrACT app, which is recommended by the NHS app library.16 Instead of cutting or hurting themselves they may wish to try a sudden burst of ‘on the spot’ activity such as star jumps or punching a pillow, drawing on their skin instead of cutting it, rubbing in a scented cream where they would hurt themselves (to nurture instead of punish), use fake tattoos to remind themselves of safer alternatives, or put a plaster on their skin as a reminder of healing.
7. Prescribe Safely—Consider Instalment Prescribing
Although psychological approaches are the mainstay of treatment for self-harm, medication may still be required for associated conditions such as depression or anxiety, and so safe prescribing is vital. Some studies have found that GPs are unfortunately more likely to prescribe than refer the patient for talking therapies8 but that may of course be related to the availability of psychological services locally. If medication is needed, then it is crucial to consider which will be the safest type (for example, avoid tricyclic antidepressants5), and if possible consider prescribing small amounts only, such as a 7-day supply repeated weekly.4 The unfortunate downside of this latter option is that if the patient pays for prescriptions they will be charged each time, which can then reduce the likelihood of them taking their medication at all.
8. Risk Assessment is Notoriously Tricky—Try to Avoid the ‘High’/‘Low’ Risk Trap
When assessing risk of further self-harm, it may be helpful to recall the ‘low risk paradox’ of suicide assessment. This has found that a significant proportion (80%) of those who die by suicide were classed as ‘low risk’ at their last assessment or contact with healthcare services.17 With self-harm the challenges may be similar. Risk is ever changing, as people are constantly reacting to whatever is happening in their life at that time, and added to this fluid background is the fact that a clinician may not have all the relevant information in front of them. Risk assessment tools for self-harm are generally not recommended by NICE, and any risk assessment should look for known (evidence-based) risk factors (including a history of self-harm or psychiatric treatment, alcohol or drug misuse, being LGBT+, isolation, or personality disorder),18,19 alongside depression, hopelessness and ongoing suicidal intent.4 NICE CG133 recommends referral, especially in those aged under 18 years, if distress or risk is felt to be rising, unmanageable, unresponsive to offers of help, or the impact on family and carers is significant and rising.5 Mental capacity may need assessment in extreme cases, and referral for specialist support will be essential in such difficult scenarios.
The recently updated NICE guideline on depression in children and young people recommends that early referral should be considered if there is evidence of depression and/or self-harm. Repeated self-harm warrants referral to tier 4 Child and Adolescent Mental Health Services, and inpatient treatment should be considered for children and young people presenting with a high risk of suicide, serious self-harm, or self-neglect.20
9. Address Other Issues While Awaiting Therapy and Suggest a Safety Plan
There may be a delay before therapy can begin, and this may mean that the person is continuing to harm themselves, albeit while being encouraged to try to stop and replace the behaviours with safer alternatives. This may be a time during which healthcare teams can address other mental health conditions, review medication, discuss harm minimisation, refer for financial or housing support, address substance issues, check on physical health, and review safeguarding needs or the needs of dependants. This may in turn ensure that the patient is in a better place emotionally and socially when therapy does commence. Drawing up a ‘safety plan’ may be a useful and practical activity. There are a variety of templates and apps, often provided by charities in the suicide prevention sector, such as Papyrus or Connecting with People, that allow people to record what they might do to keep themselves safe, what their triggers are, and who they might call on when feeling desperate, instead of self-harming.21 See Box 1 for examples of resources for further support.
|Box 1: Web Resources for Further Support|
10. Listen, Believe, and Give Hope
A compassionate, kind, non-judgemental and trusting relationship between healthcare professional and patient is key to progress and recovery. Taking the time to listen and believe them (you may be the first to do either) and to give hope and be optimistic about recovery may be powerfully therapeutic. Try to avoid phrases that may appear dismissive such as ‘it’s a phase’ or ‘attention seeking’ or negative framing of questions such as ‘you’re not thinking of harming yourself again, are you?’ which may elicit a shake of the head, despite there being a significant chance that they might. Avoid guilt trips, or comments like ‘things can’t be that bad’, as they are unhelpful and will not build the positive relationship required for recovery. Try to be direct but kind, show empathy, and avoid using stigmatising language (‘deliberate’ self-harm is no longer used as it can appear to apportion blame15). People can feel terribly ashamed and guilty, or a burden to others, and it is important to let them feel heard and listened to, taken seriously, and cared for. Box 2 contains a number of questions and phrases a GP can use to connect with people and create a constructive relationship.
|Box 2: Suggested Questions and Phrases to Use in a Consultation with a Patient who Self-Harms|
Self-harm is a common, distressing, and challenging condition that needs to be taken seriously, yet it is unfortunately not always recognised as such. Every contact with a person who self-harms is an opportunity to intervene with compassion and try to reduce both the immediate risk of harm and the longer-term risks of suicide and significant negative impact on life. It is a condition that can dominate people’s lives yet is amenable to treatment, and engaging in therapy can be transformational. GPs need to be alert to self-harm in all its forms, and aware of the predisposing risk factors and long-term risks. By remaining vigilant and being kind and supportive, practitioners can help their patients to identify underlying reasons and triggers, find safe alternatives, and help them to recover successfully in the longer term.
Dr Dominique Thompson