A person harming themselves is not attention-seeking but attention-needing. Reach in and show them you’re listening
by Rory O’Connor & Ellen Townsend + BIO
I self-harm when I feel overwhelmed, when my thoughts and feelings of being worthless are so awful, sometimes it is the only way I can make them stop.
– Beth, aged 16
Beth’s words could be those of countless others who are struggling with inner turmoil, sometimes caused by what has happened in their past or is triggered by a current crisis – or some combination of both. Self-harm, such as taking an overdose, is often driven by a desire to gain relief from ‘a terrible state of mind’. Many of us will know a Beth: she could be our daughter, our friend or a pupil in one of our classes. In this Guide, we will try to help you understand the causes of self-harm, as well as providing you with some guidance about how you might be able to help someone you know who is self-harming. We have written it with parents, siblings, relatives, friends and teachers in mind.
Self-harm can mean different things to different people. It can take many forms, but it most commonly includes overdoses of medication and self-injury through self-cutting. It doesn’t cover excessive consumption of alcohol or recreational drugs, body piercing or eating disorders.
Some researchers and clinicians find it useful to separate self-harm into suicide attempts (where there was an intent to take one’s own life) and ‘non-suicidal self-injury’ (NSSI) because there is evidence that the contrasting intentions driving the two forms of behaviour result in differences in lethality, frequency and method. However, others highlight that the motives driving either behaviour are complex, often overlapping, and can be difficult to disentangle.
In this Guide, when we talk about self-harm, we are referring to any self-injurious act, irrespective of the person’s apparent motive or intent for the behaviour – in line with the definition used by the National Institute for Health and Care Excellence in the UK. When we refer specifically to suicidal behaviour, however, we are clearer that the intent of the self-harm act was suicidal (overall, although it is difficult to estimate accurately how many people who self-harm also want to die, this could apply to as many as 40 per cent of young people who self-harm).
The precise scale of self-harm is largely hidden because many of those who self-harm do not seek help – in the UK alone, tens of thousands of instances of self-harm are thought to take place in the community without coming to the attention of health services. A review published in 2012 found that approximately 10 per cent of adolescents report self-harm by the age of 16. However, contrary to the way it’s often depicted in the popular media, self-harm is not limited to young people. Data from England show that each year self-harm accounts for at least 200,000 presentations to emergency departments by individuals of all ages. In the US, suicidal ideation and self-harm are in the top 10 reasons for presentation to emergency departments.
Sadly, there’s evidence that self-harm is on the rise, especially among young people, with some estimates based on UK data suggesting that it has risen by as much as 70 per cent in children and adolescents between 2001 and 2014 (thankfully, self-harm is rare before puberty and, reassuringly, the overwhelming majority of young people will have stopped self-harming by their mid-20s). It’s notable that LGBTQ+ young people have higher rates of self-harm than their cisgender and heterosexual peers.
Why people self-harm
In the past couple of decades, mental health experts have developed new ways of understanding self-harm and suicidal behaviour. Some focus on what are called the ‘functional explanations’ of self-harm; others have tried to unpack the ‘benefits and barriers’ to self-harm, especially to make sense of self-harm in the clear absence of any suicidal intent.
For example, for some people, self-harm is a means of coping with unbearable pain – the self-inflicted physical pain acts as a way of regulating their emotional pain. This regulation could occur through one of the body’s pain-relieving systems called the endogenous opioid system. Indeed, some young people have told us that they would struggle to stop self-harming because it feels like such an efficient way to manage difficult feelings (however, note that other studies of self-harm have found that people experience little or no pain; others still have suggested that people experience a sense of relief when the pain subsides). There’s also evidence that some people use self-harm as a way of punishing themselves for their thoughts or deeds, or for not measuring up to a standard they perceive is expected by others.
More recently, attention has turned to identifying the factors associated with the emergence of thoughts of self-harm or suicide, which are different from those associated with actually carrying out self-harm or suicidal behaviour. This line of research has shown that, if someone is feeling distressed or having thoughts of self-harm, they are more likely to actually self-harm if they are impulsive by nature, know someone else who has self-harmed, have access to some means of self-harm, and have a specific plan.
Myths around self-harm
There are many common and unhelpful myths around self-harm, which can create stigma and contribute to people’s reluctance to seek help for their distress. First, self-harm should not be dismissed as attention-seeking, rather it is much more accurate to think about it as attention-needing. Also, in almost all instances, self-harm is driven by a desire to manage overwhelming mental pain, irrespective of whether the person is suicidal or not. If you hear someone suggest that self-harm is attention-seeking, ask them to imagine how much distress a person must be experiencing for them to inflict harm on themselves as a way to manage it.
Second, asking someone about self-harm or suicide does not plant the idea into their head, rather it could be the start of a vital conversation to get them the help and support that they need. Some people who self-harm are at rock bottom, feeling low in self-worth, thinking that others wouldn’t care whether they lived or died. They might also feel ashamed of their thoughts or acts of self-harm. So it can be incredibly validating if you or someone else has taken the time to notice that they might be struggling. It also conveys a sense of human connection, which could help them get through a difficult period.
Third, although self-harm and suicidal behaviour (irrespective of motives) are more common in women and girls, many boys and men also self-harm, and significantly more men die by suicide than women. Indeed, in the UK, three-quarters of all deaths from suicide are by men and, in almost every country and region of the world, male suicides outnumber those of females.
Finally, it is a myth that the severity of the self-harm is associated with the extent of the distress or degree of suicidal intent (if such intent is present). Perceived medical severity, on its own, should never be used to decide upon treatment or support, nor should it be used as a marker of suicide risk.
When you encounter self-harm for the first time, it can be bewildering and difficult to understand. Similarly, if you are the one in the midst of a crisis, you might be struggling to make sense of your own confused and ambivalent feelings and thoughts. However, it is important to recognise that self-harm is rarely driven by a single factor. It is always an indicator of distress underpinned by many different possible motives: for some, it is a means of coping, while for others it might be driven by the pursuit of ending their pain via suicide. The fact that you are reading this Guide is a positive step – support from friends and family can be protective and helpful in preventing self-harm.
Remember: if you are concerned that you cannot keep yourself safe, or that someone you know might not be safe, do not hesitate to contact a health professional such as a GP or the emergency services.
I just felt really stupid, I was like, why have I done that? I just felt really silly, I was like, what, I’ve just done something that you know is just gonna be there for ages, and it didn’t make me feel any better about myself at all, but then I kept doing it.
– Emma, aged 17
Recognise the risk factors
If you are a teacher, a parent or a concerned friend or relative, a useful starting point is to be aware of the factors that can increase someone’s likelihood of carrying out self-harm so that you have a sense of who might be especially vulnerable. Here’s an overview of the main risk factors:
Many people who self-harm have told us that they felt overwhelmed, trapped, defeated, hopeless and rejected. These feelings might have been caused or made worse by feeling socially disconnected or by mental health problems, such as depression or anxiety. Self-harm also often happens in the context of life stressors, and is more common among people who have experienced trauma early in life. For young people, the experience of being bullied – including cyberbullying – is another important risk factor to be aware of, with victimisation being especially problematic for LGBTQ+ young people. Many people who self-harm also grapple with unhealthy perfectionism – they tend to be preoccupied with what others think of them, and spend their lives feeling that they are letting others down. So, if someone is talking about struggling to meet the expectations of others or talking about being a burden, it is worth asking if they’re doing OK.
Look out for behavioural changes and signs
Given the complexity of self-harm risk factors and how they can change over time, it’s also useful to know what concrete behavioural signs you should look out for if you’re concerned about someone you know.
A good place to start is to pay close attention to changes, especially in mood. Particularly if a person seems sadder and more depressed than usual, and/or is behaving more rashly and impulsively than usual, these could all be early warning signs. These changes might be accompanied by withdrawal from usual activities and social isolation, which highlights the importance of ‘reaching in’ to support someone rather than waiting for them to ‘reach out’ (we provide advice on how to do that below). Someone who is wearing long sleeves in warm weather or who is anxious about showing their arms in public (such as being reluctant to go swimming) might indicate that they are engaging in self-harm.
A person in extreme emotional distress might also noticeably increase their use of alcohol and/or substances (alcohol abuse is a risk factor for self-harm and might be used at the time of self-harm). Conversely, if someone you know has been feeling down recently and has inexplicably recovered, it is also worth checking in with them. The concern here is that they have settled on suicide as the solution to their mental pain and, as a result, their mood has lifted temporarily. Of course, it’s also possible that everything is fine: perhaps their crisis has receded or they have received the help or support that they needed. Our main message, however, is that it is always worth checking in with someone and asking them whether they are OK.
It is important to realise that the risks involved in self-harm can change over time. For some, self-harm might help them feel better, at least to start with, but over time this effect could disappear and be replaced with feelings of hopelessness, burdensomeness and suicidal thoughts. The safest thing to do is not make assumptions about what is happening to someone who is self-harming – listening carefully and nonjudgmentally is vital. It is always better to ask than to assume.
It’s also important to take people’s talk seriously. Given that worries about feeling like a burden on others, not belonging or feeling trapped, defeated and hopeless can be a precursor to suicidal thoughts, do keep an ear out for any such utterances, and be ready to ask how someone is feeling. For instance, relationship problems can be a significant tipping point in self-harm, so it’s also important to keep an ear out for talk about stresses and strains in relationships, especially if they persist over time.
Similarly, if someone you know talks to you about having thoughts of self-harm or suicide, it’s important to take them seriously. A commonly held myth is that people who talk about hurting themselves don’t go on to harm themselves – this is simply not true; talking about such thoughts safely can be lifesaving, and provides a valuable opportunity to intervene.
Reach in and ask if they’re OK
We’ve mentioned several times the importance of checking in on anyone you’re worried about. Let’s zoom in a little on how to go about doing that:
‘You don’t seem to be yourself, are you doing OK?’
‘Yeah, I am fine.’
‘Are you really? I’ve just noticed that you’ve been really down on yourself recently.’
‘I’m just fed up with everything, and I keep letting everyone down.’
This is the start of a real conversation that one of us recently had with a friend who was struggling. Ultimately, it led to a wider discussion about the friend’s mental health and suicidal thoughts. If you are concerned that a friend or family member is self-harming or thinking of suicide, we’d encourage you to do what we did and ask them directly if they are OK. Of course, this can be difficult to do but, if you do so with compassion and without judgment, you are unlikely to do any harm. Indeed, the person might be relieved that someone has noticed that they are struggling. Don’t underestimate the power of listening, and try to remember that you don’t have to solve their problems.
Say you ask a question specifically about self-harm and the answer comes back as ‘Yes’, try not to respond with shock or disbelief. Also, try not to minimise the other person’s distress; rather, validate how they are feeling and acknowledge that it must be difficult for them. For many people who self-harm, they have experienced trauma earlier in life, which could mean that they find it difficult to trust others. As a result, reaching out for help might be alien for them, and they might be reluctant to share what they’re going through because their feelings and emotions might not have been validated in the past. Any compassionate conversations you have with a vulnerable person have the potential to empower them and make them feel safe.
It sounds too simple, but really listening to people, compassionately and nonjudgmentally, is the secret to supporting someone at risk from self-harm. Time and again in our research, people who self-harm tell us that they do not feel listened to. So, pay close attention to what is being said, and be particularly alert as to whether they mention having feelings of being distressed, desperate, unable to cope with emotions or unable to cope generally.
We previously created an evidence-based leaflet to support safe conversations about self-harm. Top tips from the leaflet are to be curious and to ask questions such as ‘I’ve noticed you seem really down at the moment, is everything OK?’ Asking open-ended questions in this way can encourage conversation; try ‘How long have you been feeling this way?’ and ‘How bad have things got?’ Avoid giving ultimatums (such as ‘If you self-harm, I will stop speaking to you’) and be led by what the other person says. Crucially, remember that even if the person you are speaking to is not ready to talk, knowing that you are ready to listen might give them the hope they need to hold on to.
Encourage longer-term help
Ultimately, it is a personal decision about when to seek professional help but, generally, professionals would say that the earlier any help is accessed, the better the outcome. If a person you are concerned about talks about suicide, it is important to ask them if they feel able to keep themselves safe; ask if there is anything you could do to help, such as calling a doctor with them. If they have self-harmed, you might also want to explore whether any injuries require medical attention. Also, if someone has taken an overdose, remember there is no such thing as a safe overdose so, in all cases, medical attention should be sought for overdoses as a matter of emergency.
Taking a longer-term perspective, a range of talking therapies, such as cognitive behavioural therapy (CBT), dialectical behaviour therapy (DBT) and mentalisation-based therapy, have been shown to be effective in reducing the frequency of self-harm. Each of these therapies has a different focus; for example, DBT aims to help people find the balance between achieving acceptance (of difficulties or challenges) and the need for change, whereas CBT focuses on tackling the unhelpful thoughts and views people have of themselves, the world and the future. However, these different therapies all have the same endpoint: to help people not to self-harm in the future.
There is also evidence that briefer interventions, such as safety planning or what we call a ‘volitional helpsheet’, can also be effective for some people who self-harm. These brief interventions support people to consider the triggers for their self-harm and to think about strategies that they can use to keep themselves safe when they sense a crisis is escalating. Although these are usually completed by a mental health professional, if you have a friend or family member who is struggling, they can be useful tools (here is an example sheet). For instance, they can be used to help someone think of coping strategies (eg, exercise or mindfulness); to remind them to get in touch with someone or to go somewhere to provide distraction when in distress; or, if things are really escalating, to contact someone who can help to keep them safe.
To find out more about how to use a safety plan or the volitional helpsheets, there are useful resources available online. In terms of talking therapies and treatments, availability will vary by country (or even across regions in the same country), so if you are concerned about yourself or a loved one, you should ask your GP, who should be able to advise what services are offered in your area.
Understanding the role of social media in self-harm
You might have read a lot in the news recently about the supposed influence of social media on self-harming behaviour. If you’re a concerned family member or teacher, you might wonder whether you need to protect your loved ones or pupils from online social networks. However, although excessive social media use can increase risk of self-harm if a person is already struggling or vulnerable, we need to be careful not to treat social media as a scapegoat. Self-harm is rarely caused by a single factor and, for some people, social media use is incredibly beneficial, providing them with solace and support when they are struggling and feeling disconnected.
Overall, when used in moderation, social media is not likely to cause harm. That said, if you believe that social media use is affecting a loved one’s sleep, is associated with their being bullied, or is adversely affecting their self-esteem, it’s a good idea to check in with them about what’s going on.
At the same time, without question, social media has an important role to play in the management of self-harm and suicide prevention. We know from ethnographic research that people feel safer talking about self-harm online rather than in real life. While the digital world can, of course, be a risky place with the potential to cause harm, it can also be a source of support. We need to harness its enormous potential; and this is most likely to happen if online supports and interventions are co-designed with the people they are intended for, and grounded in robust research.
What’s more, we have made great strides forward in terms of breaking down stigma around mental health issues including self-harm – and part of that progress has been via social media. As a result, more people are seeking help when they are struggling – and this is a good thing.
Whether online or offline, our most important message is this: it is vital that, when people do reach out, they are met with a compassionate and supportive response. Sadly, this does not always happen. But we can all do something about that by calling out stigma whenever we see it, by showing compassion to others, and also by showing compassion towards ourselves.
The book When It Is Darkest: Why People Die by Suicide and What We Can Do to Prevent It (2021) by one of us (Rory O’Connor) gets to the heart of understanding the most tragic of human outcomes. It brings together the personal with the professional to shed light on why suicide happens and what we can do to prevent it. It is aimed at anyone with an interest in suicide and self-harm.
The freely available, evidence-based leaflet ‘It’s Okay to Talk About Self-harm’ was co-created by the Self-Harm Research Group at the University of Nottingham, which is led by one of us (Ellen Townsend). The leaflet is designed to tackle myths around self-harm, provide key information, and support safe conversations about self-harm.
It can be distressing or worrying if you think someone you care for has self-harmed. The brief video from the Samaritans ‘How to Support Someone Who Is Self-harming’ (2020) shares some things you can do to help support them.
In the video ‘What Is Self-harm? Talking About Mental Health’ (2015) from the charity Mind, four individuals talk about their experience of self-harm, what causes it, how it feels, and how they think people can help.
The free guide ‘Coping with Self-harm: A Guide for Parents and Carers’ (2015) developed by researchers at the University of Oxford provides information about what self-harm is, its causes, as well how to support young people who self-harm. It was developed by talking to parents and carers.
The book Understanding and Responding to Self-harm: The One-stop Guide: Practical Advice for Anybody Affected by Self-harm (2019) is written by the British psychiatrist Allan House, and it explores the different forms that self-harm can take, as well as the reasons for self-harm, and provides practical advice and guidance about supporting those who self-harm.
The website Self-injury and Recovery Resources is part of the research programme on self-injury and recovery at Cornell University in New York. It summarises their work, and provides links and resources to self-injury information.
The guidelines ‘Self-harm and Suicide Prevention Competence Framework’ (2018) from the National Collaborating Centre for Mental Health describe the knowledge and skills needed to support people who self-harm or who are suicidal. They should help professionals working in different settings, including teachers and youth workers, as well as mental health professionals, to more effectively support vulnerable people.