Self-harm: why it happens and how to get help

Key points

• Self-harm is when a person intentionally injures their own body, most often to cope with emotional distress [1][2].
• It is a sign of distress, not a diagnosis, and not attention-seeking [1][5].
• It is not the same as a suicide attempt, though the two overlap and it is linked to higher suicide risk [2][7].
• NICE says everyone who self-harms should be offered a psychosocial assessment, not a risk rating [6].
• NICE recommends a CBT-informed therapy tailored for adults who self-harm, not medicine [6].
• Stopping is usually gradual, with setbacks. Free listening services are open day and night [3].

What self-harm is

Self-harm is when someone intentionally damages or injures their own body [1]. It is most often a way of coping with emotional distress that has become unbearable, so it signals distress rather than a condition of its own [1][2].

If you need help now. Samaritans: call 116 123, free, 24/7. Shout: text SHOUT to 85258. NHS 111, then choose the mental health option. Call 999 if anyone is in immediate danger.

It is not the same as a suicide attempt. Not everyone who self-harms wants to end their life, and some describe it as a way of staying alive [2]. There is still a clear link with suicide, and risk is higher in the year after a hospital attendance [2][7].

UK figures are limited. NICE cites English data in which 7.3% of girls and 3.6% of boys aged 11 to 16 had self-harmed or attempted suicide, rising to 21.5% and 9.7% at 17 to 19 [7].

Symptoms

Self-harm is a behaviour, so what matters is what it does for a person. People commonly describe:

• Relief. Tension builds with nowhere to go, then eases briefly [2].
• Feeling something. A way through numbness or feeling unreal [8].
• Self-punishment. A belief they deserve it, often after abuse or shame [2][8].
• Control. Controlling one thing when nothing else feels controllable [2].
• Communication. Showing distress that cannot be put into words [2].
• Staying alive. Some describe it as what keeps them going [2].

Shame, guilt and fear of other people’s reactions come with it, and are a main reason people delay asking for help [8].

Self-harm is commonly mistaken for a suicide attempt, for attention-seeking, or for a sign of a personality disorder [2][5][6].

Types

Self-harm has no formal subtypes. It is described by the context it occurs in [6].

• During an acute crisis. An episode at a time of intense pressure, such as bereavement [2].
• As an established way of coping. Self-harm continuing over a longer period [2].
• Alongside a diagnosed condition. Depression, anxiety, PTSD, eating disorders or a personality disorder [2][4].
• In children and young people. Assessment also covers home and school life, social media and safeguarding [6].
• In older people. NICE asks for attention to depression, physical health and isolation [6].
• In people with a learning disability. NICE says an experienced assessor should carry it out [6].
• With or without suicidal intent. Intent can differ between occasions, so services ask rather than assume [2][6].

Causes and risk factors

There is no single cause. Self-harm usually follows a build-up of circumstances and feelings rather than one event [2]. Factors people commonly report include:

• Bullying, including online [2].
• Pressure at school, university or work [2].
• Family conflict, a relationship ending, or bereavement [2].
• Abuse, trauma and their after-effects [2].
• Low self-esteem, anxiety and depression [2].
• Isolation, poor physical health, money or housing problems [6].

Two popular explanations do not hold. Self-harm is not done to get attention or to manipulate people, and NHS guidance calls that suggestion insulting [5]. NICE treats it as distress to be assessed, not waited out [6].

How it is diagnosed

Self-harm is not itself a diagnosis, so there is no test for it. What happens instead is an assessment by a GP, a community mental health team, or a hospital liaison psychiatry team after an A&E attendance [3][4][6]. NICE recommends this psychosocial assessment happens at the earliest opportunity, carried out by a mental health professional and not delayed by ongoing medical treatment [6]. It usually covers:

• What the self-harm does for the person, and what led up to it [6].
• Current and past circumstances, relationships, and what has been tried before [4][6].
• What the person wants from support, and any safeguarding concerns [4][6].

NICE has moved services away from risk tools. Risk scales must not be used to predict future suicide or repeat self-harm, and people must not be sorted into low, medium or high risk, or have treatment or discharge decided that way [6]. Clinicians write a risk formulation instead, an account of that person’s own situation [6].

An assessment does not label anyone, though it may identify an underlying condition needing treatment [4]. Waiting times vary and no reliable UK figure exists.

Treatment

NICE guideline NG225 sets out how services should respond, starting from respect, dignity and compassion, and staff training in self-harm stigma [6].

At A&E. Staff should establish what medical care is needed and whether there are safeguarding concerns, then refer to liaison psychiatry as soon as possible [6]. A mental health professional should see the person at every attendance, in a private area [6].

Safety planning. NICE recommends a plan drawn up with the person rather than handed to them, covering triggers, early warning signs, coping strategies that suit them, contacts for services, and limiting access to the means of self-harm [6].

Psychological therapy. For adults, NICE recommends a structured, person-centred, CBT-informed intervention tailored for adults who self-harm, typically 4 to 10 sessions [6]. For children and young people with significant difficulty managing intense emotions who self-harm frequently, dialectical behaviour therapy adapted for adolescents (DBT-A) should be considered [6]. Diagnosis, age or substance use must not be used to withhold therapy [6].

Medicine. NICE says drug treatment should not be offered to reduce self-harm [6], though medicine may be prescribed for a diagnosed condition alongside talking therapy [4][6].

Afterwards. Where safety concerns continue, NICE recommends aftercare within 48 hours [6].

Living with self-harm

Stopping self-harm is usually gradual. It is rarely one decision that holds, and treating it that way turns every setback into proof of failure. What tends to help:

• Work out what the self-harm does for you. Relief, punishment and control call for different support, and that is what an assessment is for [6].
• Treat what sits underneath. Depression, anxiety, PTSD or an eating disorder has its own treatment [4].
• Tell one person. A GP, a listening service or one friend is enough to start [2][3].
• Plan for the moment the urge rises: who to contact, where to go, how to get through the next hour in company.
• Expect setbacks and read them as information about that day, not a return to the start [6].

If you have injured yourself and need medical care, you are entitled to it and to respect [6].

When to speak to a professional

If you need help now. Samaritans: call 116 123, free, 24/7. Shout: text SHOUT to 85258. NHS 111, then choose the mental health option. Call 999 if anyone is in immediate danger.

Speak to a GP if self-harm has become the way you cope, if you do not feel able to keep yourself safe, or if low mood, anxiety or flashbacks are there too [3]. A GP can refer you to a community mental health team, or children’s services if you are under 18 [3].

Get help the same day if you have injured yourself and need treatment, if you are having thoughts of suicide, or if you do not think you can stay safe [3].

Samaritans is free to call at any hour on 116 123, with a Welsh language line on 0808 164 0123 [9]. Shout is a free, confidential, 24/7 text service: text SHOUT to 85258 [10]. Mind’s information line is 0300 123 3393 [3].

Common questions

Is self-harm attention-seeking?

No. It is most often a way of coping with distress, and many people keep it private for a long time [1][2]. NHS guidance for supporters is explicit that calling someone attention-seeking is insulting [5].

How can someone support a person who self-harms?

Ask how they would like to be supported, and listen to the feelings behind it rather than the behaviour [5]. NHS guidance advises against pressuring someone to stop, threatening them, taking over their decisions, or suggesting they want attention [5]. Supporters can get help of their own from Mind, Rethink Mental Illness or YoungMinds [5].

Can people stop self-harming?

Many people do, though usually gradually and with setbacks. NICE recommends a therapy tailored for adults who self-harm, plus treatment for whatever sits underneath it [6]. No treatment works for everyone.

Clinical review pending

References

1. NHS. Self-harm. NHS. https://www.nhs.uk/mental-health/feelings-symptoms-behaviours/behaviours/self-harm/
2. NHS. Why people self-harm. NHS. https://www.nhs.uk/mental-health/feelings-symptoms-behaviours/behaviours/self-harm/why-people-self-harm/
3. NHS. Where to get help for self-harm. NHS. https://www.nhs.uk/mental-health/feelings-symptoms-behaviours/behaviours/self-harm/getting-help/
4. NHS. Assessment and treatments. NHS. https://www.nhs.uk/mental-health/feelings-symptoms-behaviours/behaviours/self-harm/assessment-and-treatments/
5. NHS. How to help someone else. NHS. https://www.nhs.uk/mental-health/feelings-symptoms-behaviours/behaviours/self-harm/how-to-help-someone-else/
6. National Institute for Health and Care Excellence. Self-harm: assessment, management and preventing recurrence. NICE guideline NG225, Recommendations. https://www.nice.org.uk/guidance/ng225/chapter/Recommendations
7. National Institute for Health and Care Excellence. Self-harm: assessment, management and preventing recurrence. NICE guideline NG225, Context. https://www.nice.org.uk/guidance/ng225/chapter/Context
8. Mind. Self-harm. Mind. https://www.mind.org.uk/information-support/types-of-mental-health-problems/self-harm/
9. Samaritans. Contact Us. Samaritans. https://www.samaritans.org/how-we-can-help/contact-samaritan/
10. Shout. Shout: the UK’s free, confidential, 24/7 mental health text service. Shout 85258. https://giveusashout.org/