Understanding self-harm

A vital, unmissable opportunity for suicide prevention

Professor Ellen Townsend (University of Nottingham)

Self-harm is a global public health problem which is increasing in young people, especially in young girls. Repeated cross-sectional surveys of the general population from 2000-2014, considered by Sally McManus and colleagues in Lancet Psychiatry last year, found that as many as 1 in 5 young women self-harmed in England in 2014 – the highest prevalence rate ever recorded. In mid-to-late adolescence self-harm and suicide increase at an unprecedented pace: there is no other time across the lifespan that they increase so sharply.

Self-harm is the strongest known predictor of death by suicide, with half of young people who die by suicide having previously self-harmed. Furthermore, self-harm is associated with significantly reduced life expectancy, with an average of up to 40 years of life lost to external causes. A recent longitudinal study led by Becky Mars, using data from the Avon Longitudinal Study of Parents and Children, demonstrated that self-harm without suicide intent significantly predicts the transition from suicidal thoughts to suicidal attempts. You can see why understanding and responding effectively to self-harm is a vital and unmissable opportunity for suicide prevention.

But how do we allow young people to 'tell the story of their self-harm' over time? How can we capture the complexity of self-harm, and the key transitions in the sequence leading to self-harm and beyond? We created the Card Sort Task for Self-Harm (CaTS), a novel attempt to do just this.

Much research in our field does not take time into account, so we examined the key thoughts, feelings, events and behaviours that young people say are important steps leading to self-harm. Across two studies – with more in the pipeline – we have shown that 'feeling depressed and sad' looms large for young people who self-harm. This was the most frequently chosen card by young people who completed the CaTS. Sequence analysis revealed important transitions in the pathway to first ever and most recent self-harm.

Importantly, whilst first ever self-harm revealed a significant transition to 'feeling better' after self-harm, this transition disappeared for most recent self-harm. We saw a pattern of deterioration over time, with most recent self-harm being associated with hopelessness, burdensomeness and wanting to die.

Many of the factors that young people who self-harm identified as important through the CaTS are modifiable through existing interventions such as Dialectical Behavior Therapy, Mentalisation Based Therapy, and Cognitive Behavioural Therapy. Unfortunately, these treatments involve trusting an adult enough to talk about very difficult experiences and emotions which young people who self-harm struggle with. Indeed, the second most frequently chosen card in our first CaTS study was 'I could not tell anyone how I was feeling'. To help overcome this problem, we are developing the CaTS as a new assessment framework for use in clinical settings in collaboration with international experts on assessment development, young people with lived experience, and a range of frontline staff working with young people who self-harm.

Crucially, the CaTS can help young people and the adults working with them to start potentially very difficult conversations. The CaTS also affords mentalisation and non-verbal communication: young people can place cards down describing experiences, thoughts or feelings they have had, without having to make eye contact or to speak. Thus, we feel – and our Public Patient Involvement supports this – the CaTS could be especially helpful for autistic people who struggle with eye contact and face-to-face communication.

Ultimately, the CaTS encourages collaboration in assessment, which has been shown in David Jobes' work to reduce suicide ideation. If I had one take home message for those supporting young people who self-harm, it would be to listen to them carefully and take them seriously. We can all do that.

'A one size fits all approach will not get us far'

Dr Olivia Kirtley (Center for Contextual Psychiatry, KU Leuven, Belgium)

There is never only one reason why a person self-harms. It is always a complex array of factors. The majority of people who self-harm report that it brings them some relief from intense emotional pain. People experience distress for many different reasons, sometimes due to trauma, bullying or victimisation, perfectionism, socioeconomic deprivation, or commonly, several life problems occurring together.

Laboratory and questionnaire studies are, for the most part, snapshots of thoughts and behaviours that we are interested in. The overwhelming psychological pain reported by people who self-harm occurs not in the lab, but in people's everyday lives. So as psychologists wanting to find out what we can do about self-harm, that is exactly where we need to be: in everyday life.

The Experience Sampling Method (ESM; from Joel Hektner, Jennifer Schmidt and Mihaly Csikszentmihalyi), sometimes also known as Ecological Momentary Assessment (EMA) or Ambulatory Assessment (AA), is a technique that takes research out of the lab and into daily life. People complete brief questionnaires, several times a day for multiple days. In our research, for example, we often ask participants to complete measures ten times per day for six days, with each questionnaire taking only a couple of minutes to complete. This enables us to investigate dynamic fluctuations in thoughts and feelings, as they are occurring in the moment. We can capture a wealth of information about individuals' social context that we would otherwise miss with conventional assessments, because these experiences occur between lab visits or clinical appointments.

ESM research on self-harm and suicide is still at an early stage and ESM is an underused methodology in the field. In 2009 Matthew Nock and colleagues from Harvard University conducted a seminal study of non-suicidal self-injury (NSSI) in adolescents using EMA and found that thoughts of NSSI most commonly emerged when adolescents were feeling sad/worthless, overwhelmed, or afraid/anxious. Engagement in NSSI behaviour, however, occurred more when they felt rejected, self-hatred, numb, or angry with themselves or others. In another EMA study with college students, led by Michael Armey, negative affect rose rapidly immediately before individuals self-harmed, then gradually fell after self-harm.

Recently Evan Kleiman and colleagues used EMA to investigate short-term fluctuations in suicidal ideation among people in the general population who had recently attempted suicide, and individuals who were currently receiving inpatient care for suicide risk. Across both studies, they found a high degree of moment-to-moment variability in suicidal ideation and also in key risk factors, including perceived burdensomeness and thwarted belongingness; however, these risk factors were not predictive of suicidal ideation at subsequent time-points. This highlights the importance of investigating how well-known risk factors translate to the context of everyday life. Other researchers have emphasised the importance of examining within-person variability in suicidal ideation, with different 'phenotypes' characterised by differing levels of variability in suicidal ideation.

These studies tell us that a 'one size fits all' approach to self-harm will not get us far. We must take into account differences within as well as between individuals, and begin to pay more attention to the psychosocial context that surrounds self-harm. By taking a dynamic and contextually-based approach to investigating self-harm, we can identity factors that lead to distress and develop interventions to target these – before distress escalates to the point where someone self-harms.

Developing cultural understandings of self-harm

Doctoral Researcher Margaret Hardiman (University of Birmingham) is completing a PhD via the university's Global Challenges Funding Scheme exploring self-harm and suicide in low to middle income countries, specifically young Pakistani women living in the UK and Pakistan.

Currently relatively few studies consider cultural and geographic differences in self-harm. We know that self-harm rates are increasing across the globe, but we don't really have a good picture of what's happening in low- and middle- income countries (LMICs) and countries like Pakistan. There are various reasons for why we don't have this information; self-harm and suicide are illegal in Pakistan which makes it difficult for people to access support or openly speak about it. In Islam it's seen as haram to harm one's self because you're going against God's will, and in Pakistan religion is intertwined with society. This makes it really difficult for people to come and speak about any kind of mental health issue, self-harm or suicide.

Cultural understandings of self-harm can also differ where there might be no translations for western clinical terms such as depression or self-harm. So, mental health may be understood through other mechanisms such as spiritual possession or be described through physical symptomology. The criminalisation of self-harm with an undertone of cultural taboos, a lack of mental health care and ability to physically access the support and the agency to do so (particularly amongst women) make it challenging to get a full picture of self-harm in LMICs and hinder our ability to support those in need.

To gain an insight into understandings and experiences of self-harm we're interviewing young Pakistani women (age 16-25) with experiences of self-harm, family members of young Pakistani women who have self-harmed and community stakeholders (i.e. people who work with or have an understanding of self-harm in young Pakistani women) in the UK and Pakistan. We also want to explore the impact of migration, and whether conceptualisations differ between Pakistani populations in the UK and Pakistan. Ultimately, we really need to work together across borders and disciplines to foster the exchange of expertise.

However, we also need to make sure that the voices of individuals are heard and that the research community makes a greater effort to co-produce, collaborate and listen. I think there's a danger with global mental health research of going in with a neo-colonial approach, taking the information, leaving, and not giving anything back, based on an arrogant assumption that we know more which isn't the case. It's so important to work with people who often have an abundance of knowledge and insight but who might not have the same level of funding, support or ability to share that.

'Listen carefully, respond kindly'

Dr Ruth Wadman (University of York)

There is an emerging body of qualitative interview research with young people who self-harm. It has the potential to offer unique insights into this complex phenomenon, and suggest better ways to support young people who self-harm. Here I will focus on a qualitative interview study from the 'Listen-up!' project (led by Professor Ellen Townsend at the University of Nottingham). The findings, taken from three papers, relate to the experiences of young people aged between 13 and 21 years with a history of repeated self-harm (some of whom had experience of being 'looked-after' in social care). We used in-depth interviews, and interpretative phenomenological analysis.

Our findings emphasise the affective and relational nature of self-harm. Difficulties in relationships with parents (both arguments and broader worries about family breakdown) and peers (particularly long-term peer victimisation/bullying) play a key role in precipitating self-harm. For young people looked-after in care, a change in residential placement (and the social and emotional upheaval that goes along with this) is often reported to lead to self-harm. Young people described self-harm as a purposeful coping behaviour (providing relief or self-punishment in the face of serious distress), but it could at times also be reactive (in response to strong feelings of anger for instance). Our understanding of self-harm needs to be situated in this context of interpersonal struggles and intense emotions.

Self-harm is deeply personal; young people prefer to keep it private and hidden. They find self-harm and the associated mental distress difficult to talk about. Young people can also experience shame and regret following self-harm. Clearly this has implications for help-seeking. Should a young person's self-harm be disclosed or discovered by parents, an unhelpful parental response or feelings of shame could deter further help-seeking.

There are challenges even when a young person does reach out for support. Often young people do not believe they can stop self-harm completely, which may be linked to their perception that it is an ingrained, almost addictive, behaviour. Reports of experiences with clinical services are, at best, mixed. Some young people report feeling personally let down by mental health services at an organisational level – '…just empty promises really'. Looked-after young people report being patronised or not listened to, and a sense that 'nothing can be done'.

We found that young people welcomed the opportunity to talk about their self-harm for research purposes, and they were pleased that their experiences could help other young people in the future. Reflecting upon the interviews and our findings as a whole, there is an overwhelming sense that young people who self-harm need the adults around them to listen carefully and respond kindly. Such an intervention, whilst not 'state-of-the-art', needs reinforcement as a good starting point for any self-harm support strategy. 

'Online friendships are a double-edged sword'

Mitch Prinstein (University of North Carolina)

When you talk with kids who have engaged in non-suicidal self injury (NSSI) and attempted suicide and ask them why they've done so, they very frequently tell you it was stress from their peer relationships that compelled them. There are few things that don't seem to be affected by peers – we also see effects on substance use, risky sexual behaviour, a lot of externalising behaviours, illegal activity and so on. So we're doing a lot of research which seeks to understand how it is kids experience stress amongst their peers and the role that might play in NSSI and suicidality.

Children who have best friends who have engaged in self-injury are at much greater risk. Yet some peers provide really important friendships and support during times of stress – perhaps especially for vulnerable teens who don't have the opportunity to feel connected to others with similar attitudes or backgrounds as themselves in their offline lives. We recently submitted a paper that showed how kids at risk for self-injurious thoughts and behaviour were protected by close friendships with folks online. Of course it's a double-edged sword… kids online are also more likely to get victimised as well.

But even controlling for other factors that may play a role – stress the community's experiencing, depression or difficulties at home, for example – peer relationships tend to be a predictive factor above and beyond all that. It's something quite specific and unique. That's inevitable perhaps, given the way adolescents' brains change in a way that makes them crave more peer interaction. Teens are looking for any opportunity to feel noticed, or valued, or visible among their peers. Those kinds of experiences have way more meaning and importance to kids.

Social rejection even has effects at the level of the expression of our DNA. If you look at a child before and after social rejection you can see in their blood changes in the ways their DNA has responded to that stress. I find it fascinating that the effects can get under the skin so completely.

'Do not use risk assessment tools and scales to predict future suicide or repetition of self-harm'

Dr Leah Quinlivan (NIHR Greater Manchester Patient Safety Translational Centre; Centre for Mental Health and Safety, University of Manchester)

Risk scales are widely used as part of assessments despite limited evidence of their predictive power. We have found poor predictive accuracy across a range of diagnostic performance indicators for risk scales following self-harm, and these findings are supported elsewhere. In our prospective cohort study of risk scales following self-harm, tested scales performed no better than simply asking the clinician or the patient for their estimation of risk for repeat self-harm. Some scales, such as the widely used 'SAD PERSONS scale', performed significantly worse. Consistent with 2011 guidelines from the National Institute of Clinical Excellence, risk scales should not be used to determine patient management or predict future risk of suicidal behaviour.

Resources

More about the CaTS can be found here: https://sites.google.com/view/self-harm-research-group/resources/the-cats-card-sort-task-for-self-harm

Further details on the 'Listen-up!' project can be found at www.listen-up.ac.uk

To speak to Samaritans call: 116 123

References (by Author)

Ellen Townsend

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Hawton, K., Witt, K.G., Salisbury, T.L. et al. (2015). Interventions for self-harm in children and adolescents. Cochrane Database Syst Rev, 12 (CD012013).

Hawton, K., Witt, K., Salisbury, T.L.T. et al. (2016). Psychosocial interventions following self-harm in adults: A systematic review and meta-analysis. Lancet Psychiatry, 3, 740-750.

Jobes, D.A. (2012). The collaborative assessment and management of suicidality (CAMS): An evolving evidence-based clinical approach to suicidal risk. Suicide and Life-Threatening Behavior, 42, 640-653.

Mars, B., Heron, J., Klonsky, E.D. et al. (2019). Predictors of future suicide attempt among adolescents with suicidal thoughts or non-suicidal self-harm: A population-based birth cohort study. Lancet Psychiatry, 6(4), 327-337.

McManus, S., Gunnell, D., Cooper, C. et al. (2019). Prevalence of non-suicidal self-harm and service contact in England, 2000–14: Repeated cross-sectional surveys of the general population. Lancet Psychiatry, 6, 573–581.

Morgan, C., Webb, R.T., Carr, M.J. et al. (2017). Incidence, clinical management, and mortality risk following self harm among children and adolescents: Cohort study in primary care. BMJ, 359, j435.

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Townsend, E. (2019). Time to take self-harm seriously. (Commentary) Lancet Psychiatry, 6(4), 279-280.

Townsend, E., Wadman, R., Sayal, K., et al. (2016). Uncovering key patterns in self-harm in adolescents: Sequence analysis using the Card Sort Task for Self-harm (CaTS). Journal of Affective Disorders, 206, 161-168.

Wadman, R., Clarke, D., Sayal, K., et al. (2017). A sequence analysis of patterns in self-harm in young people with and without experience of being looked-after in care. British Journal of Clinical Psychology, 56(4),388-407.

Olivia Kirtley

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Carr, M.J., Ashcroft, D.M., Kontopantelis, E. et al. (2016). The epidemiology of self-harm in a UK-wide primary care patient cohort, 2001-2013. BMC Psychiatry, 16, 53.

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Davidson, C.L., Anestis, M.D., & Gutierrez, P.M. (2017). Ecological momentary assessment is a neglected methodology in suicidology. Archives of Suicide Research, 21(1), 1-11.

Fisher, H.L., Moffitt, T.E., Houts, R.M., et al. (2012). Bullying victimisation and risk of self-harm in early adolescence: Longitudinal cohort study. BMJ, 344, e2683.

Hektner, J.M, Schmidt, J.A, & Csikszentmihalyi, M. (2007). Experience sampling method.  Thousand Oaks, California: SAGE Publications Inc.

Kleiman, E.M., Turner, B.J., Fedor, S., et al. (2017). Examination of real-time fluctuations in suicidal ideation and its risk factors: Results from two ecological momentary assessment studies. Journal of Abnormal Psychology, 126, 726-738.

Kleiman, E.M., Turner, B.J., Fedor, S., et al. (2018). Digital phenotyping of suicidal thoughts. Depression and Anxiety, 35, 601-608.

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Ruth Wadman

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Wadman, R., Clarke, D., Sayal, K., et al. (2016). An interpretative phenomenological analysis of the experience of self-harm repetition and recovery in young adults. Journal of Health Psychology, 22, 1631-1641.

Leah Quinlivan

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Quinlivan, L., Cooper, J., Steeg, S., et al. (2014). Scales for predicting risk following self-harm: an observational study in 32 hospitals in England. BMJ Open, 4(5), e004732.

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