Understanding self-harm

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What is self-harm?
Why do people harm themselves?
Who is most likely to self-harm?
Is self-harm an attempt to commit suicide?
Is self-harming behaviour attention-seeking?
What triggers it?
What can I do to stop self-harming?
What help can I get?
How can friends and family help?
References
Useful organisations
Further reading

'I belong to a women's self-harm support group. The group was the start of changing my life. The encouragement and support from both has given me the strength and courage to continue my life, and I now value myself. I still self-harm, but nowhere near as much as I used to. By talking about it, I am learning to deal with my feelings.'

'I am a survivor of both sexual abuse and self-injury. I no longer self-injure, but it has been a long struggle to try to acknowledge and work through emotions that once felt overwhelming in their power.'

'Self-harm involves all of us on some level. We may all punish, distract or numb ourselves, as a way of dealing with difficult feelings or situations.'

This booklet is for anyone who self-harms, their friends and family. It should give readers a greater understanding and knowledge of the condition and of what they can do to help overcome it.

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What is self-harm?

Self-harm is a way of expressing very deep distress. Often, people don't know why they self-harm. It's a means of communicating what can't be put into words or even into thoughts and has been described as an inner scream. Afterwards, people feel better able to cope with life again, for a while.

Self-harm is a broad term. People may injure or poison themselves by scratching, cutting or burning their skin, by hitting themselves against objects, taking a drug overdose, or swallowing or putting other things inside themselves. It may also take less obvious forms, including unnecessary risks, staying in an abusive relationship, developing an eating problem (such as anorexia or bulimia), being addicted to alcohol or drugs, or someone simply not looking after their own emotional or physical needs.

These responses may help someone to cope with feelings that threaten to overwhelm them; painful emotions, such as rage, sadness, emptiness, grief, self-hatred, fear, loneliness and guilt. These can be released through the body, where they can be seen and dealt with. Self-harm may serve a number of purposes at the same time. It may be a way of getting the pain out, of being distracted from it, of communicating feelings to somebody else, and of finding comfort. It can also be a means of selfpunishment or an attempt to gain some control over life. Because they may feel ashamed, afraid, or worried about other people’s reactions, people who self-harm often conceal what they are doing rather than draw attention to it.

It's worth remembering that most people behave self-destructively at times, even if they don't realise it. Perfectly ordinary behaviour, such as smoking, eating and drinking too much, or working long hours, day after day, can all be helping people to numb or distract themselves and avoid being alone with their thoughts and feelings.

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Why do people harm themselves?

A person who self-harms is likely to have gone through very difficult, painful experiences as a child or young adult. At the time, they probably had no one they could confide in, so didn't receive the support and the emotional outlet they needed to deal with it. The experience might have involved physical violence, emotional abuse, or sexual abuse. They might have been neglected, separated from someone they loved, been bullied, harassed, assaulted, isolated, put under intolerable pressure, made homeless, sent into care, into hospital or to other institutions.

Experiences like these erode self-esteem. Emotions that have no outlet may be buried and blocked completely out of awareness. If a trusted adult betrays or abuses them, and there are no other witnesses, children will often blame themselves. They turn their anger inwards. By the time they become adults, self-injury can be a way of expressing their pain, punishing themselves, and keeping memories at bay.

There is often an absence of pain during the act of self-injury, rather like the absence of sensation that often occurs during abuse or trauma. The body produces natural opiates, which numb it and mask the emotions, so that little is felt or realised consciously. A badly traumatised person may end up feeling quite detached from their feelings and their body. Some may injure themselves to maintain that sense of being separate, and to convince themselves that they aren't vulnerable. Others may injure themselves in order to feel something and know that they are real and alive.

There can often be myths and negative attitudes surrounding self-harming and they exist even in the healthcare industry. Professionals can often make assumptions as to why someone is self-harming and therefore how to treat them. There can be instances of healthcare professionals with an unsympathetic attitude to someone who comes to them with injuries; for example, believing that a person who is cutting themself is causing their own injuries and therefore wasting the time of the nurse who has to stitch their wounds. NICE (the National Institute for Health and Clinical Excellence) produces guidelines on the treatment of self-harm, explaining the need for exploring the underlying reasons someone may be self-harming, rather than just the self-harming behaviour itself. (See References and Useful websites)

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Who is most likely to self-harm?

According to recent research, the majority are young women, although the percentage of young men seems to be on the increase. Self-harming behaviour is also significant among minority groups discriminated against by society. Someone who has mental health problems is more likely to self-harm. So are those who are dependent on drugs or alcohol, or who are faced with a number of major life problems, such as being homeless, a single parent, in financial difficulty or otherwise living in stressful circumstances. A common factor is often a feeling of helplessness or powerlessness with regard to their emotions.

Recent research focusing on young people suggests that 10 per cent of 15 to 16 year olds have self-harmed, usually by cutting themselves, and that girls are far more likely to self-harm than boys. The most common reason is 'to find relief from a terrible situation'. Young people are often under great pressure within their families, from school and among their peers. Many young people report having friends who also self-harm.

The research suggests that young people who self-harm are much more likely to have low self-esteem, to be depressed and anxious. They seem to be facing more problems in life, but may be less good at coping with them. They may retreat into themselves, feeling angry, blaming themselves, tending to drink and smoke too much and to use more recreational drugs. They confide in fewer friends, and tend not to talk to their parents or other adults, or to ask for the help they need. (See About self-harm, a booklet for young people.)

Physical, emotional or sexual abuse
Women often find themselves in a caring role, putting their own needs last. This can grossly undermine their sense of worth, their opinions and strengths. In due course, a woman may come to feel she is an unimportant, silent witness to the abuses she has to endure. She may lose her sense of identity, power and rights. To survive, she may cut herself off from her real needs; for example, if the focus for this is the size and shape of her body, she may drastically restrict what she eats. (See Further reading.)

If men conform to the macho stereotype that expressing emotion is a weakness, it can leave them unable to feel their feelings, and detached from that side of themselves. They may have less difficulty showing anger than women, but if they are in prison, where pent-up feelings can't be released, men are more likely to turn to self-harm, especially if they have been abused.

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Is self-harm an attempt to commit suicide?

Self-harm is about trying to stay alive, despite the pain people are in. Although, there is a relationship between self-harm and suicide, many more people self-harm than kill themselves, and most people don't hurt themselves so badly as to risk their lives. Of those who do, suicide may not have been their intention; it's the feelings they want to wipe out.

Whether someone wants to live or die may seem to be a straightforward choice. But some people are suspended in a grey state of survival, where choices and decisions are kept on hold. This is where self-harm happens.

For those who self-harm, surviving is subject to rigid controls; feelings are suppressed for fear of what may lie behind them. If living means having to cope with acutely painful feelings and memories, and there is not enough support available, the choice not to be alive may be more understandable. When someone you care about talks about death, it's natural to fear they may go through with it, but these are the very feelings they need to explore. (See What help can I get?) Remember that human beings have an enormous capacity to survive great pain.

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Is self-harming behaviour attention-seeking?

Because it can be hard to understand, healthcare professionals, friends and relatives sometimes mistakenly regard people who self-harm with mistrust or fear and see their behaviour as attention seeking and manipulative. If someone you know self-harms, you may feel helpless when faced with their wounds, and your own feelings and fears about the situation may cause you to blame them instead of supporting them (see How can friends and family help?). Bear in mind they may be using the only way they can to communicate their plight and to get the attention, care and comfort they need. However upsetting it may be for you, it doesn't necessarily mean this is their intention. Whether people have deep wounds or slight injuries, the problem they represent should always be taken very seriously. The size of the wound isn't a measure of the size of the conflict inside.

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What triggers it?

You may harm yourself once or twice at a particularly difficult time in your life, and never do so again. But self-harming can become an ongoing way of coping with current problems and may occur regularly, on a monthly, weekly, or daily basis, depending on circumstances. The trigger could be a reminder of the past, such as an anniversary, which sets off a hidden memory, or something unexpected could happen to cause a shake-up. But sometimes, ordinary life is just so difficult that self-harm is the only way to cope with it.

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What can I do to stop self-harming?

The single most important thing to remember is that you have choices: stopping self-injury can begin now.

• Knowledge is power. Gather as much information as possible about your own behaviour. Keep notes of what is going on when you feel the need to harm yourself, so that you can identify, over a period of time, specific thoughts which come up. It's also useful to keep a daily diary of events and feelings, and to record how you cope with or channel powerful emotions of anger, pain or happiness.
• Try to talk about your feelings with someone supportive. Even though you may feel you are alone, there are others who can understand your pain and help to boost your strength and courage. Many people find that joining a support group of people with similar problems is an important step towards making themselves feel better, and changing their lives. If there are no appropriate support groups in your area, your local Mind associations may be able to help start one. (See Useful organisations for more information.)
• Work on building up your self-esteem. Remember you are not to blame for how you feel; your self-injury is an expression of powerful negative feelings. It's not your fault. Make lists of your feelings, and then write positive statements about yourself, or the world around you. If you can't think of any, ask friends to write things they like about you. Keep these in a place so that they are visible. Make a tape of your own voice saying something affirming or reading your favourite stories or poems. Hearing your own voice can be soothing, or you can ask someone you trust to record their voice reading to you.
• Try to find ways to make your life less stressful, give yourself occasional treats, eat healthily, get plenty of sleep and build physical activity into your life, because this is known to boost self-esteem and lift low moods.
• Have the telephone numbers of friends, or local and national helplines where you can find them easily, if you need to talk to somebody in a crisis. (See Useful organisations.)
• Think about your anger and what you do with it. If you weren't busy being angry with yourself, who would you really be angry with? Write a list of people who have caused you to feel like this. Remind yourself you deserve good things in life, not punishment for what others have done to you.
• Line up a set of cushions to represent people who caused you pain. Tell them how they hurt you and that you don't deserve punishment. Kicking or hitting cushions is good. Try to do this with someone else, if possible, so that the experience is shared and you do not hurt yourself.
• Creativity is a powerful tool against despair. This doesn't have to be about making something. Whatever lifts you out of your pain and makes you feel good is creative. If you feel like it, try drawing or painting how you feel. Some people draw on themselves, using bright body colours.
• If you feel the need to self-harm, focus on staying within safe limits. A supportive GP will give you good advice on minimising and caring for your injuries and help you to find further help.

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What help can I get?

If experiences were so painful they forced you to deal with your emotions by hurting yourself, you may now seriously doubt whether you can deal with them in any other way. But people do move forward, to grieve over past events or a lost childhood and work through the fear and confusion surrounding them. With plenty of support, they learn that they can cope with the pain, anger and rage, which need to surface.

The important thing is to find ways to start talking to someone you trust. It could be to a friend, a family member, a professional counsellor, a psychologist or a psychotherapist.

A professional should have the training to listen to you and help you reach your feelings and manage them in a different way. Problems in the present and from the past all need to be addressed. If you can, find someone who specialises in treating people who self-harm, who have eating problems or who have been abused. (See Useful organisations and Further reading.)

Talking to your GP
NICE recommends that you should be offered a full assessment of your physical, psychological and social needs, by a professional who has been trained in the treatment of people who harm themselves, in an atmosphere of respect and understanding. If your GP is dismissive or unhelpful, you can contact the Patient Advice and Liaison Services (PALS), listed in your phone book under the local NHS Trust. You have a right to change your GP, if necessary. (See Useful organisations.)

Your GP may offer you a number of treatment choices, including various forms of counselling or therapy. One option might be cognitive behaviour therapy (CBT), which is a practical treatment that involves looking at what happens just before you self-harm, encouraging you to keep a diary of self-harming episodes and finding other channels for your feelings. CBT does not usually explore, in depth, the underlying causes of self-harming. (See Further reading).

If your self-harming is severe, you may be referred to psychiatric services for further assessment, treatment and support. In an emergency, you may be taken into hospital. People's experience of these services is very variable. Even though NICE guidelines are designed to improve the treatment people receive, when time and resources are limited it may be easier for staff to make snap judgements, use diagnostic labels and offer medication, than to spend time looking for the underlying causes of distress. If you find that this is the case, you may need an advocate, who can speak for you and ensure you are properly treated. This could be a friend, relative or a professional. (See The Mind guide to advocacy.)

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How can friends and family help?

If someone you love and care about is self-harming, it can be very difficult to cope with your own feelings of shock, anger, guilt, grief and helplessness. You may be very afraid of what might happen. Try to enlist the help of family, friends and professionals to support you. (See Useful organisations.)

Although you may feel helpless, what you do or don't do can make a lot of difference. If you pay due attention to their injuries, you affirm that they and their body are worth caring about. But don't just focus on the injuries. It's important that you appreciate how difficult your friend or relative is finding life. Showing them you want to understand will matter a great deal.

You can begin by gently encouraging them to examine their feelings and to talk to someone about why they self-harm. You may find what they have to say difficult to hear. If it feels too much for you, help them to find someone else to talk to. It's possible to be honest with them about your own feelings and not to panic, blame them, treat them as if they are mad, or make them feel guilty. Being uncritical will help them feel accepted and cared for, instead of even more self-hating. Keep emphasising all the non-harming aspects of the person's life to help develop and support their sense of self-worth.

Don't expect change to happen quickly; and don't hold on to any expectation that your friend or relative can stop self-harming just because you want them to. People who self-harm are trying to resist feeling the full weight of their emotions. This defence mechanism can't be dismantled easily. It takes time for people to learn that their feelings won't destroy them. It's important you resist the temptation to step in, constantly, to try to solve the problem. In the end, each individual has to draw on their own strengths and find their own healing inner resources.

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References

Self-harm: short-term treatment and management (National Institute for Clinical Excellence 2004) (www.nice.org.uk)
Self-harm: understanding the NICE guidelines
(National Collaborating Centre for Mental Health/Mind)
Youth and self-harm: perspectives (Centre for Suicide Research, University of Oxford/Samaritans)
Non-fatal suicidal behaviour among adults aged 16-74 in Great Britain The Office for National Statistics (The Stationery Office 2002)
Children or adolescents who try to harm or kill themselves (National Statistics 2001)

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Useful organisations

The Basement Project
PO Box 5, Abergavenny, Wales NP7 5XW
tel. 01873 856 524
web: www.basementproject.co.uk
Publications, groups and workshops for people who self-harm

Bristol Crisis Service for Women
tel. 0117 925 1119
web: www.users.zetnet.co.uk/bcsw
Charity supporting women in emotional distress, particularly those who self-harm

British Association for Counselling and Psychotherapy (BACP)
tel. 0870 443 5252
web: www.bacp.co.uk
For details of practitioners in your area

DABS (Directory and Book Services)
4 New Hill, Conisbrough, Doncaster DN12 3HA
tel. 01709 860 023
web: www.dabsbooks.co.uk
Books and information for anyone affected by child abuse

NAPAC (National Association for People Abused in Childhood)
helpline: 0800 085 3330
web: www.napac.org.uk
National information service for people abused in childhood

National Self-harm Network (NHSN)
PO Box 7264, Nottingham NG1 6WJ
web: www.nshn.co.uk
Survivor-led organisation supporting those who self-harm

Samaritans
By post: Chris, PO Box 9090, Stirling, FK8 2SA
Helpline: 08457 90 90 90
Minicom: 08457 90 91 92
web: www.samaritans.org.uk 
email: jo@samaritans.org
24-hour emergency helpline

Survivors UK
helpline: 0845 122 1201
web: www.survivorsuk.org
For men who have experienced any form of sexual violence

United Kingdom Council for Psychotherapy (UKCP)
tel. 020 7014 9955
web: www.psychotherapy.org.uk
Regional lists of psychotherapists are available free

YoungMinds
tel. 020 7336 8445
parents' information service: 0800 018 2138
web: www.youngminds.org.uk
For anyone concerned about a child’s mental health

Useful websites

www.nch.org.uk/selfharm

www.nice.org.uk

www.selfharm.org.uk

www.siari.co.uk

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Further reading

About self-harm (Mind and Barnardo’s 2007)
Conquering a sense of inferiority (Mind 2004)
Cutting: the risk – self-harm, self-care and risk reduction (National Self-harm Network 2000)
Healing the hurt within: understand self-injury and self-harm, and heal the emotional wounds (2nd ed) J. Sutton (How To Books 2005)
Heal the hurt: how to forgive and move on A. Macaskill (Sheldon Press 2002)
How to accept yourself Dr. W. Dryden (Sheldon Press 1999)
How to assert yourself (Mind 2006)
How to cope with suicidal feelings (Mind 2006)
How to help someone who is suicidal (Mind 2004)
How to improve your mental wellbeing (Mind 2006)
How to increase your self-esteem (Mind 2006)
How to look after yourself (Mind 2006)
How to recognise the early signs of mental distress (Mind 2004)
Managing anger: simple steps to dealing with frustration and threat G. Lindenfield (Thorsons 2000)
The Mind guide to advocacy (Mind 2006)
The Mind guide to managing stress (Mind 2006)
Overcoming childhood trauma: a self-help guide using cognitive behavioural techniques H. Kennerley(Robinson 2000)
Overcoming low self-esteem: a self-help guide using cognitive behavioural techniques M. Fennell (Robinson 1999)
Understanding addiction and dependency (Mind 2005)
Understanding anxiety (Mind 2006)
Understanding borderline personality disorder (Mind 2007)
Understanding depression (Mind 2007)
Understanding eating distress (Mind 2004)
Understanding psychotic experiences (Mind 2004)
Understanding talking treatments (Mind 2005)
Visible memories: a film about self-injury (DVD/video) Croydon
Mental Health Users’ Group (One Lung Publications 1998)
Who’s hurting who? Young people, self-harm and suicide H. Spander (42nd Street 2001)

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This booklet was written by Diane Harrison and revised by Jenny Sharman
First published by Mind 1995. Revised edition © Mind 2007
ISBN 9781874690320
No reproduction without permission