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Self-harm: understanding the causes and treatment options

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In response to growing concern about the increasing number of young people performing acts of self-harm, the Mental Health Foundation and The Camelot Foundation recently launched a UK-wide inquiry into self-harm among 11-25-year-olds. The inquiry is the first of its kind. It aims to understand the causes of deliberate self-harm more fully and to explore what health care services can do to address it.


VOL: 100, ISSUE: 15, PAGE NO: 24

Celia Richardson, public affairs, The Mental Health Foundation


In response to growing concern about the increasing number of young people performing acts of self-harm, the Mental Health Foundation and The Camelot Foundation recently launched a UK-wide inquiry into self-harm among 11-25-year-olds. The inquiry is the first of its kind. It aims to understand the causes of deliberate self-harm more fully and to explore what health care services can do to address it. Incidence
Rates of self-harm in the UK are the highest in Europe, and are most prevalent among adolescents and young adults. Hospital admission figures report that 24,000 teenagers are admitted to hospital every year as a result of deliberate self-harm and the numbers doing so continue to rise (Samaritans and Centre for Suicide Oxford University, 2002). Over the last 20 years there has been a significant increase in the occurrence of self-harm. The incidence of self-harm varies among groups: - Young women perform acts of self-harm more frequently than young men - the rates for females are seven times higher than the rates for males (Royal College of Psychiatrists, 2002); - Rates among young men and boys have almost doubled since the 1980s (Mental Health Foundation, 2003); - Numbers among the female prison population are particularly high; - Asian women are six times more likely to self-harm than other women (Babiker and Arnold, 1997). The average age for people to begin performing acts of self-harm is 13 years. The youngest child reported to have self-harmed is just seven years old (Bywaters and Rolfe, 2002). Defining self-harm
The term ‘self-harm’ is generally understood to mean deliberately inflicting injury on oneself. The most common methods include: - Cutting skin over and over; - Swallowing small amounts of toxic substances; - Burning and scalding; - Banging and scratching. Hair pulling and excessive substance abuse are also common methods of self-harm. At present, deliberate self-harm is poorly understood and until recently there has been little research available to shed light on why such a considerable number of young people are compelled to hurt themselves. The inquiry aims to discover why people self-harm and, more importantly, aims to learn how to prevent young people from self-harming and how to intervene in the lives of those who already do so. Anyone has the potential to self-harm; there is no typical ‘self-harmer’. Triggers (Bywaters and Rolfe, 2002) have been linked with experiences such as: - Unwanted pregnancy; - Being bullied at school; - Conflict with parents; - Parents divorcing; - Abuse; - Rape; - Bereavement; - Entering care. Much of the literature on self-harm links the behaviour to suicide. However, the majority of young people who self-harm do not intend to commit suicide. It is widely accepted that self-harm is used as a coping strategy in response to profound emotional pain. Many young people do it in order to release feelings of anger and self-hatred - to alter their state of mind. It can be a way to communicate distressing feelings that are difficult for them to express. Providing support
Those who self-harm often keep it very well hidden and services only see a fraction of the young people who do harm themselves. More worrying, however, is that many of those who come into contact with services do not receive the support they need. Recent investigations into the services available for young people such as the provision of information, advice, and counselling revealed a lack of adequate resources. The consequence is that young people are unable to access the support they need (Wilson, 2001). In an assessment of A&E departments, more than half of those who had self-harmed were discharged without psychiatric assessment (National Institute for Clinical Excellence, 2001). Young people have also reported that when they do come forward to seek help or end up in A&E departments, they often face responses from professionals, which are unsupportive and unhelpful (YWCA, 2002). This can result in individuals feeling isolated and they may feel like they are being judged as timewasters, compounding their existing negative emotions. According to Andrew McCulloch, chief executive of the Mental Health Foundation: ‘The problem is little understood by professionals in health, education and social care, and because of this, young people are often not referred to experts who can help them. The patchy provision of services adds to a problematic situation for adolescents because they fall between children and adult mental health services. This gap is significant.’ Overcoming prejudice
Self-harm can touch on difficult feelings for professionals who encounter people who self-harm, and these feelings can become institutionalised in statutory treatment and care. Like many other people associated with someone who self-harms, medical and nursing staff may feel distressed, frightened, angry, or sick (Bird and Faulkner, 2000). Acknowledging these feelings and improving awareness of the prejudice and stereotypes associated with self-harm appears to be key in providing useful support to young people. Self-harm, because it is not understood, is often seen in a negative way as attention-seeking behaviour. Yet the reality is that the young person who self-harms needs care and treatment. Dr McCulloch suggests: ‘The increase in self-harm is one of a number of indicators in the mental health field that show something is wrong. It may be visible evidence of growing problems facing our young people or of a growing inability to respond to those problems.’ However, he adds: ‘There is a desire across the health and social care spectrum to develop appropriate responses but the evidence base is limited. Self-harm is a complex issue and our inquiry will have to be broad in its outlook.’ Treatment guidelines
NICE has produced clinical guidelines for treating those who self-harm. However, these focus on short-term physical and psychological treatment in primary and secondary care. In order to build on these guidelines and explore the problem further, the inquiry aims to thoroughly research the incidence, causes, and treatment of self-harm in young people and identify examples of best practice among service providers. The inquiry, which is to last 18 months, will take evidence from young people, parents, carers, policy makers, service commissioners, staff, and senior managers in health, education, social care, and voluntary sector organisations. Its main objective is to produce a stronger knowledge base and it is hoped that the findings can then be used to develop good practice guidelines and resource packs for individuals and organisations who work with young people who self-harm. The findings will also be used to make policy recommendations to local and national government. Young people will be consulted throughout the project. For Susan Elizabeth, director of the Camelot Foundation, one of the key priorities of the inquiry is: ‘It should reflect the views and experience of young people … to achieve this we will be consulting regularly with five sites across the UK, where groups of young people who self-harm already meet. We want to make sure that young people’s views are fed into the inquiry at every stage.’ Conclusion
The inquiry aims to produce practical and thoughtful approaches to the prevention and treatment of self-harm in young people, which can inform future education and training and provide strategies that service providers can usefully introduce into care. It is also hoped that there will be an increase in awareness and understanding across the care spectrum. This article has been double-blind peer-reviewed.

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