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Big story: more harm than good

04 October 2019

Rates of self-harm are rising steeply, especially among young women, but the majority are still not able to access the right medical or psychological care. Can you play a helpful role? Journalist Juliette Astrup investigates.

Rates of self-harm have almost trebled over a 14-year period, with one in five young women in England aged 16 to 24 saying they had self-harmed, research shows. A study, published in The Lancet Psychiatry, tracked non-suicidal self-harm (NSSH) rates from 2000 to 2014 using three surveys of people in England aged 16 to 74. It finds rates have risen across both sexes and all age groups since 2000; in the population as a whole, the self-harm rate rose from 2.4% in 2000 to 6.4% in 2014 (McManus et al, 2019).

Significantly, the increase was largest among women and girls aged 16 to 24, with 19.7% of those questioned in 2014 saying they’d self-harmed, up from 6.5% in 2000 (McManus et al, 2019).

While the findings are worrying, they perhaps come as no surprise, having been reflected in other research across the UK. A BBC investigation in Northern Ireland earlier this year, for example, found that the number of teenage girls self-harming had jumped 66% in the five years between 2013 and 2018 (Monaghan, 2019), while a recent Scottish study found that one in six 18- to 34-year-olds of both sexes had self-harmed (O’Connor et al, 2018).

The Children’s Society’s latest annual Good childhood report on eight- to 17-year-olds in more than 2000 UK households found that nearly a quarter (22%) of girls aged 14 said they had self-harmed, and nearly one in 10 boys (Children’s Society, 2018).

Relief through pain

Self-harm is known to be used as a coping mechanism in times of emotional distress (National Self-Harm Network, 2019) so it is significant that the McManus study shows that the prevalence of using NSSH to relieve unpleasant feelings of anger, tension, anxiety or depression has roughly trebled in men and women between 2000 and 2014, again most markedly in young people (McManus et al, 2019).

The authors are at pains to warn that using self-harm to cope with emotional stress carries serious long-term implications. Study co-author Professor Louis Appleby says: ‘There is a risk that self-harm will become normalised for young people, and individuals who start to self-harm when young might adopt the behaviour as a long-term coping strategy. Furthermore, NSSH may be associated with later suicide. As young people get older, reaching age groups that already have higher suicide rates, the self-harm they have learned may become more serious and more likely to have a fatal outcome’ (University of Bristol, 2019).

What’s driving the trend?

While the McManus study doesn’t look into the factors behind this apparent increase in emotional stress among young people, others shed a little more light. For example, the Good childhood report revealed children were least happy with school and their appearance (Children’s Society, 2018). The same top two concerns were also highlighted in a recent survey by the charity YoungMinds.

YoungMinds campaigns manager Nick Harrop says the reasons for self-harming can be complex, but adds: ‘Difficult experiences in childhood, such as growing up in poverty, family problems and experiencing abuse or neglect, can have a huge impact on a young person’s mental health.

‘A recent survey we carried out with 7000 young people who had looked for mental health support also showed that 77% of young people see pressure from school or college as having a significant impact on their mental health, while 69% felt the same about their body image [YoungMinds, 2019].’

Weak services support

While a growing body of research clearly points to increasing prevalence of self-harm and its potential life-long implications, what is being done to address it? Not enough, according to the McManus study, which found that less than half of all those subjects reporting self-harm said they’d been in contact with medical or psychological services as a result (McManus et al, 2019).

While stigma around self-harm can be a barrier to reporting, as the McManus study points out it is not the only factor at play. The knowledge and confidence of healthcare and other professionals in addressing the issue must be considered, and so too must pressure on services and difficulties accessing care. A recent audit in Scotland found that one in five young people referred to CAMHS were rejected (Scottish Government, 2018); similarly, a report on CAMHS referrals in England found that between one-fifth and one-quarter of referrals were rejected, most commonly because they were not deemed suitable or serious enough (Education Policy Institute, 2018).

Nick at YoungMinds, which has just launched the ‘Act Early’ campaign calling for young people to be given help with their mental health earlier, agrees that ‘for many it’s still far too hard to get help when they need it’. He adds: ‘While some positive initiatives are occurring in the NHS, schools and local areas, they aren’t enough and services remain overstretched. The government must take action to address the factors that can affect young people’s mental health, and ensure early intervention is a priority.’

Steven Jones, professor at the University of Chester’s medical school, who has published widely on deliberate self-harm among other subjects, says that, with few of those self-harming being treated by mental health services, community practitioners are often the first – or only – ones working with these individuals, and so have a key role to play.

What can CPs do?

Steven says:‘Self-harm is a physical representation of some distress that’s going on – and that is worth exploring. What led you to do it? What was going on at the time? Did you feel some kind of release? What was the intent of your harm?

‘The individuals who self-harm might be quite complex, but the methods to approach them are often quite simple: be available, listen, don’t judge, and look at services they might be referred to.’

Recognising the huge pressure on mental health services and long waiting times, he adds: ‘I think that people can be put off referring. But you’ve got to focus on the young person or adult in front of you and what’s best for them. You can understand the reasons and the pressures – but that shouldn’t be a reason for someone not being seen and assessed. When referring you are not asking them to take on the person and treat them. You are asking for an assessment and possible intervention approaches.

‘You can try to use the language that referral agencies want to hear: “I have carried out a risk assessment measure, and in my clinical opinion this person should be seen sooner rather than later. And here’s the evidence that’s led me to that.”

‘Spending some time face to face with referral agency staff, if only a few hours, might improve referral pathways and relationships.’

Prevent and protect

As well as identifying need, Steven believes that healthcare professionals such as health visitors and school nurses can also consider preventative and protective factors: ‘It needn’t necessarily be medical interventions. You might think about social prescribing. What can be done to reduce isolation, to help people feel part of a group or community?’

And healthcare professionals can also have a part to play in tackling the stigma around self-harm which, rather than ‘normalising’ it, can reduce the risks, adds Steven. ‘Part of it is getting the message out that discussing self-harm or suicidal ideas doesn’t increase the risk – it reduces it. To make it acceptable to talk about it and discuss it actually reduces the risk of a person going on to cause themselves significant harm.’

As the findings of the McManus study highlight, developing public health and school-based interventions to prevent and reduce self-harm are vital. ‘Young people need health and educational services to be available, and health professionals need to discuss self-harm with young people and encourage them to find safer ways of coping,’ says co-author Professor Appleby (University of Bristol, 2019).

Lead author Sally McManus adds: ‘The availability of services needs to be improved, especially for young people, so that health, education and social care professionals can discuss the subject with them and support better emotional health’ (University of Bristol, 2019).

But sadly, as this latest study indicates, without the sufficient scaling-up of services to meet the increase in instances, self-harm, with all its potentially harmful long-term consequences, could yet rise further. 

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References:

Children’s Society. (2018) The good childhood report 2018. See: https://www.childrenssociety.org.uk/what-we-do/resources-and-publication... (accessed 9 September 2019).

Education Policy Institute. (2018) Access to children and young people's mental health services 2018. Education Policy Institute. See https://epi.org.uk/wp-content/uploads/2018/10/EPI_Access-to-CAMHS-2018.pdf (accessed 5 September 2019).

McManus S, Gunnell D, Cooper C, Bebbington P, Howard L, Brugha T, Jenkins R, Hassiotis A, Weich S, Appleby L. (2019) Prevalence of non-suicidal self-harm and service contact in England, 2000-14: repeated cross-sectional surveys of the general population. The Lancet Psychiatry 6(7): 573-581. See https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(19)30188-9/fulltext (accessed 9 September 2019).

Monaghan J. (2019) NI hospitals see 28 self-harm cases daily. BBC News. See: https://www.bbc.co.uk/news/uk-northern-ireland-47308668 (accessed 9 September 2019).

National Self Harm Network. (2019) What is self harm? See: http://www.nshn.co.uk/whatis.html (accessed 18 September 2019).

O'Connor R C, Wetherall K, Cleare S, Eschle S, Drummond J, Ferguson E, O'Connor DB, O'Carroll RE. (2018) Suicide attempts and non-suicidal self-harm: national prevalence study of young adults. BJPsych Open 4(3): 142-8. See: https://www.cambridge.org/core/journals/bjpsych-open/article/suicide-att... (accessed 9 September 2019).

Scottish Government. (2018) Rejected referrals to child and adolescent mental health services: audit. See: https://www.gov.scot/publications/rejected-referrals-child-adolescent-me... (accessed 9 September 2019).

University of Bristol. (2019) Despite increase in rates of non-suicidal self-harm, few people receive medical or psychological support. See: https://www.bristol.ac.uk/news/2019/june/selfharm-lancet.html (accessed 9 September 2019).

YoungMinds. (2019) Huge gaps in early support for young people with mental health problems – new survey. See: https://youngminds.org.uk/about-us/media-centre/press-releases/huge-gaps... (accessed 9 September 2019).

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