Over the last couple of decades there has been a steady increase in the number of young people who are harming themselves.

This seems to be a worldwide phenomenon, at least in westernised countries. 

The act of self harm, which usually involves deliberately cutting, burning or otherwise harming the body, is not a diagnosis in itself, but is a symptom of psychological distress. 

There are many reasons why people cut or burn themselves, and it is important to understand the motivation of the individual concerned, rather than trying to clump everyone together into one homogenous group.

Self harming behaviour generates a range of responses from the world around us. These cover the full spectrum from caring to rejection to abject horror, and often reflect the inner world of those involved in caring for a person who has harmed themselves.

Unfortunately, the response of many in the community, and even of some professionals is both strong and often negative.

Self harm is often seen as being a manipulative, attention seeking process. However this could not be further from the truth.

Recently, YoungMinds, a UK mental health charity, issued a report with a concerning statistic. This suggests that nearly 50% of professionals involved with the care of young people fail to either understand the motivation behind the act of self harm, and struggle to fully empathise with those who self harm.

When young people hurt themselves they continue to attract approbation and stigma from the general public and health professionals alike. This seems to come about because of misinformation and lack of knowledge about the many differing reasons that underly self harm.

50% of professionals involved with the care of young people fail to understand the motivation.

In recent years several different terms have been used to describe self harming behaviour.

• Self injury.
• Deliberate self harm.
• DSH.
• Non-suicidal self-injury.
• A cry for help.
• A symptom of personality disorder.
• Parasuicide.

Epidemiological surveys that have been undertaken in several countries, report the incidence of cutting in young people to be around 7%.

An Australian study, of 1800 students carried out in 2012, showed a 10% incidence in girls and a 6% incidence in boys. Another, earlier Australian study looked at 1699 high school students aged 15-16 years, this showed a one year prevalence rate of 5%, with girls again reporting a higher rate than boys.

In other words, a significant minority of young people self harm at some point during their childhood. This represents a widespread and sizeable community health problem.  However, only a small minority of those who cut then actively seek medical attention. 

This reveals a large area of unmet need. The number of people who self harm tends to fall once the young people enter early adulthood.

Only a minority of those who cut seek medical attention.

In a survey that looked at the reasons young people gave for cutting, less than 1 in 100 of the young people said that they either intended or wanted to die.  This compares to a figure of about 1 in 10 of those who self poison.

Cutting was carried out in a more impulsive way than self poisoning, with less than an hour of rumination and planning before the act.

In comparison to those who self poison, cutters as a group also report feeling more depressed, to have more self-directed anger and of wanting to relieve strong emotions. Girls report a much greater element of self punishment than boys.

Young people give many differing reasons why they have felt it necessary to cut.

• To gain relief from a strong emotional state.
• Self punishment.
• Desire to be dead.
• To get their own back on somebody.
• To frighten someone.
• To see how much people care.
• To gain some attention.
• As a demonstration of how awful they feel.
• To find out how much someone loved them.
• As a way to avoid committing suicide.

Research has also cast a light on the underlying conditions where cutting is more likely to occur.

1. Depression. About 1 in 5 will have tried cutting to try to help themselves deal with their depressive symptoms. Young people show a higher rate of depressive symptoms than do adults.
2. Obsessive compulsive disorder.  Some of those who cut have symptoms suggestive of an addictive element to their behaviour, one study  demonstrated the presence of at least one addictive symptom in nearly all the young people in the series. While others seem to do it as a compulsive almost habitual action a bit like trichotillomania.It has been suggested that there may be a small subset of cutters for whom the behaviour is a compulsion.
3. As a way of gaining release from their current predicament. This may be as a way to escape from difficult environmental situations or where excessive demands are placed upon the young person. This is often seen where strong emotion are triggered by reliving past traumatic events.
4. Past or current trauma. There is a high incidence of past and current trauma among those who cut. This seems to help with emotional control of strong negative feelings. Self harm is often seen in those who have a history of being in care, exposed to divorce, illness, physical or sexual abuse, and impulse control problems in their families during early childhood. There is experience of peer conflict, substance abuse, identity issues and bereavement during adolescence. PTSD following abuse is often accompanied by cutting where it can be used as a form of self punishment or as an aid to emotional regulation.
5. Emotional regulation or coping strategy. Adolescents in this group often show poor problem solving strategies, and cutting may be seen as a way to communicate distress or occasionally as a sign of non-cooperation of protest. Social and active coping strategies seem to be protective.
6. Anger.
7. Guilt.
8. Self blame.
9. Self loathing.
10. Loss of control.
11. Emotional detachment. This has two sides to it. For some people cutting is about actually being able to feel something while for others it is about stopping being overwhelmed by feelings.
12. Substance misuse. This can both contribute to underlying mental health difficulties as well as be disinhibiting, making the threshold to cut lower.
13. Personality disorder.
14. Care seeking behaviour.
15. Cultural identification – tribal or youth subculture.  This is seen as a cultural norm in some tribal people where scarification is part of a transition ritual into adulthood.  Some subcultures use cutting as a mark of belonging, while tattooing and body piercing are popular at present in western culture, some people go to extremes with this and could be seen as self harming.

It is not unusual for self harming behaviours to improve, or even remit completely, without any active intervention as adolescence continues. However, self harm can be an early indicator of significant mental health issues in young people, and as such needs to be assessed carefully. Early intervention to treat any underlying condition then becomes possible.

Through the early identification of those at risk of self harm not only is it possible to intervene to reduce the likelihood of its occurrence, but also reduce the risk of further progression to mental health disorder. 

Although only a tiny percentage of those who cut themselves go on to complete suicide there is a significantly greater incidence of cutting in those who do complete suicide, so early identification of self harm can also serve as an early indicator of those at risk of completing suicide and so permit earlier treatment to prevent such an outcome.

In attempting to engage a young person in a helping relationship around self harm the following strengths make the process easier.

• Confidence. This ranks high on any list as signs of nervousness or anxiety about self harm tend to lead to the sufferer becoming disinterested and untrusting of help.
• Empathy. To be able to stay with the young person while difficult emotions and topics are discussed will help them to make sense of what they are experiencing.
• Knowledgeable. Being able to discuss the nature of the cutting experience and to help manage depression and low self-esteem which can both be primary and secondary problems.
• Understanding. To be able to recognise the patient’s despairs and to share that knowledge.
• Nurturing and caring approach to their difficulties. Even when they are trying to push help away.
• Optimism. Both about recovery and their ability to find better coping strategies and to make long-term changes and improvements to their life.

Any one who shows these traits will be well placed to help. Using their relationship with the young person to bring about lasting change.

The time is here to recognise that self harm is more than just a behaviour that is highly confronting to our own emotional make up, and see it for what it really is, a serious symptom of distress with diverse causes that requires a prompt response and thorough assessment.

The earlier that effective help can be offered the easier it is to achieve the best outcomes.

If this is something that has affected you, or someone you are close to, then you might find the following links helpful.

Useful links.

http://www.headspace.org.au

http://www.youthbeyondblue.com

http://www.lifeline.org.au

Tel:131114