Self-harm: Short-term pain is a long-term suicide risk

The risk of somebody dying by suicide in the year after a self-harming episode is about 100 times greater than that of somebody in the general population

The incidence of self-harm is on the rise in Ireland, but there is still a lack of awareness around the problem, and the fact that people who self-harm are at an increased risk of dying by suicide.

It is very difficult for a parent to pick up on the fact that their teenage child is self-harming unless they actually walk in on the act or see visible scars, explains Dr Paul Surgenor, director of research at Pieta House. One of the biggest problems is that teenagers think that engaging in deliberate non-fatal self-harm such as cutting is "not serious".

“Parents generally are not clued into this and don’t know how to respond. Self-harming is not an attention-grabbing thing, and they are not doing it to create visible scars, it’s very private and personal. People tend to cut the tops of their arms or legs where they cannot be seen. When parents do find out, all they see is the blood or the scars and they think their child is suicidal. They flip out and kids hate that, they can’t understand why their parents are making such a big fuss. There’s a disconnect there,” he says.

Poisoning

The main method of self-harm in Ireland is poisoning according to hospital admission figures, but the main method used by those who present to services like Pieta House, particularly younger people, is cutting. Other behaviours include biting and scratching. Males are likely to self-harm in a more violent way.

In Ireland and the UK, self-harm is regarded as being on the continuum of suicide. Any suicide attempt that does not result in death is regarded as self-harm, but many people who self-harm have no intent to end their lives.

“Nationally and in Pieta House, we know that self-harm is on the rise. And also that the gap between males and females is closing – it used to be associated with just girls. Presentations of self-harm to our services were up nearly 20 per cent last year.

“There is a big problem, especially among adolescents, in understanding what self-harm is and what it does. They think it’s normal, they cut and feel better afterwards as it does give them an initial sense of relief.

“The short-term physical pain distracts them from their mental anguish, they don’t realise or care that it’s taking them further down the road towards suicide. They see it as a way of coping but it’s a destructive way. At Pieta, we never tell somebody to stop self-harming straight away, instead we gradually get them to look at other ways of coping.”

While there are small groups around the country doing great work in the prevention of self-harm, most parents, teachers, guidance counsellors, therapists, clinicians and emergency department staff are not sure what to do when they encounter self-harm, says Surgenor.

In an effort to address this knowledge deficit, St Patrick’s Mental Health Services, in partnership with Pieta House, Ireland’s centre for the prevention of self-harm or suicide, came together yesterday to host the first self-harm conference in Ireland.

Best practice

The aim of the event was to discuss and disseminate best practice in the area of managing and preventing self-harm, while identifying and prioritising areas for exploration and development.

“The whole idea was that everybody who attended the conference would leave with something concrete and tangible that they could try in their area, and that we would leave with a set of recommendations and priorities that research should be focusing on, so that there is collaboration and joined-up thinking.”

On the positive side, Surgenor points out that official figures from the National Suicide Research Foundation, which are based on hospital presentations, show that the incidence of self-harm is either decreasing or levelling off.

This means that fewer people are getting to the point that they require hospitalisation.

Keynote speaker Prof Nav Kapur, one of the UK’s leading experts in self-harm and suicide, told the conference that self-harm was one of the most common reasons for medical admission in the UK.

“It’s quite a common problem not just in Ireland and the UK, but across the world. Studies have found that 10-25 per cent of young people may have harmed themselves in the previous year and it can have potentially serious consequences. When we followed people long-term, we found they were at higher risk of suicide or dying of other causes even if they had low intent at the time of the self-harm episode.

“Our studies have shown that the risk of somebody dying by suicide in the year after a self-harming episode is about 100 times greater than that of somebody in the general population,” he noted.

In terms of what needs to be done in this area, the University of Manchester professor points to the evidence that talking therapies such as cognitive behavioural therapy, interpersonal therapy and problem-solving therapy “all seem to help a bit” in reducing a person’s risk of self-harming again.

“Researchers need to focus on what works, why it works and who it works for. In the past there was one approach for everybody – people who had a high level of suicidal intent or significant depression and others who did not. We need to develop new psychological treatment and learn how to target patients.”

Attitudes

Kapur says there is huge variation in the UK in terms of self-harm services and while some patients report good treatment experiences, he is aware that “sometimes attitudes are not as they should be”.

“One of the top messages that came out of the NICE Guidelines for Self-Harm in the UK, which I chaired, was that people who self-harm should be treated with the same care and compassion as a patient with any other illness. Service users have told me they feel blamed, and this is not acceptable. The situation is probably similar in Ireland.”

Director of services at St Patrick's Mental Health Services, Tom Maher, said it had seen an increase in the prevalence of self-harm among its own services users, particularly from 2008. However, he said this had started to level out in 2013-2014.

He explained that St Patrick’s has developed community group therapy sessions which help people find more constructive responses to distressing emotions.

Where somebody is assessed as being depressed and/or suicidal, they may be admitted to the inpatient service or referred to one of the dean clinics around the country for treatment.

“We found that the underlying emotional distress in our cohort of service users who self-harmed was not being dealt with by the structures we had in place so we decided to take a new approach to therapy. We don’t say ‘stop self-harming, we’ll get you better’, instead we give people the tools to deal with those nasty emotions themselves.” For more information, see nice.org.uk

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