By Katherine Brown.
Support: “to give or be ready to give help to somebody if they need it”. Few would argue against the idea that those who self-harm should be given support to overcome distress and cope in more adaptive ways. But with studies suggesting that approximately half of those who self-harm do not receive any help [1, 2] what support is realistically available to those who self-harm?
Informal support networks, such as friends and family, can play an important role in supporting those who self-harm. In Fortune, Sinclair and Hawton’s (2008)  study of adolescents’ help-seeking behaviour, friends and family were the main people contacted for help both before and after episodes of self-harm. Discussing problems and negative feelings with peers (sometimes termed ‘co-rumination’) has been shown to reduce the likelihood of engaging in self-harm . Being able to easily communicate with parents has also been associated with reduced risk of self-harming . It therefore appears that for many, informal support networks are both a preferred and a successful form of support when in distress. Although the reasons for this will vary, it seems likely that part of why informal support networks can be so effective in supporting those who self-harm is their involvement of deeply personal relationships. The personal nature of these relationships may lead to increased trust and a tailoring of care, both of which have been highlighted as important when supporting those who self-harm [5, 6]. However, this is not to say that it is easy for people to rely on their informal support networks. Some people who self-harm may not wish to disclose such behaviours to those that they are closest to . Others may lack an informal support network, or in some cases find that their relationships with friends and/or family are factors that contribute to their self-harm . It is therefore crucial to remember that other forms of support are available.
A range of more formal support services are available. Just a few examples include listening telephone lines, outpatient therapy providers and hospital care. These services have the benefit of being able to provide evidence-based support through formally trained staff and/or volunteers. A particularly strong example of these benefits can be seen in the organisation Samaritans. Samaritans is a listening service for anyone in distress which is free to call, email or write to and describes supporting those who are suicidal as a core part of it’s remit . The organisation does not only use research findings to shape it’s practices but actively conducts studies. These studies are both internal, to evaluate their services, and external through collaboration with universities and the government. This allows Samaritans to keep their services up-to-date and effective for those seeking their support. An independent two-year study into the organisation found that most callers felt better immediately after using the service, more than seventy percent rated the service favourably and more than eighty percent would be willing to use it again . In contrast, those who self-harm have previously identified problems within professional services such as a lack of knowledge about self-harm and having poor communication skills . Clinicians too have also described potentially negative influences on the care they provide, such as fearing for patients’ life following self-harm, challenges of attempting to maintain professional boundaries and feeling abandoned by co-workers . It is therefore important for formal support services to frequently evaluate the quality of support they offer, and to think about how to maintain feelings of independence amongst those they serve. One promising way in which services may promote both recovery and independence amongst their users is by including safety planning interventions as part of their care. Safety planning interventions typically involve identifying signs of an upcoming mental health crisis, listing coping techniques and useful contacts to turn to during a crisis, and creating ways to avoid means of self-harm. Research shows that despite being brief interventions these can reduce self-harm and increase attendance at therapy when added to usual treatment .
Self-help resources may also be beneficial to those who self-harm. For instance, in Smith and Clarke’s (2003)  analysis of self-help groups,members reported that attending reduced their feelings of isolation and increased their self-esteem. Online forums have similarly been found to have benefits, with Johnsons’ (2011)  study finding that more than half of those who used online communities reduced the frequency of their self-harm. Poignantly, many forms of ‘self-help’ involve connecting those seeking help with one another rather than being entirely independent processes. Risks such as normalisation of self-harm and featuring of distressing content have been suggested as potentially problematic aspects of ‘self-help’ group membership. . More independent forms of self-help may, for some, be preferable. When this is the case resources such as (reputable) mobile apps are worth considering. For example ‘Calm Harm’, developed by a clinical psychologist and a group with lived experience of self-harm, draws on principles from Dialectal Behaviour Therapy (DBT) and sets tasks designed to help manage urges to self-harm. An initial pilot study indicated an eighty-four percent reduction in self-harm amongst users and recent analysis of user data indicates that ninety-three percent of users reported a reduction in their urge to self-harm after completing one of the apps activities . Other apps such as ‘BlueIce’ (available through the NHS) are designed to be used in addition to therapy but when support is needed outside of sessions. ‘BlueIce’ includes independent self-help features such as a mood diary and suggested activities to reduce distress. It also gives prompts of phone numbers to call for further help. Research has found that the app is easy to use and accessible, with the independent self-help features reported as particularly beneficial .
The diverse nature of ‘support’, and limitations of different types, is not to say that effective support cannot be reached. Rather, it is a testament to the need to match appropriate supports with the individual requiring them. By understanding the difficulties that someone who self-harms is facing and the world they uniquely live in, the best forms of support can be identified and provided. Getting the right support may not be an easy process but it is one that is worth pursuing, both for those trying to get and those trying to give support.
Some UK-based resources that can help with mental wellbeing include:
Samaritans: Call 116 123 (UK)
Write to Chris, Freepost RSRB-KKBY-CYJK, PO Box 9090, STIRLING, FK8 2SA
Calm Harm: Further information at https://calmharm.co.uk/
BlueIce: Further information at https://www.oxfordhealth.nhs.uk/blueice/
DistrACT: Further information at https://www.nhs.uk/apps-library/distract/
NHS app library: https://www.nhs.uk/apps-library/filter/?categories=Mental%20health
Safety Planning Interventions
Staying Safe: Information and planning tools at https://stayingsafe.net/home
National Self-Harm Network: http://www.nshn.co.uk/index.html
Directory of peer-support groups:
- Ystgaard, M., Arensman, A., Hawton, K., Madge, N., Heeringen, K., Hewitt, A., Wilde, E., Leo, D. & Fekete S., (2009), Deliberate Self-Harm in Adolescents: Comparison Between those who Receive Help Following Self-Harm and Those who do Not, Journal of Adolescence, Vol. 32, No. 4, pp. 875-891, DOI: 10.1016/j.adolescence.2008.10.010
- Rowe, S., French, R., Henderson, P., Ougrin,, D., Slade, M. & Moran, P., (2014) Help-Seeking Behaviour and Adolescent Self-Harm: A Systematic Review, Australian and New Zealand Journal of Psychiatry, Vol. 48, No. 12, pp. 1083-1095, DOI: 10.1177/0004867414555718
- Fortune, S., Sinclair, J. & Hawton, K., (2008), Help-Seeking Before and After Episodes of Self-Harm: A Descriptive Study in School Pupils in England, BMC Public Health, Vol. 8, No. 369, DOI: 10.1186/1471-2458-8-369
- Latina, D., Giannotta F. & Rabaglietti, E., (2015), Do Friends’ Co-Rumination and Communication with Parents Prevent Depressed Adolescents from Self-Harm?, Journal of Applied Developmental Psychology, Vol. 41, No. 1, pp. 120-128, DOI: 10.1016/j.appdev.2015.10.001
- Skegg, K., (2005), Helping Those Who Self-Harm, The Lancet, Vol. 366, No. 9495, pp. 1471-1483, DOI: 10.1016/S0140-6736(10)61092-6
- Lindgren, B., Svedin C. & Werkö, S., (2018), A Systematic Literature Review of Experiences of Professional Care and Support Among People Who Self-Harm, Archives of Suicide Research, Vol. 22, No. 2, pp. 173-192, DOI: 10.1080/13811118.2017.1319309
- Doyle, L., Treacy, M. & Sheridan, A., (2015), Self‐harm in Young People: Prevalence, Associated Factors, and Help‐Seeking in School‐Going Adolescents, International Journal of Mental Health Medicine, Vol. 24, No. 6, pp. 485-494, DOI: 10.1111/inm.12144
- Sinclair, J. & Green, J., (2005), Understanding Resolution of Deliberate Self Harm: Qualitative Interview Study of Patients’ Experiences, BMJ, 330 No. 1112, doi:10.1136/bmj.38441.503333.8F
- Ferrey, A., Hughes, N., Simkin, S., Locock, L., Stewart, A., Kapur, N., Gunnell, D. & Hawton, K., (2016), The Impact of Self-Harm by Young People on Parents and Families: A Qualitative Study, BMJ Open, Vol. 6, No. 1, DOI: 10.1136/bmjopen-2015-009631
- Stace, S. & Wyllie, C., (2011) An Evaluation of Samaritans Emotional Support Services: Summary Report, Samaritans. Retrieved from: https://media.samaritans.org/documents/Samaritans_service_evaluation_Nottingham_-_Summary.pdf
- Taylor, T., Hawton, K., Fortune, S. & Kapur, N., (2009), Attitudes Towards Clinical Services Among People who Self-Harm: Systematic Review, The British Journal of Psychiatry, Vol. 194, No. 2, pp. 104-110, DOI: https://doi.org/10.1192/bjp.bp.107.046425
- Wilstrand, C., Lindgren, B., Gilje, F. & Olofsson B., (2007), Being Burdened and Balancing Boundaries: A Qualitative Study of Nurses’ Experiences Caring for Patients who Self‐Harm, Psychiatric and Mental Health Nursing, Vol. 14, No. 1, pp. 72-78, DOI: 10.1111/j.1365-2850.2007.01045.x
- Stanley, B., Brown, G., Brenner, L., Galfalvy, H., Currier, G., Knox, K., Chaudhury, S., Bush, A. & Green, K., (2018), Comparison of the Safety Planning Intervention With Follow-up vs Usual Care of Suicidal Patients Treated in the Emergency Department, JAMA Psychiatry, Vol. 75, No. 9, pp. 894-900, DOI:10.1001/jamapsychiatry.2018.1776
- Smith, A. & Clarke, J., (2003), Self-harm Self Help/Support Groups, London: Mental Health Foundation, Retrieved from: https://www.mentalhealth.org.nz/assets/ResourceFinder/self-harm-self-help.pdf
- Johnson, G.M. (2011). Online Communities for those who Self-Injure: A Description of Members with Implications for Adolescent Health. In S. Barton, J. Hedberg & K. Suzuki (Eds.), Proceedings of Global Learn Asia Pacific 2011–Global Conference on Learning and Technology (pp. 251-256). Melbourne, Australia: Association for the Advancement of Computing in Education (AACE). Retrieved August 5, 2020 from https://www.learntechlib.org/primary/p/37181/
- Dyson, M., Hartling,L., Shulhan, J., Chisholm, A., Milne, A., Sundar, P., Scott, S. & Newton, A., (2016), A Systematic Review of Social Media Use to Discuss and View Deliberate Self-Harm Acts, PLOS ONE, DOI: 10.1371/journal.pone.0155813, Retrieved from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0155813
- Calm Harm FAQ’s, ‘What Evidence Is There That Calm Harm Works?’ Retrieved from: https://calmharm.co.uk/faqs/
- Grist, R., Porter, J. & Stallard, P., (2018), Acceptability, Use, and Safety of a Mobile Phone App (BlueIce) for Young People Who Self-Harm: Qualitative Study of Service Users’ Experience, Journal of Medical Internet Research, Vol. 5, No. 1, DOI: 10.2196/mental.8779