Self-Harm audio transcript

Self-harm – An NHS self help guide

The written version of this guide was Commended at the British Medical Association Patient Information Awards 2018

Introduction

This guide is for people who deliberately harm themselves and are unhappy about it. It is also for family and friends who may have difficulty understanding this behaviour.

People who have experience of harming themselves have contributed to the writing of this guide.

It offers self help advice. However, anyone who self-harms should also see their GP (Family Doctor).

“I need to feel something, to know that I exist. Burning myself allows me to be in control of my body. It sometimes seems as though it is the only way I can feel alive or in control of anything… it is something I carefully plan when things get bad…”

“Tension builds inside me and I get to the point when I feel I will explode. When I cut myself it all disappears, it seems like the badness goes out of me, my anger dissolves… for a while…”

“I hurt myself when I want to hurt others… it is better to hurt myself than them”

“It’s a downward spiral… small cuts lead to bigger cuts”

“I self-harm to ‘punish’ myself. But I feel guilty doing it, it’s my only coping mechanism, it works for me. It plays into my ‘self-hatred’. I am not doing it to spite my family but they think I am punishing them”

These are the thoughts of people who have self-harmed. You may have had similar experiences yourself or you may have a friend or family member who self-harms. Although people don’t often talk about self-harm, it is relatively common, little understood and very distressing.

This guide aims to help you to begin to:

Understand self-harm, what can cause it and keep it going.
Explore ways of controlling self-harm.
Discover other ways of getting help.

More than half of people who die by suicide have a history of self-harm.

The following are some things to look out for that may mean you are at risk:

Do you think that you want to die or to kill yourself?
Have you planned a way to kill yourself?
Do you feel hopeless about the future and can think of no reason to live?
Have you had a suicide attempt in the past?

If you have answered yes to any of these questions please tell someone and seek help. If you feel you are in immediate danger of taking your own life ring your local emergency service (999).

Understanding self-harm

What is self-harm?
Many people harm themselves in some way, by smoking, drinking, working too hard or exercising too much. But for some people this self-harm is more apparent and can be quite severe.

Self-harm is sometimes known as self-injury and is where someone harms their body without wanting to die. Many people who harm themselves also have suicidal thoughts. But most feel that there is a difference between suicidal acts and acts of self-harm. They may say “I didn’t want to die, I just needed to get rid of terrible feelings”.

Some people may harm themselves many times each day. It may involve a lot of ritual. Some people may feel addicted to the self-harm behaviour. Others may only harm themselves occasionally when under emotional stress.

Who self-harms?
People who self-harm may feel distressed a lot of the time. They may be stressed and very sensitive to rejection.

Self-harm is not determined by a person’s race, age, education, or social group. Research has suggested that more women than men harm themselves (men may show their feelings in other ways). It tends to begin in adolescence and may decrease or disappear in the thirties, although not always, and can begin later in life. Sometimes people begin to self-harm following difficult life events including debt, bereavement, bullying and relationship breakdown.

Some people who harm themselves have been sexually, emotionally or physically abused in their early life. It may be useful to seek help such as a talking therapy if you have experienced abuse.

Some mental health problems are linked with self-harm, including emotionally unstable personality disorder, depression, bipolar disorder, schizophrenia, and drug and alcohol-use disorders. Help is available through your doctor for these conditions.

Why do people self-harm?
People often don’t know why they harm themselves at the time. But through talking to a lot of people who harm themselves, research has allowed us to begin to understand what may be happening. You may recognise some of the following reasons. Do any of these apply to you?

To manage moods or feelings

To escape from feelings of emptiness, depression or shame
To stop feeling spaced out, disconnected or unreal, sometimes called dissociation.
To relieve pent up tensions, pressure or anger.
To feel something – to know you still exist.
To feel in control.
To express or stop sexual feelings.
To forget something.
As an alternative to killing yourself.
To get a thrill or an adrenalin rush.

To fit in with beliefs or thoughts

To punish yourself because you feel you are ‘bad’.
To maintain negative belief “I’m flawed, worthless, weird”.
To escape from feelings of guilt.
To cope with the expectations of others for example regarding your sexuality or regarding arranged marriage.

To communicate

To let people know how bad things are.
To make your body show your pain.
To express anger towards others and yourself, but on your own body.
To obtain and maintain a response from others that you feel you wouldn’t otherwise get.
To punish others via your own body.
To get people to listen to you.
To feel part of a group and have an identity.

Many people who self-harm regard their behaviour as a way of surviving. It may be a means of coping with unbearable emotional pain. Their reasons for self-harm tend to be complex and may include many of those we have listed. Self-harm can be very addictive and can be a difficult pattern to change. Sadly some people do kill themselves whilst self-harming. This is most common in those who take overdoses of tablets or medicines.

Misusing medicines or tablets can be very dangerous. Even small ‘overdoses’ can kill.

In what ways do people self-harm?

People who self-harm may cut or burn themselves. They may pull out their hair, punch themselves, bite themselves, poison themselves, pluck at or scratch their skin. They may generally put themselves at risk. There are endless different ways of self-harming. It may be dramatic, hidden, or ritualistic. It may be permanently mutilating, and may seriously disfigure their body before they are able to gain control of it.

How do other people react?

Carers, friends, relatives or workers may react to self-harm in various ways. Some responses may be helpful, others less so.

Typical reactions, some helpful, many unhelpful, include:

Feelings of others:

Fear
Anger
Disgust
Panic
Worry
Distress
Guilt
Helplessness
Detachment/coldness/dislike
Confusion
Concern
Not caring
Feeling criticised
Feeling attacked
Feeling useless

Actions of others:

Setting rules and restrictions
Stepping in to “solve” the problem
Taking people to hospital
Punishing
Being extra sensitive
Offering more support
Withdrawing
Not talking about it
Talking too much about it
Stepping up observation
Looking for experts
Being over-intrusive
Threatening to withdraw or leave
Challenging you to self-harm “go ahead then, cut yourself”

Later on we will offer advice on how friends, family and workers can offer a more helpful response.

Why do people want to stop self-harming?

Many people who self-harm want to stop. These are some of the reasons that they give.

“It hurts sometimes”.
“When my wounds become infected they are really painful”.
“Trying to escape things by giving yourself scars only reminds you of the things you are trying to escape”.
“Every time you see where you self-harmed it reminds you of when you did it and makes you down again”.
“People treat you funny if you have the scars”.
“It upsets the people you are close to…”
“I can’t wear short sleeved t-shirts in the summer”.
“I can’t go on holiday to hot countries…”
“I’m thinking about the future and what my children would think of the scars…”

If you self-harm you may have your own reasons to stop.

You may find it helpful to write them down.

How can I control my self-harm?

Ask yourself the following questions.

Do I need to change my life circumstances?
If you are living in a situation that is emotionally or physically unsafe it will be difficult for you to stop self-harming. If you are in a violent or abusive atmosphere ask yourself why you are staying. Try to plan how you might change your situation. It may help to talk this over with someone else such as a friend, your GP, healthcare professional or a counsellor.
What leads me to self-harm?
Keep a diary of your self-harm to help you understand it better. Your diary could include the day of the week, what was happening, what you thought, how you felt and what you did.

For example:
On Monday John ‘put me down’ again when we were out with his mates. I thought – ‘I’m just rubbish’ and felt empty, gutted and afraid. I waited until we got home then ‘cut’ myself in the bathroom.

People often find there is a clear pattern of events that leads them to harm themselves. If you know this you can begin to try and change. Think back to the last time you self-harmed and make your own diary.

Try and keep a regular diary like this. This can be difficult and painful – it may be hard to capture your thoughts. But once you have discovered the pattern to your self-harm you can begin to try out methods to alter that pattern. Many people find that they self-harm following conflict or pain in a relationship.

Ways to stop harming yourself

This is a crisis list. These are immediate short-term solutions. Please make a note of those that you feel you might try …

Try to delay the act in any way you can. Go for a run, clean the house, go to the shops.
Find some company. Most people self-harm when alone so go to a public place, be with a good friend or a safe family member. This may prevent you from harming yourself.
Distract yourself. Flick through a magazine, try sudoku, an online or mobile phone game, tidy up.
Try the 10 minute delay tactic. Say to yourself that you will wait 10 minutes to self-harm. Try and keep busy during this time. When the time is up, think again. Can you wait another 10 minutes?
Do something for yourself. Eat something nice, pamper yourself, buy yourself something.
Do something for someone else such as your friend, child or partner.
Try relaxation and breathing exercises. Sit back comfortably in a chair or lie out on a bed. Relax all muscles in your body, beginning at the feet and working upwards. Concentrate on your breathing: breathe in for five seconds through your nose, hold your breath for five seconds, then breathe out slowly. Repeat this.
Use other strong sensations to help distract you. Try loud music, a cold shower, a fast run, squeeze something very hard, smell strong perfume, eat hot chillies.
Exercise. Jog, run, swim, cycle, dance, run up and down stairs.
Call a friend or someone you trust.
Plan something. A holiday, a walk, a night out, to do some voluntary work, to take up some study, or join a club.
Try to keep away from things you may use to harm yourself.
Shout out loud “No” or “Stop”. This helps some people to delay the self-harm.
The urge to harm yourself may come in waves, try to ‘surf the urge’, remember the strength of the urge will reduce in time, try to accept it and let it pass.
Try to be clear about what you are feeling – is the emotion you are feeling: fear, shame or guilt, anxiety, anger, rage, sadness or depression? Try and observe, label and accept the emotion. Ask yourself why you are feeling it. Remember that you are not the emotion – you don’t have to act on it.
Look at a safety plan if you have made one.

If you feel you must hurt yourself

Try less destructive ways of doing it. For example, pinching yourself or holding an ice-cube in your hand, instead of cutting.
Do not share razors or implements with other people because of the risk of HIV and hepatitis. Use clean implements.
If you are cutting yourself think of the scarring that will be left in the future. Avoid deep cuts.
Aim to reduce the number of times you self-harm and the amount of time spent.
Try not to feel too angry with yourself for having done it. Try to make some longer term plans to avoid doing it in the future. Recognise that it is a difficult pattern to break.
Learn to clean and dress cuts to avoid infection.
Remember that if you overdose you are no longer in control of what happens. Even small overdoses can kill.

Some people feel they need to keep using self-harm until they have progressed with other issues.

What longer term solutions are there?

Do I really want to stop harming myself? Make a list of reasons to continue and reasons to stop, the pros and cons of self-harming, the good things and the bad. Make sure to list all the negatives – the scars, the waste of time and energy, the risk of permanent injury and even death, etc. (listen back to the reasons other people have given).

Can I improve the way I communicate?

If you feel that self-harm is a way that you communicate emotional pain, then it may be helpful to work on communicating in other ways.

The following are important questions to ask yourself:

What do I feel like when I harm myself?
Have I ever tried to express in words how bad I feel?
If not, could I think of words to describe what I feel like?
Could I share this with anyone? (A friend, family member, therapist)
Might it help to write it down first of all?
What do I fear might be the response of those people to what I have to say?

Try to learn to describe how you feel. Try to learn to say no when you would like to. Courses and books on learning to be assertive are widely available. Try assertiveness training. Ask a friend to go with you if your confidence is very low.

Understand yourself and others

If you feel that your self-harm is often in reaction to others around you, it may help to try to increase your understanding of yourself and others. Give yourself some calm time to think in detail about your feelings, thoughts, motives, intentions, beliefs, desires and needs of yourself and others. Slowing things down and trying to see both positions can be really helpful. Try to be kind and empathetic in your understanding of yourself and others. This is sometimes called ‘mentalising’ or ‘thinking about thinking’. You can learn to do this better through a therapy called Mentalisation Based Therapy. This is usually done in a group, and may be available through your local mental health services. You can find out more through the suggestions made in the useful books and information section in the written version of this guide.

Do I blame myself for everything?

Many people who harm themselves have experienced some physical, sexual or emotional abuse in their past. Unfortunately they often feel they must take the blame for what has happened to them even if they were very young when this abuse occurred. It can help to reconsider this self-blame.

Try this approach. Imagine a friend told you a story almost identical to your own – would you blame him or her because someone else abused them? If not, then why do you continue to blame yourself for what happened to you? Try to be compassionate towards and understanding of yourself, try not to be critical of yourself. Some therapies will help you to learn to be more self-compassionate.

Am I looking after myself?

Take good care of yourself; allow yourself relaxation, pleasures, time for yourself, luxury. Don’t allow yourself to feel guilty about this. It is what you need and deserve. Are there issues from your childhood that you need to understand? If there are, try and talk them over with someone. Find a therapist who may be able to help you review this area of your life. Ask your GP or healthcare professional about this.

How can I cope with overwhelming feelings?

Try self-calming techniques. Try relaxation of the body (see the guide in this series about managing anxiety). Or ask your GP or healthcare professional about medication. Use the senses to calm yourself. Try to stay in the ‘here and now’ in your mind.

Touch – Massage yourself, especially your face and shoulders. Touch some soft fabric, such as silk or velvet. Concentrate on the feelings and learn to enjoy them.

Hearing – Listen to some soothing music. Concentrate on the sounds around you. Learn to enjoy sounds.

Vision – Look at a beautiful picture, film or object. Concentrate on it and try to enjoy the pleasure of it.

Smell – Try perfume, flower scent, or the smell of coffee. Spend some time concentrating on this.

Taste – Taste and slowly appreciate something you really enjoy.

Use your imagination – Picture pleasant scenes and feelings. Give yourself time and space to try out these things.

How can I replace some of the unhelpful things I’ve used for coping?

Make a list of things you might enjoy and build these into your day. Here are some examples:

Listening to music.
Looking round the shops.
Eating chocolate.
Going to see, or streaming, a film.
Watching sport.
Going out on a trip.
Reading a good book.
Being creative: painting, writing, cooking.
Doing nothing.
Reading the paper in peace.
Going out with friends.
Doing some sport.
Try mindfulness.
Try relaxation.

Mindfulness and relaxation classes are becoming very popular, and you may find there are classes you can attend locally. Examples of where you can download free mindfulness and relaxation exercises can be found in the written version of this guide. Mindfulness can be helpful in managing self-harm.

Make sure there are some good things happening each day and each week. Plan ahead. Build these moments into your life.

What about my relationships?

Look at the relationships you have. Nurture the good ones and end those that might be destructive.

If similar destructive relationships are happening to you again and again then try to think what goes wrong. Talk it over with someone. Try to think how you can break the cycle.

What about self help?

There are various contacts for self-help groups and organisations. The internet can also be a good source of advice but some websites may be distressing.

How can I help a friend or family member who self-harms?

It may help to:

Recognise how distressed the person is even if they don’t seem to be. Encourage their attempts to control self-harm and don’t despair or become angry if they fail to control it.
Keep an accepting attitude towards it. Try to discuss it and try to help him or her to think of ways to control it.
Get medical help if the injuries are serious.
Discuss with them the idea of seeing a therapist. The GP or healthcare professional is a good first port of call for this.
Be there for them.
Encourage the person to stay in company, where they will be less likely to harm themselves.
Seek support yourself if the problem continues.
Offer practical help (e.g. look after children, go shopping with the person etc.).
Give them time and talk on their terms.

Where can I get further help?

We hope the information in this guide will be useful to you in beginning to understand self-harm. There are other guides in this series which may be helpful, including advice on coping with anxiety, depression, abuse and other mental health issues.

The internet can be a source of help but please use with caution as some of the content may be distressing. In addition, some websites can be extremely unhelpful, encouraging self-harm and suicidal behaviour.

It may also be helpful for you to seek further support, particularly if you are feeling anxious and/ or depressed. Your GP or healthcare professional may be the best person to talk to first. They may refer you on to local mental health services, where you should be offered a talking therapy.

Talking therapies recommended by National Institute for Health and Care Excellence (NICE) include therapy tailored to each individual which includes cognitive-behavioural, psychodynamic or problem-solving approaches. Other approaches that have been shown to be useful include dialectical behaviour therapy and compassion focussed therapy.

It is important to remember that if you seek NHS help for self-harm, the National Institute for Health and Care Excellence states that you can expect to be treated with compassion, respect and dignity. Please do not hesitate to get help if needed.

A list of useful contacts, books and references are available in the written version of this guide.

Written by Dr Lesley Maunder and Lorna Cameron, Consultant Clinical Psychologists.

Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust has developed this resource with the support of NHS healthcare staff, service users and local voluntary sector groups.