View source for Supporting people who are self-harming

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This page discusses situations where a person is causing themselves '''physical 'harm' in connection with mental/emotional distress'''. 
Not everyone sees this behaviour as inherently harmful, but we have '''used the term 'self-harm'''' because this label is widely used among people with lived experience. In many situations 'self-injury' may be more precise, but it may also be perceived as more clinical. The term '''self-harm''' encompasses self-injury, along with other actions viewed as physically 'harmful' (such as changes in eating habits or substance use).
You should '''take your lead on what language to use from the person you are supporting''' - whether this is self-harm, self-injury, or labels that '''focus on the particular action''' (for example, 'cutting').
This guide should be used alongside the general [[Mental Health Intervention Protocol]].
== Discussing self-harm ==
It’s important to '''understand the person’s attitudes and priorities''' around their self-harm before you try to offer any other support. Different people may self-harm for different reasons, and may have very different perspectives on their actions, so there is '''no response which will be equally helpful to everyone'''. Creating a space for non-judgemental discussion of self-harm can also be a valuable '''form of support in its own right''', by helping to reduce the shame which some people may feel about the topic.
The [[Active listening resource|active listening resource]] sets out some approaches which may help you to get a better understanding of where the person is coming from, and which section of this page is most relevant to their needs.
However, you '''should not push people into discussing their self-harm''' when they are unwilling to do so. Remember that some people may have encountered hostile, coercive or punitive responses from others, and may be wary that you will react in a similar way. Others may simply not consider the topic a priority.
When you are communicating about self-harm, it’s also important to '''consider your own boundaries and needs'''. If you would find a conversation distressing or shocking, you may need to help the person find alternative sources of support, while emphasising that you are not judging them or their behaviour. If you force yourself to have the conversation, then react negatively, this is likely to be more upsetting for the person than if you excuse yourself from the discussion altogether.
=== Discussing Motivations ===
When you discuss the topic, you should be aware that people may use self-harm for a '''range of different reasons'''. Some (out of many) possible motivations include:
* to '''distract''' from other distress
* to '''release anxiety'''
* to '''self-punish'''
* to gain a sense of '''control'''
* to relieve '''dissociation'''
* to make '''emotional pain visible'''
'''This is by no means a complete list''' and you should '''treat each person’s situation as unique'''. Even if you have previously supported a person around self-harm, they may have '''different reasons for doing it on other occasions''', and may need a different kind of support. 
For some people, self-harm is a signal that they are experiencing '''crisis''', whilst for others it is a common coping strategy and doesn't signal overwhelming distress. It is therefore essential that you '''don't make assumptions''' and that you '''take your lead from how the person you're supporting describes their experiences'''.
You may also need to consider whether the person '''experiences a different reality from you'''. They may self-harm as a way of dealing with distress related to this, or may be injuring themselves in direct response to what they perceive (for example, if they see their skin as contaminated.)  See ‘[[Supporting people perceiving a different reality to you protocol|Supporting people perceiving a different reality]]' for more on this topic. 
However, if you know that a person self-harms and that they perceive different realities, '''you should not assume that they are self-harming ''because'' they perceive different realities'''. For many people, this may be unrelated to their self-harm.
It can be helpful to talk with people about their '''motivations''' for self-harm, in order to get a better understanding of what the action means to them. However, you should take care that this '''does not come across as a demand for them to justify their behaviour'''. For example, a question like 'Why do you do it?' may feel judgemental or intrusive. Instead, it is often better to use [[Active listening resource|active listening]] skills and ask questions such as:
* Would you like to talk about why you find self-harm helpful?
* What does self-harm mean to you?
* If you could describe in words, sounds, images or emojis what this is like for you, what would you say?
Be mindful that some people may not want to have detailed conversations about their reasons for self-harming, and may prefer to focus on the more practical forms of support discussed below.
=== Discussing Attitudes ===
People’s '''feelings about their self-harm''' vary hugely. Some people feel intensely distressed by the fact that they self-harm, while others do not see it as a problem. Some people may view their self-harm as an sign of how severe their emotional pain is, and want you to recognise its significance. Others may see it as a useful coping mechanism, and prefer a matter-of-fact response. 
People may also have experienced a wide range of '''unhelpful responses from others''', including mental health professionals, which may influence how they feel about discussing it with you. For example, some people may feel that their self-harm has been overemphasised at the expense of other issues which are more important to them. Others, particularly people psychiatrised with certain diagnoses, may have had their self-harm treated dismissively because it is perceived as 'attention-seeking'.
It’s therefore essential that you [[Active listening resource|actively listen]] to get an understanding of '''what self-harm means to the individual person'''. Your response should aim to match their emotional needs.
=== Discussing Support Needs ===
If you are offering ongoing support to someone who self-harms, it’s useful to '''discuss it at a time when they are not in crisis''', to clarify what they find helpful or unhelpful. What people need and how they feel about self-harm often '''vary over time''', so you should check in with the person at different points to see if their views have changed. Even if one approach worked for them in the past, you should not force it on them if they no longer find it helpful.
In these discussions, you should '''avoid making assumptions about the person's priorities and goals'''. Don't assume that everyone who self-harms sees it as their main problem, or that they want to stop. Some people may want support with stopping, but others may see it as a vital coping mechanism, and prefer to focus on reducing the risks attached to their self-harm. Other people may not wish to focus on their self-harm at all, but may want support with the underlying difficulties for which the self-harm is a coping mechanism. 
'''‘Supporting someone to self-harm more safely’''' and '''‘Supporting someone to avoid or delay self-harming’''', below, suggest some possible forms of support you could offer, depending on the outcome of this conversation.
== Self-harm and Coercion ==
In QueerCare, we believe that '''you should not try to stop someone from injuring themselves unless they have asked you to do this.''' For example, you should not take tools away without their consent, or threaten them with negative consequences if they self-harm. 
This would contradict our key principle of '''working with the person, not holding power over them'''. It is also likely to be harmful and counterproductive for other reasons:
* They are likely to '''lose trust''' in you as a source of support for other difficulties.
* It may '''increase their emotional distress''' and therefore '''increase, rather than decrease, their desire to self-harm'''. Feelings of shame, or feelings of lacking control, are both common triggers for self-harm; both of these emotions are likely to be exacerbated if you try to stop the person from doing it.{{cite|'Holly et al, 'Self-injury and harm minimisation on acute wards, Nursing Standard 26,38; Accessed: 2020-09-17|external|https://journals.rcni.com/doi/abs/10.7748/ns2012.05.26.38.51.c9113}}  
* If they do self-harm, they may feel pressured to conceal this, making them '''more likely to use dangerous improvised tools''', '''less likely to clean their tools''' before use, and '''less likely to seek medical help''' with injuries.  
* Many people use self-harm as a way of coping with distress. Even if you prevent the person from injuring themself, you will have '''deprived them of a coping mechanism''', without relieving the distress itself. 
Some people will have '''experienced coercion or punishment from the mental health system''' in connection with their self-harm. For example, people may have been excluded from therapy after self-harming, been incarcerated, been physically restrained, or been denied anaesthetic while their injuries were being treated. It is essential that any support you offer '''does not add to the person's trauma by replicating these  dynamics'''. 
If you find the self-harm upsetting, you are always entitled to '''consider your own mental health''' when deciding whether you are able to offer support. However, it's important to make clear that this is a boundary you are setting for your own wellbeing, '''not a punishment or an ultimatum'''.
There may occasionally be a risk that the person will feel you 'don't care enough to stop them' if you do ''not'' use coercive methods. If someone sees self-harm as a way of communicating their emotional distress, they '''might perceive acceptance of their self-harm as an acceptance of their distress.''' If they see it as self-punishment, they might feel that they are not entitled to stop unless someone else insists on this. As always, it’s important to listen carefully when the person talks about their self-harm, and to respond in ways that address their emotional needs. If they seem to view it as a marker of how intense their distress is, your response should make sure to validate their emotional pain, and emphasise that they deserve support with this.
The next section discusses some possibilities for '''offering support if you are concerned about the person’s safety, without preventing the self-harm altogether.'''
== Supporting someone to self-harm more safely ==
If the person is hurting themself in a way which '''risks serious injury or long-term damage''', you should try to discuss whether they would be willing to take any '''steps to reduce this risk.''' This does not mean that the person must stop injuring themself; it means that you could work with them to find safer ways of doing so.
In addition to reducing the risk of serious harm, this may also provide a '''form of emotional support.''' 
* Many people experience '''feelings of shame''' around self-harm, particularly if they have previously encountered negative reactions from others. This can act as a '''barrier to seeking support with any underlying emotional distress'''. For some people, it may also create a vicious circle where this '''shame itself becomes a trigger for self-harm.''' Practical, nonjudgemental discussions of safety techniques can help to '''reduce the shame''' attached to the topic.{{cite|Louise Pembroke, 'Harm minimisation: limiting the damage of self-injury'; Accessed: 2020-09-17|external|http://www.dbdouble.freeuk.com/harmminimum.htm}} 
* If the person has previously met with coercion or punishment, it can also help to '''build trust''' by demonstrating that you will not react in this way, even when you learn the full details. 
* The act of carrying out harm reduction techniques can also function as '''a source of emotional reassurance''' in its own right. Steps such as cleaning the tools beforehand, or dressing the injuries afterwards, may '''help the person to feel that they are deserving of care''', even when they are experiencing the desire to hurt themself. 
If you support a person to reduce risks such as infection, you may therefore also help to reduce their emotional distress, even when you are not directly trying to do so.
Before you bring up this topic, it's important to consider whether you are able to '''discuss the person's injuries without appearing shocked or disgusted'''. If you find this difficult, you could still '''share safety resources''', such as our [[Safer self-harm resource|Safer self-harm]] guide and [[First aid for self-harm resource|first aid resource]].
However, you '''should not assume that everyone who self-harms is in need of safety advice.''' Remember that many people who self-harm are already well informed about these issues and experienced in practicing harm reduction. It may still be helpful to raise the topic, as a way of communicating non-judgmental support, but you should avoid making assumptions about people's levels of prior knowledge.
=== Safer self-harm guidance ===
Some key points of harm reduction include:{{cite|National Self-Harm Network, 'Cutting the Risk'; Accessed: 2020-09-17|external|http://www.arwtraining.com/wp-content/uploads/2015/02/02-Cutting-the-Risk-Practical-Harm-Minimisation.pd}} 
* Focus on '''fleshier parts of the body''', e.g. the outer arm is safer than the wrist
* Avoid the '''neck, wrist, groin, and joints'''
* Try to '''go slowly''', and look at what you are doing
* Use '''new or sterilised''' tools
See the [[Safer self-harm resource]] for more detailed advice on how to reduce the risks attached to different kinds of injury, and the [[First aid for self-harm resource]] for guidance on how to treat injuries and identify danger signs.
=== Safer self-harm materials ===
If the person does not have access to appropriate '''first aid supplies''' for their injuries, you should try to help them to acquire these.
If they are cutting themself with dangerous tools (e.g. non-sterile blades, or ones with jagged edges), you should also try to discuss whether they could '''acquire safer implements,''' or [[Safer self-harm resource|clean the ones which they are using]]. Sterile blades are widely available online from websites such as Medisave. If the person would have difficulty with this - for example, if they are worried about keeping a delivery private from housemates -  you may wish to help them access safer tools.
=== Safety check-ins ===
It might also be useful to consider whether you could offer a '''safety check-in'''. If the person is planning to self-harm and knows that they may be tempted to cause themself serious harm, they could '''message or call you beforehand, and again immediately afterwards''', to confirm that they are safe. You should have a clear agreement with them about the circumstances in which you would call an ambulance if you don’t hear from them afterwards.
=== Safer self-harm and 'substitution techniques'  ===
Mental health professionals often encourage people to adopt techniques which create a '''painful sensation without breaking the skin or leaving long-lasting marks'''. Common suggestions include 
* squeezing ice cubes
* snapping an elastic band against your wrist.
However, these actions are usually framed as a means of preventing forms of self-injury (e.g. cutting or burning) which are perceived as less acceptable. Although they still cause pain, they are often presented as being an 'alternative' to self-harm, rather than a form of self-harm. Many people who self-harm will therefore already be familiar with these suggestions, and may have negative experiences around being pressured to adopt them even when they are unhelpful.
Other substitution techniques aim to '''create the appearance of injuries''', rather than the sensation. Common suggestions include
* using red ink or paint on the place you want to injure
If the person you are supporting wants to avoid permanent marks, or wants to remove any risk of infection, you can '''discuss whether they find any of these methods helpful''', or whether they have any other ideas for a safer alternative method. However, you should not present these techniques as 'better' or assume that everyone will want to prevent scarring. It's important to remember that many people will not find these substitutes adequate, and may even find that they increase the desire to carry out other kinds of self-injury.{{cite|Wadman et al, 'These Things Don't Work, Archives of Suicide Research 3,24'; Accessed: 2020-09-17|external|https://www.tandfonline.com/doi/full/10.1080/13811118.2019.1624669?}}
In any discussion of alternative techniques, you should also be aware that '''different people will have different goals''' when they injure themself. Some people’s main motivation may be to feel pain, but others may find it more important to see blood, or may feel that scars are an important element of their self-harm. If you are helping someone to plan a safer replacement method, it can be useful to start by identifying '''which aspects of their current self-injury method''' are most important to them, so that they can choose the technique which comes closest to matching this.
== Supporting someone to avoid or delay self-harm ==
If the person wants support to avoid or delay self-harm, you should try to '''discuss in advance''' what form of support they would find most helpful.
Remember that a person’s goal may be to '''reduce the frequency of their self-harm''', or to '''reduce the severity''', rather than to stop completely. If they ask you for support in dealing with urges to self-harm, '''don't assume that they have decided to stop altogether'''. 
It's important to be '''clear about what you can and can’t do''', and to consider the risk to your own mental wellbeing.  If you don’t feel able to interact with the person when they are in crisis, you can  help them to '''make plans''' in advance. You could also discuss whether they have '''other people in their networks''' who might be able to help in different ways.
You can '''suggest ideas''', but keep in mind that one strategy will not work for everyone. Even if a person has found a technique helpful before, it may not work for them every time. Some possibilities include:
=== Offering distractions ===
Some people find it useful to '''delay for a short time''' (for example, 5 minutes) when they feel the need to self-harm. This might be because they are waiting to see if the urge passes, or it might be because they want to be in a calmer state of mind so that they can control the level of damage. Having something to distract their attention at this point may make it easier for them to hold off.
If the person wants to try this, you could '''offer to provide a distraction''' yourself at the point of crisis. Some people might find it helpful to have a '''pre-agreed signal''' to indicate that they need this (for example, sending a blank message or a particular emoji), so that they don't have to discuss it at the time.
If you won't be able to do this, you could '''help them to plan distracting activities''' in advance. Some people may prefer distractions which focus their thoughts on a different topic, such as doing a puzzle or playing a game on their phone. Others may find distracting physical sensations more helpful - for example, taking a warm or cold shower. If the person isn’t sure what would be most useful, you could help to identify some possible options by talking through the specific emotions/sensations which accompany their desire to self-harm.
=== Offering to talk ===
Some people may find it helpful to '''share their feelings''' when they are in crisis. If you feel able, you could offer to sit with them in person, talk on the phone, or message. See our [[active listening resource]] for more on this. 
If you aren't able to offer support in a crisis, you could discuss other possible ways of processing their emotions, such as:
* Identifying negative thoughts which they frequently experience, and planning responses or affirmations.
* Writing in a journal, and discussing this with someone at a later date if needed.
You could also discuss whether they would be able to talk to anyone else, and help them to make plans around how to raise the topic with others. Even if they don't feel able to mention the self-harm, it may still be worth considering whether they can access any other sources of support for emotional distress.
=== Discussing triggers ===
If the person can identify any particular '''factors which may trigger them to self-harm''', you could help them make plans for how to deal with these. You may wish to use [[Mental Health Intervention Protocol#In_and_Out|‘In/Out’, ‘Stressors’ and ‘Environment']] as a starting point for discussion.
If they are self-harming regularly, they might find it helpful to keep a diary of incidents as a way of identifying potential triggers.
=== Removing tools ===
In some cases, the person might find it helpful if you are able to keep their self-injury tools in a safe place. Their goal might be to avoid self-harm altogether, or they might aim to reduce the frequency by making it harder to self-harm impulsively. You should be clear on '''how the person would like you to respond if they ask you to hand over the tools''' - do they expect you to refuse, or to comply? Either way, you should not take on this role unless you feel able to act according to their wishes.
If you are not able to store their tools yourself, you could help them to '''plan other ways of delaying their ability to access implements'''. For example, they could keep the tools in a place which can only be accessed by a ladder, or freeze them inside a block of ice.