Supporting people who are self-harming

This protocol is a draft. It has not yet been accepted as protocol and may be incorrect or poorly cited. Please do not use this in your work until it has been accepted.

Please see #protocols on Slack to discuss this protocol further.

This page discusses situations where a person is causing themself physical injury in connection with mental distress. It can be used alongside the general Mental Health Intervention Protocol.

It is important to recognise that people may use self-injury for a range of different reasons. Some possible motivations may 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

However, this is not an exhaustive list and you should treat each person’s situation as unique. Even if you have previously supported a person around self-injury, they may have different reasons for doing it on different occasions.

You may also need to consider whether the person is experiencing a different reality from you. They may be experiencing distress related to this, or may be injuring themself in direct response to what they perceive (for example, if they see a part of their body as contaminated.) See ‘Supporting people perceiving a different reality' for more on this topic.

However, if you know that a person self-injures and that they perceive different realities, you should not assume that they are self-injuring because they are perceiving a different reality. For many people, this may be unrelated to their self-injury.

How to support someone who is self-injuring

When discussing the topic, try to remain calm and non-judgmental. Make it clear that you are willing to talk about the self-injury, but do not push the person to do so. Remember that people may have experienced hostile, punitive or coercive responses from others, and may be wary that you will react in a similar way.

It is vital that you act with the person’s consent and that you do not make assumptions about their priorities and goals. Don't assume that everyone who self-injures sees it as their main problem, or that they want to stop. If the person is more interested in receiving support with their underlying difficulties, you should not focus on the self-injury at the expense of this.

You should not try to stop someone from injuring themself 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-injure.

This would contradict the principle of respect for a person’s agency. 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-injure. Feelings of shame, or feelings of lacking control, are both common triggers for self-injury; both of these emotions are likely to be exacerbated if you try to stop the self-injury.
• If they self-injure, 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.
• Even if you do prevent the person from injuring themself, you will have deprived them of a coping mechanism for emotional pain, without relieving the distress itself.

Some people will have experienced coercive or punitive treatment from the mental health system in connection with their self-injury. For example, people may have been excluded from therapy after self-injuring, may have been incarcerated or physically restrained, or may have 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-injury upsetting, you should always consider the risk to 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.

If you are offering ongoing support to someone who self-injures, it can be useful to discuss it at a time when they are not in crisis, to clarify what they find helpful or unhelpful. The following sections cover some different issues which may be relevant to these discussions.

Supporting someone to self-injure more safely

If the person is hurting themself in a way which risks serious injury or long-term damage, you should consider discussing with them whether they would be willing to take steps to reduce this risk. This does not mean that the person must stop injuring themself, but they may be able to find safer ways of doing so.

In addition to reducing the risk of unintended harm, this may also provide a form of emotional support. Many people experience feelings of shame around self-injury, particularly if they have previously encountered negative reactions from others. This can act as a barrier to seeking support with any underlying emotional distress. It may also create a vicious circle where this shame itself becomes a trigger for self-injury.

Practical discussions of safety techniques can help to reduce the shame attached to the topic, by creating a space for the person to talk openly about the specifics of their self-injury and receive non-judgmental support. Similarly, if the person has previously met with coercive or punitive responses, it can help to build trust by demonstrating that you will not react in this way, even when you learn the full details.

It is therefore important that you only pursue these conversations if you feel able to discuss the person's injuries without appearing shocked or disgusted. If you find this difficult, you could share safety resources, such as our Safer self-injury guide.

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 the risks of infection, you may therefore also reduce their emotional distress, even when you are not directly attempting to do so.

However, you should not assume that everyone who self-injures is in need of safety advice. Remember that many people who self-injure 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 not make assumptions about people's levels of prior knowledge.

Safer self-injury principles

Some basic points of harm reduction include:

• 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-injury resource for more detailed advice on how to reduce the risks attached to different kinds of injury.

Safer self-injury 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. 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-injure 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-injury 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-injury, rather than a form of self-injury. Many people who self-injure will therefore already be familiar with these suggestions, and may have negative experiences around being pressured to adopt them.

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 these methods helpful. However, you should not present these techniques as 'better' or assume that everyone will want to prevent scarring. Some people may feel that the scars are an important element of their self-injury.

Supporting someone to avoid or delay self-injury

If the person does request support to avoid or delay self-injury, you should 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-injury, 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 is 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 can suggest ideas, but remember that different strategies will work for different people. For example, you could:

Offer 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.

If the person wants to try this, you could offer to provide a distraction yourself at the time of crisis, or 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 kind of distraction would be most useful, you could offer to help them identify some possible options by talking through the specific emotions/sensations which accompany their desire to self-harm.

Offer to talk

Some people may find it helpful to talk about 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 the active listening resource for more discussion of this.

If you aren't able to do this, 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

Discuss triggers

If the person can identify any particular factors which may trigger them to self-injure, you could help them make plans for how to deal with these. You may wish to use ‘In/Out’, ‘Stressors’ and ‘Environment' as a starting point for discussion.

If they are self-injuring regularly, they might find it helpful to keep a diary of incidents as a way of identifying potential triggers.

Remove 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-injury altogether, or they might aim to reduce the frequency by making it harder to self-injure 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.