Self harm strategy and action plan 2023 to 2027

Our Understanding of Self-Harm

Definition and Interpretation

Self-harm is defined by the National Institute for Health and Care Excellence (NICE) in their most recent guidelines (2022) as intentional self-poisoning or injury, irrespective of the apparent purpose. This definition which is widely accepted, both clinically and academically, is what we are using as our working definition.

Our interpretation is that injury includes both physical and psychological injury and would include any behaviour that serves a function of self-harm and adversely affects a person’s psychological or physical health. Our starting point for this strategy is that compassionate support should be available to anyone affected by self-harm, however they themselves define it.

It is also important that this strategy links to other policies that work to address obvious health harming behaviours such as eating disorders, smoking, alcohol use, substance use, risky sexual behaviours, violence and gambling. While many may not consider these forms of self-harm, they often have similar drivers and functions for people, and we will work collaboratively to share learning and good and emerging practice that supports recovery.

Functions of Self-Harm

Self-harm is not a mental health condition or illness but a range of behaviours that can be an indicator of poorer mental health and wellbeing or can sometimes occur as a result of mental illness or learning disability. Self-harm is complex and varies widely from individual to individual. It can serve a variety of functions, including but not limited to:

• Coping with or distracting from distressing emotions or circumstances, including traumatic or adverse experiences
• Regulating emotions, providing release, comfort or restoring calm. For some people providing care to oneself following self-harm can be helpful (and can be a way to protect against suicide)
• Communicating feelings that are difficult to articulate or have not been listened to
• Gaining control or agency over one’s body, feelings or circumstances
• A compulsion or habitual behaviour
• A form of self–punishment or cleansing, sometimes linked to feelings of shame, guilt or low self- esteem
• A way to feel real, present, alive or escape dissociation

“When I was 16 my relationship at the time broke down... It was after this that I started to self-harm due to the immediate relief it gave me from the overwhelming emotions I was feeling. It became my coping strategy” - Supported Person, Self-Harm Network Scotland

“For some people, it is about coping and not necessarily about wanting to kill themselves” - Youth Advisory Group Member

Prevalence and Risk Factors

We know that self-harm can affect anyone, from any background, any gender and at any age. The most recent Scottish Health Survey reported that 25% of 16-24 year olds and 10% of adults said they had ever self-harmed. Data also suggests self-harm rates are rising.^[3] However, the evidence also suggests that with the right care and support most people can and do stop self-harming^[4].

The available evidence, including robust qualitative evidence, also highlights further important aspects of prevalence. For example, self-harm appears to be most prevalent among young women,^[5] with girls over 3 times more likely to report self-harm than boys.^[6] Marginalised people are also at increased risk, this includes neurodiverse people^[7], LGBT+ people^[8], people who are care experienced^[9], those involved in the justice system^[10], and people experiencing severe and enduring mental illness.^[11]

In addition, we understand that there can be higher rates of self-harm among people who have experienced childhood adversity or trauma.^[12] Furthermore, people who are affected by a range of ‘social determinants’ for poorer mental health also have a higher prevalence of self-harm. Evidence shows that socioeconomic status can be a factor.^[13] For example, people living in the most deprived areas have a higher prevalence of self-harm (17%) compared to those living in the least deprived areas (4%).^[14] Additionally, life events particularly those that can lead to stress and worry can increase the risk of self-harm, for example relationship breakdown, having a baby or bereavement.

Within each of these higher risk groups there will be people who experience stigma or discrimination and many who face additional barriers to accessing support. For example, language barriers, fear of re-traumatisation or structural barriers such as lack of access to health care or financial resources. In light of this, we will take steps to ensure that our approach focuses on reaching and meeting the needs of groups that evidence identifies as being at higher risk and we will always look for opportunities to address inequalities.

Finally, we recognise that if we only focus on groups with highest prevalence, or who engage in the most common self-harming behaviours, we may miss other people who need help. This could have implications for people who feel they do not ‘fit’ society’s expectations of someone who self-harms in terms of them being understood, accessing support, and navigating services. Therefore, this strategy and action plan is for anyone affected by self-harm.

Prevention of Self-Harm

As already highlighted, this strategy sits alongside The Mental Health and Wellbeing Strategy and Delivery Plan which has a strong focus on preventing the underlying drivers of poor mental health and wellbeing that can increase the risk of self-harm. However, our engagement has shown that the word ‘prevention’ in relation to self-harm can inhibit people from seeking help, especially if they fear they will be told to immediately stop self-harming.

This is because many people use self- harm as a way to cope. Taking away the means to cope without first offering support to develop other ways to manage, can be detrimental. We will take a careful, evidence-based, person-centred and trauma-informed approach within our actions, which will focus on helping people to find safer ways to manage their distress, over time, and with the right support.

“It’s not a helpful response to be told, ‘Just stop!’” - Youth Advisory Group Member

“Before I reached out I was quite nervous and anxious. I didn’t know what to expect... I thought that I would be told that I have to stop self-harming, that I’d have to throw away my materials and I didn’t want that” - Supported Person at Self-Harm Network Scotland

We acknowledge there could be a concern that describing self-harm as ‘a way to manage distress’ could inadvertently encourage or normalise the use of self-harm, especially among children and young people. We will continue to support children and young people to develop good mental health and learn healthy ways to manage difficult emotions. We will also continue to be guided by evidence about prevention and early intervention as it evolves, seeking to support everyone to achieve the highest level of mental health and wellbeing possible.

We also recognise that the data and evidence around prevalence and incidents of self-harm is complex and evolving. More behaviours being recognised as self-harm and work to encourage help-seeking could result in an increase in disclosure of self-harm in the short-term. However, as work progresses we would hope to see a reduction in self-harm over time.

Self-Harm and Suicide

We know self-harm can be a risk factor for suicide and this is why this strategy and action plan is aligned with our work on suicide prevention^[15]. For some people the line between a suicide attempt and an act of self-harm is blurred. Some people may not be sure of the outcome they intend, have resigned themselves to ‘what will be will be’, or their desired outcome may change either over time or even within a single episode. However, for many people, self-harm is a way to manage difficult emotions and circumstances and they do not have suicidal intent. This strategy will maintain strong links with suicide prevention policy and practice, through the implementation of joint work where that benefits those who self-harm as well as people who are affected by suicidality. Our joined up approach will ensure that where someone’s self-harm indicates they may be at elevated risk of suicide, the right support is available to keep people safe.

Stigma and Discrimination

The engagement around this strategy suggests that self-harm is highly stigmatised and people who self-harm may face discrimination. Many people report being aware of stigmatising narratives around self-harm such as it being ‘manipulative’, or ‘attention seeking.’ This can lead to self-stigma and feelings of isolation and shame, which can limit attempts to seek support. People who have self-harmed have told us that they hid their self-harm because they felt shame and feared what others might say or do.

“Having short sleeves with exposed self-harm scars on my arm, means the whole train carriage will be looking at me and whispering to who they’re with.”^[16]

While we have heard examples of empathetic and compassionate responses, we have also heard responses can be unhelpful, judgemental or even punitive, which can often lead to people not reaching out in future. Stigma can also have an increased impact on those who are marginalised, have experienced trauma and those living in small or rural communities, all of which can increase barriers to accessing support.^[17]

Furthermore, our understanding is that the higher prevalence of self-harm in marginalised communities (such as LGBT+ or neurodiverse communities) is usually not related to specific characteristics but is a response to the misunderstanding, stigma, prejudice, discrimination and abuse marginalised people experience within society.^[18] This is known as ‘Minority Stress^[19]’. This nuance can sometimes be missed when people are seeking support and can then exacerbate that person’s feelings of isolation and stigmatisation. We also recognise that data and evidence is limited about people who are marginalised in a number of ways, or who are coping with a range of difficult circumstances. We will therefore continue to build our understanding of self-harm in different communities, particularly when people are experiencing multiple inequalities.

Embedding Equality and Inclusion in our Approach

We are determined that this programme of work properly reaches and meets the needs of marginalised groups and adopts an inclusive approach for everyone affected by self-harm, focusing on groups we know are at higher risk. This approach has been informed by working closely with people with lived experience who have helped us to understand the barriers they face in accessing help and with partners who advocate for marginalised communities, as well as reviewing evidence (which is set out in our Equality Impact Assessment). We are aware of a significant gap in data and evidence regarding people from racialised communities and we will work to address this as part of our action plan.

As we implement the action plan, supported by the continued involvement of people with lived experience from diverse and varied backgrounds, we will embed equality, diversity and inclusion across our approach. We will work with partners to ensure that people and services who are supporting someone who has self-harmed can do so compassionately and in a way that is inclusive, accessible, and rooted in good and emerging practice and evidence.