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Introduction

The purpose of this study was to explore the links between non-suicidal self-harm and attempted suicide in young people, and in so doing, to identify possible ways of reducing the risk of suicide among young people who self-harm.

Methods

The research involved one-to-one depth interviews with 20 young people aged 14-25 from across Scotland who had experience of both self-harm and attempted suicide.

'Self-harm' is defined here as an act of self-injury or self-poisoning which is not intended to result in death. Self-harm is therefore distinct from 'attempted suicide', an act of self-injury or self-poisoning which is intended to result in death. It is important to note, however, that the actual behaviours that constituted self-harm were defined by the young people themselves, not by the researcher.

Interviews took place between April and October 2006. The sample included 8 young men and 12 young women.

About the young people in this study

The young people who took part in this study were a diverse group with a wide range of backgrounds and experiences. Their lives were complex and sometimes chaotic. Despite the differences between them, there were also some striking similarities.

Among these young people, the mean age at which self-harming began was 12.5 (median 12.0). The mean age of first suicide attempt was 16.2 (median 17.0). Two individuals first attempted suicide at the same age at which they began self-harming and four only began self-harming after their first suicide attempt. All spoke of suicidal impulses over many years which had not been acted on.

Multiple life difficulties and serious family problems, in some cases involving physical and/or sexual abuse and neglect were common among this group. All grew up in families that were under pressure in some way.

Young people's experiences of self-harm and attempted suicide

When asked what form their self-harm took, young people gave details of a large range of methods. These included self-cutting, self-battery, overdosing, burning, pulling hair, drug and/or alcohol misuse and forms of eating disorder. Overdosing was the most common method of attempting suicide among both sexes.

In describing the circumstances in their lives that first prompted them to self-harm, three things were mentioned, often in combination: (i) being bullied or ostracised at school; (ii) being abused or neglected at home; and (iii) having a serious argument with parents or friends.

Young people also explained their reasons for starting to self-harm in terms of how they felt at the time - i.e., because they felt lonely, isolated, depressed, out of control, frustrated, stressed and/or worthless.

When asked about the circumstances that prompted their suicide attempt(s), some individuals described specific events. However, it was more common for the suicide attempt to be the culmination of a long period of feeling depressed, isolated, stressed and exhausted. In general, young people did not tell anyone they were thinking of killing themselves. However, it was not unusual for young people to "change their minds" following an attempted suicide by overdose, and to phone someone for help.

The links between self-harm and attempted suicide

In general, young people made a very clear distinction between their self-harm and the times when they had attempted suicide. This was the case even if they used the same methods for both self-harm and attempted suicide.

However, there was disagreement about whether self-harm and attempted suicide were linked, or completely different. Those who saw them as linked tended to see self-harm on a continuum with suicide at one end. Those who saw them as different felt they were different simply because the individual's intention was different. For those in this group, suicide became an option when self-harm "didn't work" or when they no longer got any satisfaction from it.

Young people said that their self-harming often changed in significant ways just before a suicide attempt. Some said it became more frequent. Others said it stopped altogether, usually because "it wasn't working anymore." It was also common for young people to say that they stopped self-harming for a period of time immediately after a suicide attempt.

Discussion and implications

In general, young people who self-harm see self-harm and attempted suicide as two different things. However, the findings of this study suggest that they are linked.

Self-harm is a symptom of something wrong. The 'something wrong' may relate to the young person's external circumstances, but more importantly, it is an outward manifestation of the young person's internal response to their circumstances. This internal response may include self-hatred, rage, depression, severe anxiety and despair. All of the young people in this study had had suicidal feelings over a long period of time. Many said that it was their self-harming that kept them alive. However, when life became too difficult to deal with, and self-harm no longer seemed to work, then suicide became an option.

The findings of this study have implications for services, policy and public health.

Young people who self-harm and who are at risk of suicide may be in contact with a wide range of services, including schools, colleges and universities, housing and homelessness services, employability services, addiction services, social work services and prisons. Awareness of the issue of self-harm should be raised among staff in these services.

On average, young people attempted suicide 4-5 years after they began self-harming. This 4-5 year period provides a crucial window of opportunity to intervene to prevent suicide.

For young people who self-harm and who are thinking of suicide, asking for help is extremely difficult. Increasingly serious episodes of self-harm and repeated overdoses may be an attempt by the young person to seek help. NHS services need to be aware of this and not dismiss these young people as "attention-seeking." Negative and judgemental responses by professionals only reinforce the individual's beliefs that no one cares about them.

Young people felt that having someone to talk to, whom they could trust, and who truly listened was one of the things that helped them most. At the same time, young people have to be given help in ways that feel comfortable to them. Drop-in services, self-harm support groups and one-to-one sessions with a trusted project worker or CPN were seen as particularly helpful ways of meeting young people's needs.

As part of its focus on improving intervention with people at risk of self-harm or suicide, Scotland's Mental Health Delivery Plan has made a commitment to train 50% of key frontline healthcare professionals in using suicide assessment tools/suicide prevention programmes by 2010. However, in terms of self-harm, the focus of this commitment is on "people whose self-harming behaviour puts them at high risk of suicide". The findings of this research suggest that all people who self-harm may be, or may become, at risk of suicide. Therefore, professionals need to know how to intervene appropriately in all cases of self-harm, irrespective of the person's assessed risk.

In relation to this, the evaluation of the first phase of Choose Life recommended that NICE guidelines on the treatment of self-harm should be adopted in Scotland. This recommendation has been agreed by the Scottish Government.

The findings of this study suggest a need for further research on the links between self-harm and suicide in young men. If these young men are in contact with services at all, they are likely to be found in drug/alcohol treatment services, housing and homelessness services and criminal justice services, rather than in services targeted at young people who self-harm.

Further details from:

d.griesbach@griesbach-research.co.uk

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