Risk Factors and High-risk Populations
Risk Factors and High-risk Populations
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Common risk factors for self-harm include being female, from more deprived areas, having restricted educational achievement, mental disorders, alcohol or substance misuse, a family history or peer group who self-harm, stressful life events, including Adverse Childhood Experiences (ACEs), and stigma associated with poor help-seeking behaviour.
Alcohol is involved in nearly 60% of episodes of self-harm that present to the emergency department. Over a third of people who self-harm misuse alcohol or are alcohol dependant (Ness et al, 2015).
Whilst suicide and self-harm are not exclusively limited to specific groups, it is important to note there are groups of people particularly vulnerable to self-harm. Many individuals fall into more than one of these groups.
Whilst suicide and self-harm are not exclusively limited to specific groups, it is important to note there are groups of people particularly vulnerable to self-harm. Many individuals fall into more than one of these groups.
Select the image for a complete list of these groups.
The most commonly affected group are those with mental health problems. 15-20% of people with serious mental health problems die by suicide
Care leavers
Bullied or victimised, and to a lesser extent perpetrators
Survivors of abuse, neglect or violence including sexual abuse and domestic violence
People living with long-term physical health conditions or physical and/or mental disabilities
Problem gamblers
People bereaved or affected by suicide
Lesbian, gay, bisexual, and transgender people
Some minority ethnic groups
Asylum seekers (including unaccompanied asylum seeking children)
Rough sleepers, the homeless and those at risk of homelessness
Prisoners and others in contact with the criminal justice system
Certain occupational groups with increased knowledge of and ready access to means (such as doctors, nurses, veterinary surgeons, veterans, farmers and other agricultural workers)
Although many risk factors are hard to change when you come into contact with people, certain risk factors such as poor physical health and mental health diagnoses are directly treatable. Such treatment can directly decrease the impact of that risk factor! In addition, carefully listening, understanding and compassionately recognising the risk factor is important in and of itself.
Rapid change
Remember, that risk factors may also change rapidly over short periods.
For example, from changing life events, fluctuation in severity of mood and or alcohol consumption.
Suicidal behaviours
It is also equally important that you remember to ask about suicidal behaviours and self-harm in people with such established risk factors. This is particularly true when they present with issues related to alcohol or feeling low and thoughts of suicide.
Emotional distress
It is also especially important to remember the risks and opportunities for decreasing such risks in those with current emotional distress, depressive symptoms, unpredictable risky behaviour and/or in unstable social situations.
For example, during relationship breakdowns people can be extra vulnerable.
Volitional factors
Remember that most people never act on their thoughts of self-harm. However, ‘volitional factors’ are thought to be particularly associated with actual self-harm (O’Connor et al, 2018). What we mean is that such ‘volitional factors’ increase the likelihood that someone who thinks about self-harm acts on their thoughts. It's like an accelerant to a fire, something that makes a fire more likely, but on its own did not cause the fire.
These ‘volitional’ factors include: impulsivity, exposure to the self-harm or suicide of others, having access to the means of self-harm, and increased physical pain tolerance.
Protective Factors
Protective factors are equally important. They reduce a person’s vulnerability to self-harm and suicidal behaviours. Protective factors can help individuals cope, to be more ‘resilient’ in particularly difficult circumstances.
Protective factors can help to minimise the risk of self-harm and include:
Strong connection to family and community support; social connectedness
Psychological and social skills in problem solving, tolerance of distress, conflict resolution and non-violent handling of disputes
Restricted access to the means of suicide
Seeking of help
Easy access to high quality care for mental and physical illness
Personal, social, cultural and religious/spiritual beliefs that support personal wellbeing
It is important to also be aware that, despite having (some) protective factors, some people do still self-harm. Others will still go on to take their own lives. So, it’s important to engage, personally and uniquely with each individual and their circumstances. Explore the person’s motivation. Explore their intentions, risk and protective factors by asking about them.
Where appropriate and with consent and an awareness of confidentiality, seek other sources of information from friends and family, or hospital records.
Knowing Where Appropriate Intervention Can Help
There have been improvements in how services and sectors respond to people who self- harm. But, too often those who present in distress still feel stigmatised for their self-harm and suicidal behaviours.
Common behaviours which trigger this kind of experience include professionals experienced as not listening, nor picking up on cues.
People report that it is unhelpful when professionals respond in a simplistic, parental type of way. For example, asking people to just ‘stop self-harming’.
Non-judgemental responses are particularly important because each contact should be viewed as an opportunity for helpful support and intervention. The need for compassion linked to reflection, is paramount.
We also need to respond to the individual in the knowledge that suicide following self-harm cannot be predicted by considering demographic risk factors alone. For example, even seemingly mild self-harm behaviour can in fact be an indicator of extreme distress.
Factors for referral
Factors that may justify referral for aftercare and/or referral for specialist mental health or social services include :
Chronic alcohol misuse
Multiple repeat attempts
Depression
Physical illness
Social isolation
In addition, those with active (ongoing) suicidal plans or intent, people with psychotic symptoms, older people and children/adolescents should all be offered aftercare and/or further referral specialist support.
Sign-posting to appropriate sources of help and support for specific issues or characteristics in a persons’ life is also important to consider in your action plan. For example, where there are problems with gambling, prisoner support, physical illness.
Remember this might include third sector organisations.
Sign-posting on to talking therapies, as well as of course, to organisations such as Samaritans is appropriate.
Common Myths About Self-harm
Myth 1: People who self-harm are “attention seeking”
Self-harm is often a deeply private behaviour, and people may go to great lengths to hide it. Some feel ashamed, ambivalent or distressed. If a person approaches you and talks about self-harm, it has likely taken courage to do so. They are putting a great deal of trust in you. This is still the case if they approach you in anger or seem to self-harm to bring about a desired outcome e.g. resolve a relationship break-down.
Many people reveal self-harm as a means of seeking support. This is not “attention seeking” behaviour so much as a communication of a need for help.
Myth 2: All people who self-harm are trying to end their lives
Some self-harm behaviours may be related to suicidal thoughts and plans. However, for many people, self-harm is experienced as a coping mechanism. Rather than trying to end their lives, people may be using self-harm as a means to manage their distress and carry on. If or when this coping strategy fails their risk of escalation may be to more risky forms of self-harm or frank suicide attempts.
There is a relationship between self-harm and suicide but suicide is, thankfully still much rarer. It’s helpful to try and understand the reasons and circumstances why a person is self-harming. Remember, that these motivations and factors may change. This will help you decide the appropriate action.
Myth 3: Self harm is something that happens with a certain group, sex, or ethnicity
Although self-harm is more likely to occur in certain groups of people, it is not exclusive to any of them. Self-harm can and does occur in all ages, sexes, cultures, and ethnicities.
Myth 4: Self-harm means cutting
Many people do use cutting as a method of self-harm, and this is probably the most visible form. Unexplained cuts, burns or bruises may be signs of self-harm in a young person.
However, other methods include burning, hitting the head or limbs against objects or walls, scratching, interfering with existing wounds, pulling out hair, breaking bones, or self-poisoning with medications or other substances.
Myth 5: Self-harm means the person has a mental illness
There is an association between mental illness such as depression and self-harm. However, self-harm is a behaviour, often a coping mechanism signalling distress, not a mental illness. People who are not mentally ill may use self-harm to cope with emotional distress.
Myth 6: Self-harm is very rare
It is difficult to know the real numbers of people who self-harm. The private nature of the behaviour and the stigma associated with it mean that it is likely that many people who self-harm do not seek help or if they do, not from health services. Around 1 in 130 people self-harm. Some may seek help from healthcare but most are in the community.
Myth 7: Asking someone about self-harm makes them more likely to do it
There is no evidence that a conversation with someone about their self-harm where you try to understand their reasons, and their circumstances makes them more likely to self-harm again. Nor is there evidence that it puts the idea into their head. In fact, non-judgmental conversations may encourage them to seek help in the future.
Myth 8: The only successful intervention is that which comes from a mental health specialist such as a psychologist or psychiatrist
Any person who can listen and provide humane ordinary support to a suicidal person or a person who self-harms, can provide a useful intervention.
Myth 9: Self-harm is manipulative
Self-harm is something people can (at times) control when other things in life feel out of their control. It often demonstrates the degree of distress and level of crisis and helplessness the individual feels. It may indicate chronic life-long difficulties in having their needs met. Anger and punitive responses do not work.
Looking After Yourself
Supporting an individual who is in crisis or self-harming can be challenging. It may evoke all sorts of difficult feelings. You need to be aware of how to maintain your own well-being. You need to have routes through which you can talk to someone supportive to you about how the contact has affected you. This supportive person/s should also offer help around how you manage any distress it has raised for you.
This means being prepared with a tool kit of ways to manage your own emotional reactions. Having support from an appropriate other person is often crucial, and this tool kit will then help you to cope with distress and work through problems. Your toolkit can include seeing friends, listening to music, reading, walking, exercising. It is likely to involve some form of reflection and taking perspective. However, it will be whatever works best for you.
Key Points and Further Information
Whilst people who self-harm or attempt to take their own lives may be more likely to belong to certain groups, it is not possible to predict suicide or self-harm from membership of vulnerable groups alone
Anger is never a helpful reaction to self-harm or suicide attempts
Compassion, listening, being kind and thoughtful, as well as professional and helpful is always essential
Ask people who self-harm if they were trying to kill themselves
Psychological support and investigation following self-harm is essential
Take care of yourself when you are helping someone who self-harms
Taking away the means will not necessarily keep someone safe. Having the option for self-harm may be helping them to stay alive
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