Understanding Self Harm

The Hurt Beneath the Harm

Self-harm is often misunderstood and individuals who self-harm are often labelled as ‘attention-seekers’ and perceived as ‘wasting’ health care resources. In my professional experience I’ve been privy to both compassionate and invalidating recounts of how self-harm has been received by professionals, both medical and psychological.

I can’t quite put my finger on what motivated me to write this; perhaps procrastination from other larger tasks… or perhaps the desire to destigmatise and reframe self-harm. Probably the latter, but the former is a bonus.

I preface this nearly 3000 word essay / blog with a content warning; there are descriptions and narratives around injurious behaviours, there are paragraphs that discuss suicide – please go gently through this or leave now – whatever you need to do to keep yourself safe and comfortable. At the end of the document are some helplines, please reach out to these if you need support.

I began self-harming when I was around 13/14 years old – it was a fairly ‘new’ phenomenon at the time and I’m certain I distressed my parents and worried my teachers; neither of whom really put it back onto me – which is always a good thing. I look at the scars I’ve given myself and it all feels a little superficial now but I recognise it isn’t and it wasn’t and regardless of the depths of injuries or the significance of the injuries a person makes, it doesn’t invalidate the depths of the distress they are experiencing beneath the surface.

I was very lucky – I got a lot of support and help from a mental health system that was under much less pressure back then and I gave words to the pain I was experiencing and spoke them out loud to someone who could hold my pain and support me to get better.

Let’s Talk Numbers:

As I began my research around statistics, I realised there’s very little data out there around self-harm. Great Britain doesn’t collect data on self-harm presentations which varies from Northern Ireland (and Southern Ireland) both of whom operate a country-wide self-harm monitoring system (we’re some pups over here!), Giving us a unique lens on how self-harm is experienced.

What’s important to recognise about our self-harm registry is it only contains data of self-harm presentations in the Emergency Department (ED).

According to Ross et al (2023) we are able to determine that Northern Ireland has the highest rates of self-harm within the UK; for every 1 individual in England (per 10,000 people) there are approx 1.75 people in Northern Ireland.

Our biggest presentations of self-harm occur in adults aged 18-64 and females appear more frequently with self harm in Eds than men; this does not mean that men do not suffer and it certainly doesn’t mean that men do not self-harm but rather women attend hospital with their injuries – I remind you that our largest population of deaths by suicide are men.

Back to Self-Harm though…

What is Self-Harm:

Self-harm is a behaviour (fun fact they did try to classify it as a diagnosis in the DSM but it didn’t stick)– this is important; self-harm is not a mental health condition but can form part of a person’s experience of a mental health condition; an individual does not need to be diagnosed with a mental illness to exhibit self-harm behaviours. Clinically Self harm is referred to as Non-Suicidal Self Injury (NSSI).

What separates self-harm and suicidal behaviours are the intent; Suicidal behaviours are made with the intent to end suffering - die - (acknowledging that suicide is often not about dying itself but ending unbearable pain), Self-Harm behaviours are often used by an individual to keep themselves alive “about one in five ideators will subsequently present with SH over a 5-year period” (Griffin et al., 2020) (ideators being those experiencing suicidal ideation).

That being said, individuals who self-harm are at greater risk of attempting to or ending their life by suicide according to Klonsky et al, whose research identified closer links between Non-Suicidal Self Injury and Suicide than other established risk factors (mental health conditions).

I want you to consider self-harm as a coping strategy; like someone who goes and lifts weights in the gym, or a person who meditates or another who swims – self-harm is a way for an individual to reduce emotional distress. It is not a healthy way of reducing emotional distress, but for some people who perhaps haven’t been taught, or developed alternative methods it is their way of coping.

Even though the point of Self-Harm is to stay alive, there are risks associated. Often self-harm becomes ineffective, or the impact in reducing distress lessens which can lead to an individual injuring themselves more seriously or in a riskier fashion to elicit similar relief or it can lead to accidental death.

Again, the intent is not to die – it is to remain alive.

What are we coping with:

In my experience individuals self-harm for different reasons, but we can categorise these loosely under the following headings:

Emotional Distress: in the sense of distressing, intense emotions that an individual cannot communicate or soothe in any other way. The person is so overloaded and agitated (in a state of anxious activation) that they simply must do something to ease the distress.

Dissociation: in the sense that an individual’s nervous system is completely overwhelmed and they have moved into a state where they are numb and disconnected from self or reality. It is in this uncommon but not unique state that someone SHs to feel ‘real’ or feel ‘something’ or to bring themselves out of the disconnection and back into the here and now.

Self-Hatred / Punishment: this is very much the category that I would fall into “slightly more than one-half of people report that they self-injure as a form of self-directed anger or self-punishment” (Klonsky 2007). This can be motivated by shame and anger when an individual doesn’t have the tools or words to communicate those deep feelings.

These are simply what I have observed and we cannot pigeonhole every person.

The Self-Harm Cycle:

Self-Harm can become a cyclical process. By understanding the cycle and how someone came to be in it we can develop greater empathy for the person behind the self-harm. I didn’t consciously decide to hurt myself, at the different stages of my life where I had engaged in self-harm I was either out of alternative coping strategies or hadn’t developed tools to cope. In my personal experience, once I was in the cycle (which is a very secretive and private experience) it’s difficult to get out - this is where professional support is important - so an individual can speak about their distress and develop alternative ways to manage.

Figure 1: Self-Harm Cycle (adapted from Sutton, J 2009) Healing the Hurt Within

I want to talk us through this – it gives important context to the stages that an individual moves through when it comes to self-harm.

Emotional Suffering: We all experience emotions, and the landscape of emotions can vary – some are pleasant to experience, they make us feel good. But there are emotions that are uncomfortable to feel – sadness, worry, etc. In most cases, we can experience that discomfort and move through it – especially if we have good coping tools and emotional support. But the cycle itself often begins here (it doesn’t have to and it doesn’t always but for the purposes of this piece we’ll begin here) especially if an individual doesn’t have those tools or people, or cannot access them.
Emotional Distress: If unmanaged & unexpressed these emotions can become more distressing – it’s now incredibly difficult to experience and we may wonder if we will ever feel well again. With a good coping toolbox and access to support we might be able to abort the cycle here – however if we have forgotten, abandoned or don’t have access to coping tools and support we can move into…
Overwhelm / Panic: this is an anxious and agitated state. Our bodies need to do something to release the intense emotional distress we are experiencing. The emotions are too much and therefore we are activated – again, without good regulating strategies we become overloaded and we try to soothe the distress through pain.
Self-Harm: this is when we make an intentional injury to ourselves, the intent is not to take our life, the intent when we harm ourselves at this stage is to release the emotional overload we have entered. Injuries will vary from person to person.
Relief: there is an emotional relief that happens, and this often comes from the physiological response our body has to harm. When we are injured our body releases endorphins from what we know as the endogenous opioid system, our bodies own pain relieving system. So we feel good, but this is temporary. (Störkel et al., 2021)
Shame / Guilt / Grief: and this is the hard truth, the relief is temporary, because we haven’t dealt with the underlying emotional distress – we’ve simply flooded ourselves with feel-good chemicals to take the edge off and suddenly we’re feeling remorse, guilt, shame or even grief for acting on our desire to self-harm … and so the cycle moves into spin again.

Types of Self-Harm:

Non-Suicidal Self Injury varies from person to person and there are as Sutton (2009) would describe as ‘Direct’ and ‘Non-Direct’ self-harm, I don’t want to go into a lot of detail around types of self-harm as reading and visualising these things can be distressing and triggering.

Methods of self-harm are often completed in discreet areas that can easily be hidden or concealed. The behaviour is often more secretive than society expects.

Self-harm varies in severity but regardless, a person is intentionally hurting themselves to deal with emotional overwhelm.

What isn’t Self-Harm:

Eating Disorder: Eating Disorders are not self-harm, they have roots in emotional distress but they are distinctly psychological illnesses, Eating Disorders are described as a “severe and persistent disturbance in eating behaviours and associated distressing thoughts and emotions” (Guarda, 2023) but they are not self-harm, meaning they are a mental health condition – they meet a certain set of criteria and are diagnosable – they cause major disruption to a persons day to day life.

Excoriation (Skin-Picking) Disorder: while this looks like a form of self-harm it falls under the DSM-5 heading of OCD – when an individual “repeatedly picks at their own skin, to the point of causing skin lesions… the person has repeatedly tried to decrease or stop the picking without success, and the behaviour causes significant distress or significant problems with work, social interactions, or other activities” (Gellar 2023). It can also be described as a body-focused repetitive disorder and is often an unconscious act; it can co-occur with other mental health conditions and sometimes presents alongside ADHD.

Trichotillomania (hair pulling) disorder: “People with trich feel an intense urge to pull their hair out and they experience growing tension until they do. After pulling their hair out, they feel a sense of relief.” NHS (2021).

Both Trich and Skin Picking could easily be misconstrued as self-harm but both conditions fall under the category of ‘compulsive disorders’.

Many people also feel alcohol dependency or misuse falls under the heading of ‘self-harm’ and while the use of alcohol is detrimental to our physical and mental health, and often it is used to cope with stress or overwhelm it still seems to teeter on the tightrope of whether it is considered typical self-harm. I suppose when we look at self-harm through the psychiatric lens of ‘Non-Suicidal Self-Injury’ (NSSI) alcohol doesn’t meet the ‘criteria’ as NSSI is described as “intentional, direct injuring of body tissue without suicidal intent.” Klonsky (2006)

‘What isn’t self-harm’ this sections title does not mean to detract from the seriousness of the conditions, it also does not mean to invalidate that they serve as a function at some point for the individual to cope with distress. Compulsive Disorders (and OCDs) and eating disorders emerge from distress.

Impulses and Rituals

I try to view self-harm under two headings – although it is worth stipulating that self-harm can happen under other circumstances and one person may oscillate between both ‘types’ or ‘states’ of self-harm;

Impulsive: impulsive self-harm often takes place without forethought and in reaction to significant emotional overload – forethought is important here as impulsive self-harm often uses instruments or means that aren’t safe, sanitised and the injuries themselves can be riskier to the individual. Impulsive self-harm can be swift and anecdotally the ‘relief’ associated with impulsive self-harm is shorter with movement into the grief/shame state quicker.

As I write this piece I wonder: is the Self-Harm we see presenting in Emergency Departments been ‘impulsive’? Where an individual has reacted in the moment and injured themselves more severely than intended?

Ritualistic: According to Sutton (2009) ritualistic self-harm is reported to be the more common state of self-injurious behaviour. Ritualistic self-harm is intentional and planned; instruments and means used are often specific for the ritual and cleaned appropriately. Included in the ritual itself is the wound-care that takes place after, which some SH’ers report as an important part of their own self-care – imitating the kind of emotional care and love they wish to receive for their psychological distress.

Misconceptions around Self-Harm

Several misconceptions surround self-harming behaviours:

Only Young People Self-Harm

While young people are more vulnerable to engaging in self-harm behaviours, it isn’t exclusive to young people. As we have read from the NI Self-Harm Registry the statistics are greatest in the 18-64 age gap for presentations in ED. That being said, it is of significant importance to safeguard young people who are self-harming given their neurodevelopmental, social and behavioural vulnerabilities in comparison to adults. “Young people who self-harm are at a significantly greater risk of suicide. Almost a quarter of young people who died by suicide in NI had presented to EDs with self-harm” (Ross et al 2023). It is imperative to get a young person support and help for their self-harm and emotional distress. (see helplines and intervention programmes at the end of the document)

Self-Harm is Attention Seeking:

This misconception makes my blood boil; what I do know anecdotally about self-harm is that most people who self-harm will go to great lengths to hide the harm they have caused to themselves (and I can speak from personal experience to this) – injuring themselves in areas that are unseen. Often when challenged about injuries SH’ers will have an ‘excuse’ for how that harm came to be.

It therefore challenges that societal claim that self-harm is ‘attention seeking’.

Let me take this a step further though; because what we have learned is that self-harm is a way of dealing with intense and overwhelming distress. When we are in a state of distress what do we naturally do? We naturally seek to soothe it. Human beings are a social species and Maté and Maté (2024) would speak to our need to belong and care for one another as the essence of being human. We soothe distress and increase safety by forming connections … so perhaps we can call this something else; perhaps we can consider Self-Harm as a ‘CONNECTION SEEKING’ behaviour.

I am seeking connection: to self, to others who might help me, to relief because I am hurting, I have an unmet need that I cannot communicate in any other way.

Conclusion

If I could ask you to take anything away from this piece, it would be that people who self-harm are not trying to waste resources, or gather attention – they’re trying to process a deep distress without the adequate tools or words to do so. I would hope you see past the behaviour and set aside judgement or assumptions to focus on the person presenting in emotional pain. Our gut will want us to stop the self-harm; but please focus your attention away from preventing the person from injuring themselves and put it into getting support for the individual and empathising with their distress.

I have included regional and UK wide resources below:

Helplines:

Northern Ireland:

Lifeline: 0808 808 8000

UK Wide:

Samaritans: 116 123

SHOUT: (text) 85258

Papyrus: 0800 068 4141

Northern Ireland has a Self-Harm Intervention Programme (SHIP) which can be accessed via a referral through the GP. If you are concerned about your own self-harm and would like professional support to develop alternative coping strategies and explore the emotional disruption that impacts self-harm please reach out to your GP, or you’re welcome to contact me to explore therapy on @mindfulmessages or mindfulmessagesni@gmail.com

References:

Ross, E., O’Reilly, D., O’Hagan, D. and Maguire, A. (2023). Mortality risk following self‐harm in young people: a population cohort study using the Northern Ireland Registry of Self‐Harm. Journal of Child Psychology and Psychiatry, 64(7). doi:https://doi.org/10.1111/jcpp.1378.

Klonsky, E.D., May, A.M. and Glenn, C.R. (2013). The relationship between nonsuicidal self-injury and attempted suicide: Converging evidence from four samples. Journal of Abnormal Psychology, 122(1), pp.231–237. doi:https://doi.org/10.1037/a0030278.

‌ Sutton, J. (2009). Healing the hurt within : understand self-injury and self-harm, and heal the emotional wounds. Oxford, U.K.: How To Books.

Griffin, E., Kavalidou, K., Bonner, B., O’Hagan, D. and Corcoran, P. (2020). Risk of repetition and subsequent self-harm following presentation to hospital with suicidal ideation: A longitudinal registry study. EClinicalMedicine, 23, p.100378. doi:https://doi.org/10.1016/j.eclinm.2020.100378.

Guarda, A. (2023). What Are Eating Disorders? [online] American Psychiatric Association. Available at: https://www.psychiatry.org/patients-families/eating-disorders/what-are-eating-disorders. last accessed 15 March 2025

Geller, J. (2022). What Is Obsessive-Compulsive Disorder? [online] American Psychiatric Association. Available at: https://www.psychiatry.org/patients-families/obsessive-compulsive-disorder/what-is-obsessive-compulsive-disorder. last accessed 16 March 2025

NHS (2021). Trichotillomania (hair Pulling disorder). [online] nhs.uk. Available at: https://www.nhs.uk/mental-health/conditions/trichotillomania/. last accessed 16 March 2025

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Klonsky, E.D. (2006) 'The functions of deliberate self-injury: A review of the evidence,' Clinical Psychology Review, 27(2), pp. 226–239. https://doi.org/10.1016/j.cpr.2006.08.00 last accessed 16 March 2025

Störkel, L.M., Karabatsiakis, A., Hepp, J., Kolassa, I.-T., Schmahl, C. and Niedtfeld, I. (2021). Salivary beta-endorphin in nonsuicidal self-injury: an ambulatory assessment study. Neuropsychopharmacology, [online] 46(7), pp.1357–1363. doi: https://doi.org/10.1038/s41386-020-00914-2 . Last accessed 15 March 2025

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Maté, G. and Maté, D. (2024) The myth of normal: Trauma, Illness, and Healing in a Toxic Culture. Vermilion.

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