Deep wounds

Serious self-harm is one of the top five causes of acute medical
admission to hospital. The age group with the highest admission
rate is 16-24 year olds, but those seen in hospitals represent only
the tip of the iceberg. Most young people who self-harm do not
contact health services. And when they do make contact, typically
with accident and emergency clinics, underlying psychological
problems may be ignored and vital follow-up services not
provided.

Researchers at the Thomas Coram Research Unit at the Institute of
Education, University of London, with colleagues at the University
of Leeds, have been conducting a study for the Department of Health
to follow 16- to 22-year-olds who make repeat presentations at
A&E with self-inflicted injuries or overdoses.

A&E departments concern themselves mainly with the physical
consequences of self-harm, and the psychological elements most
likely to receive attention are the short-term risk of repetition
and clear evidence of depression or serious mental illness. As an
emergency service, A&E is not designed to provide a sustained
response to these young people’s needs. So continued support must
come from elsewhere, and follow-up is offered usually through
mental health services.

The current study has looked at how the longer-term needs of this
patient group could be better served by a multi-agency approach. It
followed patients for a year to get their views of the services
offered.

One of the difficulties in treating self-harm is that it is more of
an action than an illness. It is important to understand whether it
comes as a response to one particular event, or is symptomatic of
deeper problems. The study looked at other aspects of the young
people’s lives, and found that issues such as employment, housing
and relationships should be taken into account. These all have
important implications for treatment, yet commonly receive less
attention than the presence of a medical condition such as
depression.

An earlier study, which audited case notes in 18 A&E
departments, provided valuable details of this patient
group.¹ But there were significant gaps. The brevity of
many notes meant the recording of living arrangements and
employment, education, drug and alcohol use were limited.

However, a picture emerged of a marginalised and often socially
excluded group. Many young people who self-harm come from difficult
or fragmented home backgrounds: 52 per cent of the 16- to 19-year-
olds and 31 per cent of the 20- to 24-year-olds lived with their
parents. These figures are considerably lower than the national
average. Half of them reported problems in living with parents and
were actively looking for somewhere else to live. Tracking the
young people over the course of a year revealed that many had moved
several times and a high proportion lived alone in hostels,
supported lodgings or bed-and-breakfast accommodation.

High levels of unemployment were found among this group: 44 per
cent were not working or in education while 40 per cent had no
formal qualifications. These figures, too, were well above the
norm. Alcohol use featured in 40 per cent of presentations, with
young men more likely than women to have been drinking before
presenting at A&E. The use of street drugs was poorly recorded
but it was implicated in 22 per cent of cases. However, excessive
use of drugs and rates of alcohol dependency were fairly low.

The young people taking part in the study described repeated
incidents of self-harm that did not attract medical attention or
went unreported. This pattern obscures the true figures, and the
picture is muddied further by the fact that information on previous
episodes of self-harm was missing in almost half of the case notes
examined.

The research suggested that the lack of recording stemmed from a
failure to elicit the relevant information rather than from
careless note-making. Establishing any previous history of
self-harm is the most reliable way to identify whether there are
underlying and potentially chronic psychological problems. Repeated
episodes, as distinct from a “one-off” impulsive response to an
upsetting event, are a major risk factor for future serious
self-harm and suicide. More than two-thirds of the young people
interviewed in the study had previously presented as a result of
self-harm, with 40 per cent reporting at least seven
incidents.

A strong gender bias appeared in the way problems were
precipitated. Young men were more likely to present with mental
health problems or drink and drug misuse, while young women were
more likely to talk about problems with relationships. But not all
of them could explain why they had self-harmed, nor relate it to a
specific event.

As to why information was missing from case notes, light was shed
on these omissions when patients were interviewed. Young people
described being confused, disorientated by their situation, in an
emotional state, and unable or unwilling to talk about what had
happened to them. Some were reluctant to seek medical treatment and
were brought in by friends or family; some were hostile to any
questioning and, often, a busy A&E department militated against
any in-depth examination.

Self-harm included cutting and burning themselves over long periods
of time, or punching walls and windows which often resulted in cuts
and broken bones. The young people interviewed acknowledged that
when they visited their GP or the hospital they had rarely
mentioned deliberately injuring themselves. Others described small
overdoses for which they had not sought medical help and which they
had failed to mention at their first time in A&E.

Young people often mentioned guilt about attending A&E
departments. They felt that they didn’t deserve to be there, as
they had brought the situation on themselves, and perceived staff
to be judgmental. While some interviewees were able to give
positive accounts of interaction with medical staff, for most the
difficulties in communicating their problems were compounded by
overstretched medical services and their perception of the stigma
attached to self-harm.

Young people who self-harm fall between the gaps. Since more than
80 per cent of the sample had a history of self-harm going back
over two years or more, the research suggests that it may be
necessary to view self-harm not as an event, but as a syndrome. As
such, it requires a multi-agency approach to respond to the factors
that precipitate episodes.

Most of the young people interviewed reported inadequate follow-up
treatment. And while many had refused treatment, others had hoped
for a response from service providers but had fallen through the
net. Even where services such as a mental health liaison team based
in the A&E department existed, subsequent referrals – such as
alcohol and drug counselling – often did not take place.

However, mental health services are not the only source of
professional help needed. With unemployment being a risk factor for
repeated self-harm and suicide, the level of non-participation in
the workforce and in education is worrying. Only half of the
unemployed young people received any professional help with finding
work or training. Some found low-paid work in supermarkets,
call-centres and warehouses, usually on shifts, which further
disrupted their already fragmented lives.

These young people are dealing with a range of intertwined
problems, some psychological and some practical. This complexity
has implications for both assessment and treatment. Young people
who self-harm are often unable to negotiate access to services for
themselves. They may find that an A&E department is their first
resort, but it should not be their last.

Key points

• Most people who self-harm do not contact health services.
• Most young people interviewed in the study reported inadequate
  follow-up services.
• Young men’s problems were more likely to be linked to drug or
  drink problems. Young women were more likely to talk about
  relationship problems. But not all of them could explain why they
  had self harmed.
• Nearly half of the self-harmers interviewed were unemployed.
  Many reported accommodation problems and family difficulties.
• Case notes were frequently deficient, often because of the
  state of mind of the young person, but also because A&E is too
  busy.
• Self-harm is more of a syndrome than an event and requires a
  multi-agency response.

Pamela Storey and Jane Hurry are researchers for, and
Cathy Brownjohn is communications officer at, the Thomas Coram
Research Unit. 

Reference  

¹ J Hurry and P Storey,
“Assessing young people who deliberately harm themselves”,
British Journal of Psychiatry Vol 176, 2000  For further
information, contact Pamela Storey, Thomas Coram Research Unit; tel
020 7612 6566; e-mail
p.storey@ioe.ac.uk