Self-harm

Gavin is joined by Paul Moran (Professor of Psychiatry, University of Bristol and Honorary Consultant Psychiatrist, Bristol Royal Infirmary, UK) and Helen Christensen (Scientia Professor of Mental Health at the University of New South Wales, Sydney, Australia) to discuss The Lancet's new commission on self-harm, exploring its prevalence, cultural factors, and the crucial need for better data and compassionate care. We also talk about stigma and improving mental health services globally.

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Transcript

This transcript was automatically generated using speech recognition technology and may differ from the original audio. In citing or otherwise referring to the contents of this podcast, please ensure that you are quoting the recorded audio rather than this transcript.

Gavin: Hello and welcome to the Lancet Voice. I'm your host Gavin Cleaver. It's October 2024 and today we're addressing a critical and often overlooked issue, self harm. Joining me are Paul Moran and Helen Christensen, who are both lead commissioners on the Lancet's new commission on self harm. In this episode, and this conversation, we'll explore the complex landscape of self harm, which is a behaviour that affects millions globally, and talk about the varied forms self harm can take, the significant burden it places on health systems, and the alarming gaps in data and surveillance.

I hope you enjoyed this conversation with Paul Moran and Helen Christensen.

I'm joined by Paul Moran and Helen Christensen, who are two of the lead commissioners on the Lancet's new commission on self harm. Thank you both so much for joining me today. It's a pleasure to have you with me. I thought maybe we could start off by asking a Very broad question. What is self harm?

Paul: Okay, so self harm is when someone hurts themselves on purpose regardless of the reasons for doing it and it can take many forms it's not a psychiatric diagnosis or a mental disorder It's a behavior and the sorts of behaviors that we see are many and varied but in community settings, the commonest form of self harm is self cutting.

And in hospital settings, the commonest form of self harm that presents to hospitals is self poisoning, typically overdosing. 

Helen: I would just add that it's a problem pretty much hasn't had much light focused on it compared to something like suicide. So it's an area that we really need to look at more. 

Gavin: So how big a problem is self harm and what amount of it actually gets picked up by, by services?

Paul: It's a substantial problem. And as Helen was just saying, it's one that's been neglected, really. People have had a sort of sharp eye on suicide, but self harm is, numerically a bigger problem. How much bigger? We don't really know because this is one of the things our commission talks to is the need for better surveillance of the size of the problem.

But we know from data from the global burden of disease, which largely relies on a variety of data sources. But a lot of it is Bias towards clinical data sources, hospital presentations, and vital statistics. But from that data source, the global burden of disease study, there were 14, over 14 million episodes recorded.

And we don't know if those episodes map onto 14 million people, but these are 14 million episodes, but that's huge underestimate we think globally. Looking at it, answering your question from a, there's a number of ways of looking at this. You can look at community surveys of psychiatric morbidity and mental health problems.

In the UK, the best estimate, the last best estimate was about 6% over the lifetime of people aged 16 to 74 were self harming, reported self harming. So that's 6%. So that's, that's one in 20. And we know looking at sort of emergency department data in England, over 220, 000 episodes of self harm presenting to emergency departments each year.

But these are, again, conservative estimates. 

Helen: I could just add that in Australia we've looked at this too. So you might have around about 3, 100 people who die of suicide. On top of that, you might have 29, 000, 30, 000 people who present for hospitalization, who get hospitalized for self harm. And then on top of that, if you use population samples, there's around about 400, 000 people who say that they have self harmed in the previous year.

So you've got a 10 and then another 10 fold. Increase from a suicide self harm. And the thing is, of the 400, 000 that we know self report, we don't know how many of them have seen a GP, and we don't know how many of them have had an emergency visit. So even in a Western country like Australia, which has tried to do well in reporting self harm episodes, we're really not sure exactly how many people there are and what services they do receive.

Paul: Yeah, actually picking up that point about help seeking, you're right. So the last psychiatric morbidity survey in England and Wales showed that the majority of people who reported self harm hadn't sought help. So over half hadn't sought help. And that's a pattern that we see all around the world, as Helen 

Gavin: is describing.

A question that springs to mind for me when talking about this is what was the impetus for the, for, to put the commission together? 

Paul: Multiple reasons, but, one of the biggest one was, as we were saying earlier, is that it, this has been a neglected public health problem. There's a substantial burden of disease associated with self harm.

Huge morbidity, raised mortality. So although most people who self harm don't die by suicide, risks of suicide, somebody who presents to hospital with a self harm episode are elevated multiple times. One study reported your risks of death. In the year after presentation for self harm by suicide raised by a factor of 50 compared to the general population So it's a concern in terms of it's one of the best predictors of suicide Although most people who don't who self harm don't die by suicide.

I suppose that's one reason mortality People who self harm also have raised mortality for a variety of other reasons 

Helen: Paul, I think the motivation for the commission was also that we thought we could throw new lenses on the problem, that rather than just looking at it the way it tends to be looked at from a Western perspective, and also from a sort of medical biological view, we thought by bringing in the voices of people with lived experience, people from LAMIC countries and also Indigenous peoples, we could get a better handle on what the societal factors are that will influence this behaviour.

Paul: Exactly, there, it was looking at this problem. I think it is a problem. And we had some interesting conversations about the nature of the problem. Is it a medical problem? Is it a Because we know that, as Helen was saying, there are other, there are different cultural lenses on this issue.

People have been writing and thinking and talking about self harm going back to antiquity. There are accounts of it in the Old Testament, in the Book of Kings, people cutting themselves with spears and sabers. It's actually only been in the last really 50 years or so. Medics, psychologists, nurses, emergency doctors have become more engaged with this as, and had to become more engaged with this as a public health problem.

So yeah, that was part of our motivation was to really place this in the center of, of government thinking really to start thinking about this as a public health problem. 

Gavin: It's fascinating to hear that it goes back such a long way. At least the recorded Recorded incidences of it.

Why is it? It is a very broad question. Why do people self harm? 

Paul: For a lot of many and very different reasons, and actually a person who engages in self harm repeatedly, very often the reasons, they might vary between episodes. So it's really important not to make assumptions as to why somebody's presenting with self harm on a particular occasion.

The only way to establish Why they're doing it is to ask them, and to be curious about it. Usually people engage in self harm because they are struggling to cope in other ways. They either, they don't have the psychological means, resources or the social supports in place to help them cope. And so they're using self harm as a way of managing unbearable feelings.

And the feelings we're talking about are rage, anger, anxiety, terror, those sorts of feelings. And some people self harm because they want to stop feeling like that and to not feel anything. For other people, it's paradoxically self harm can be actually stop them feeling numb. So it's to make them feel something.

Other people who feel out of control with their lives or in their relationships, self harm is something that they're doing to themselves. And it gives them a sort of granular sense of control over their lives, which might be lacking in other ways. So it's a lot of different reasons, but usually related to a feeling state.

And that's where sort of talking therapies will try to do the focus of the work. 

Helen: And I'd just add in that context that different cultures and different societies have different views about what causes suicide. And self harm, but more particularly self harm. And for example, in Indigenous communities, it seemed to arise from colonialism and the squashing of their cultures and the disempowerment of their communities.

And of course, the consequence of that is that it's not so much an individual response that's required, though they would say that's a good thing to do. It's actually trying to change the structural causes of racism, disempowerment, new structures to the societies that they used to have. And so many of the indigenous communities who participated and the researchers were very strong in the view that the cause of suicide was less about the individual and more about structural factors.

Paul: Just that we thought about it as an individual level. Helen's talked about. A view from indigenous people, I think just taking a historic view and the commission does, they commissioned a separate piece on this. It's quite interesting. Going back to the accounts in antiquity, there are, self harm's become, it's ingrained in some cultures as, going back to Helen's point about indigenous communities for Aboriginal peoples, there is this concept of sorry business, isn't there Helen?

And actually sorry cut. In other words it's part of, it's an expression of grief an expression of melancholia and sadness. So in, for some cultures, self-harm is a, if you like a, it's a functional part of their culture, and it's an acknowledgement of a way of facing grief. And the medical profession has got a strange relationship with self-harm because, the whole idea of bloodletting, which is now that's not self-harm as such, but it's an interesting con concept of.

Doctors going back centuries, removing blood as a way of dealing with a whole range of spurious ailments. I think it's, I think that the things have changed when we start seeing behavior where people are doing something to themselves and in the con in the context of an app of a, of an unpleasant feeling state.

So you can have a look at, you can examine the problem itself on from a number of different perspectives. And of course these perspectives sit uneasily alongside each other. And that's one of the main challenges that we, we face with trying to bring all this together. I, we've done a reasonable job of that, I think, but we didn't reach consensus on everything.

And that's good. Differences of opinion are important. No, that's 

Gavin: really fascinating to hear, actually. It's really interesting to get these different cultural perspectives into it. There's a lot of very strong feelings and emotions bound up in, in acts of self harm. And when we're looking at the medical profession side of things, these kind of strong feelings aren't very, aren't always associated with actually seeking help when people might think that there is a problem.

So how can the issue of people not seeking help be overcome? What are some of the what are some of the approaches? 

Helen: I think there's multiple things that can be done, but changing attitudes and laws around self harm. will lead to a reduction, I think, of stigma and discrimination, which is often a barrier to people helping seek help.

Say seek, help seeking amongst men, for example, we don't really know enough, but we should be asking them why they don't seek help. And that's often related to having had a previous bad experience of a service or believing they can solve it themselves. And actually finding that they can't or not being able to control what they think they do.

But I think this is the second point really beyond reducing discrimination and the policing, if you like, of self harm is the fact that we actually have to change the services so that they are more appropriate and more desired by those people who do self harm. Because I think not only do they not seek help, they often avoid.

And so I think you can make more compassionate services, better trained people for services. You can set up services that have peer support involved in them so that people feel that they're connecting with somebody who might have had the same lived experience. So I think multiple reasons and responses that we can do.

I do think that services should be lived by led by lived experience and that was very much strongly pushed, by our lived experience chapter 

Paul: people. Just in terms of the service response that currently exists it's pretty inadequate. Across the world, in high income countries such as Australia and England, we do okay.

We know that across the world, one in three people who present to hospital. with self harm don't get a comprehensive assessment of their needs. So the injuries are dealt with, and probably very competently, that these are the physical side of things. And actually, NICE, for example, would recommend that everyone who presents to an emergency department following an episode of self harm receives what's termed a psychosocial assessment.

That's that comprehensive assessment. But one in three people across the world aren't getting even the assessments. And that's actually a real problem because usually those assessments will be done by staff who've got a training in mental health. In England and Australia and America those services would sit within liaison psychiatry services.

And if you're not getting an assessment, you might be losing what may be the only opportunity to talk to a trained mental health professional about what's on your mind and what's driving your behavior, which you might repeat. And these psychosocial assessments are. They're cost effective, they reduce risk of repetition of self harm.

So everyone should be getting these, and that's just as a basic thing. The talking therapy and all of that's downstream after someone's got into the system. Just even just having basic psychosocial assessments needs to be happening. That's probably a staffing capacity issue, but as Helen says, there's training needs.

And training, staff training is great because it can shift staff attitudes in a more positive way. Staff often feel powerless, I think, when they're faced with self harm. And they, and what tends to happen and what can happen. Because there's a lot of self harm presenting. I was saying over 200, 000 episodes each year in England.

Staff start to become hardened sometimes in their attitudes. And so the staff training is really good because it can help reorientate attitudes and shift things. 

Helen: Yeah, I think I was shocked by some of the revelations of the commission in terms of what we had some lived experience advisors as well as obviously academics in lived experience and the descriptions they had of how they were treated in hospitals and so on was quite contemporary and quite shocking to me as a commissioner.

And I think we have to recognize that people who do experience self harm do want a different type of service sometimes, and that they should be able to lead the sort of services that might be better for them. Of course, they will require medical treatment as well as psychological interventions if that's possible.

the way it goes. But if you don't have faith in the system, then it's very hard to actually approach the help. 

Gavin: It's interesting we're talking about mental health services there. I wanted to ask, do people who self harm have a mental illness? 

Paul: No, there are two constructs. One, there's self harm, which is a behavior, and then we have a separate construct, which is mental illness, mental disorder.

And they're different. There's some overlap. Some people who self harm have underlying mental health problems, which can range in severity from mild to severe. And the sort of mental health difficulties that we would see that would be linked with self harm would be depression, anxiety, borderline personality disorder, substance misuse is sometimes linked to self harm.

You're at a higher risk of self harm if you have those underlying disorders. The self harm per se is not a mental disorder. It's not a psychiatric diagnosis. Now it's in DSM 5, non suicidal self injury. For all intents and purposes, I, it's not a, it's not a mental disorder. 

Helen: And I think the data from the LAMIC countries really illustrate this.

Very well, because it's often thought that maybe 80 to 90 percent of people who self harm or who meet clinical services for self harm may have some mental health disorder or have had one. But if you look at LAMIC countries, it seems that diagnosis status is much lower, 45 percent or so.

It just shows, I think, that you can have this. You can have self harm without a psychiatric disorder, and a lot of it is related to the context in which you have the self harming activity. 

Gavin: Broadly, and I'm sure this varies a lot across different cultures who is most statistically likely to self harm?

Paul: What we see is, yeah, there's certain groups of the population that are at particularly higher risk. Young people their, the prevalence of self harm is much higher amongst young people. 16 to 24 year olds, you're talking about that kind of age group, particularly so young women.

Um, and then we're looking at sort of other groups in society who are prone to being marginalized. People, in LGBTQIA plus communities people in minorities in minoritized racial or ethnic groups are at higher risk of self harming. Indigenous peoples, that's one of the reasons why we actually, wanted a group of indigenous peoples, but as part of the commission, they have much higher rates of self harm, probably linked to multiple social determinants of poor health in that population.

And maybe we'll come back to that a bit. Yeah, those would be the sort of the high risk groups. 

Helen: And you could add prisoners and veterans. 

Paul: Prisoners 

Helen: and veterans. And other groups. Yeah. 

Paul: Yeah. 

Helen: But the Indigenous one is quite interesting. In Australia, three times the rate in Indigenous communities.

The same for Maori groups in New Zealand. About twice to three times in Greenland, in Canada Native Americans as well in the U. S. A. It's quite common for these rates to be quite highly elevated in these groups. 

Gavin: What are some of the reasons that self harm is more prevalent in young people and in women?

Paul: The bottom line is we don't really know, we can speculate about this because the sort of causal analytic research hasn't been really done. And that's one of the things we say in our commission, we need much better longitudinal data, following people up over many years. But why, so we're slightly speculating, but one of the things that's been talked about and it sits slightly outside of this commission is whether there's been a decline in mental health amongst young people.

And actually some of the population surveys across the world suggest that might be the case. But you've got to be a little bit wary about those sort of, changes in prevalence, because that can happen for a variety of reasons. People might be more willing to report. And we wonder whether that may be the case, actually, that we're seeing more.

Self harm generally and particularly amongst young people because there's a source of culture of disclosure Which we're now seeing which maybe wasn't present 20 30 years ago. We might be better at measuring it, But I think that those sort of methodological issues aside Why might young people be more prone to poor mental health and self harming?

Because the, social pressures are immense at the moment and different to how they were post immediate World War II. The, we're in a globalized economy, pressure on jobs. We'll come back to social media maybe in a bit. It may play smart, some small role in all of this as well. 

Helen: I think I think they're generally acknowledged that there's probably an 8 to 11 percent increase.

Thanks. in self harm over the last 10 years. A lot of people strongly believe that's the case. And so I guess you're looking at factors that correlate with that particular time period. There's been a real change in how young people regard climate change. And that's become something that weighs quite heavily on their minds.

There's also economic changes so that there's less, the amount of financial security that young people have in Western societies is much reduced compared to their parents. Their economic outlook isn't as strong. So there's a huge range of potential. And as Paul says, we actually don't have the longitudinal data that measures all of these factors and allows us to do correlations across time to determine which of these factors might be the most important.

And that's also the case of social media because even though there's cross sectional associations, at this stage, the types of social media that people engage in. and changes in anxiety, depression and self harm are really not very well measured or linked. We don't have the big studies yet to be able to, And begin to determine which of these factors is most important and how it all works together and how they interact.

Gavin: Yeah, there's just simply a huge amount of factors at play when thinking about this stuff. Are there any kind of broader population correlations with self harming? Is there anything that's likely to happen to a person that makes them self harm on a very broad kind of population level? 

Paul: We know there are multiple social determinants of self harm.

Okay. So the things that drive misery in society, poverty, unemployment, war, conflict, climate change, as Helena was saying discrimination, racism, harassment, these are things that are not good for people's communities, mental health, and it starts to play out in terms of increasing your risk of self harm.

So those, those factors that drive misery, substance abuse, there's a very strong link between alcohol and self harm. Many hospital presenting cases of self harm are in the context of alcohol misuse or heavy use of alcohol at the time. So these factors are all going to increase and tip the balance towards more self harm in a population.

Helen: Yeah. And I think the commission did very well in trying to look at genetic and neurophysiological factors that also might make. So, that's quite an interesting read, I think, in the commission. So we're not saying it's also societal factors, it's also individual factors that make people more prone, as well as trauma.

Trauma continues to come out as in most mental health disorders as something that is correlated with people's self harm activity. So there's a lot to unpack there. And I think it's actually quite an interesting tipping point because I think we're moving closer to be able to look at the ways in which we can pick these factors out and try and develop models to bring them all together.

And things like artificial intelligence and machine learning are potential. methods that I think have a lot of scope in the future when we have the right sort of data sets that allow us to look at these interactions between broad societal factors and then individual and potentially even genetic factors.

Everything's very complex and I think AI could potentially offer something as long as you have the right ethics. And guardrails, obviously, around that sort of research. 

Paul: You're right to flag up again, Helen, that the individual factors. We had a large focus of work on that, led by Olivia Kirtley and colleagues, looking at individual risk factors.

There are no specific genes that have been linked to self harm or suicidal behavior, per se. There are genetic wide association studies showing. genetic effects linked to, I think 12 significant loci that we reported. I think our, you're right, Helen, although we, they're straight, to stress these other individual factors.

I think our overall feeling though, was that, from a public health perspective, those social factors are very important. And I suppose politically, I suppose to put too much weight on the individual, ultimately self harm as an individual experience, when we know there are so many. tractable social factors, poverty is a thing, isn't it?

It's passed, unfortunately, awful parts of human life and societies. But we know, for example, data in Brazil showing if you take people out of immediate pop, life threatening poverty, welfare can actually reduce significantly reduced suicide rates. And we think learning from.

From that field research, looking at suicide prevention could be very useful in informing prevention of self harm. What's the value of welfare and how does that impact on people's self harming value? So there are things that governments could do more if they want to tackle this problem or they want to work together with us to tackle this problem.

Gavin: You've always been tiptoeing about it for the whole for the whole discussion so far. But what are some of the most important recommendations from your commission? 

Helen: I think just leaping off from what Paul was saying governments really have to step up. They have to adopt a whole of government approach.

So it's not just about a health response. It's about an education response response financial, a way of improving economic conditions. It's around health equity. I think that was one of the most important things that came out for us and there is a public health problem here and it's something that governments can tackle.

There's the issue around decriminalizing self harm, which still occurs in some countries and the hurt and difficulty are, if that isn't changed, I think we just cannot have a situation where people are punished for self harming and that still exists. 

Paul: Yeah, we want people to have better access to high quality, compassionate services and effective services.

We need better evidence base. We always do in every aspect of medicine, but we know talking therapies are helpful and we could giving people easier access to those talking therapies. But even at the very sort of front door side of things, looking at the emergency departments, we need a larger proportion of patients.

Receiving comprehensive assessments of their psychosocial needs. And patients are often, people, you're not a patient if you're actually in the system, but people struggle to get into the system, the health system very often, because self harm gets excluded very often from wider parts of the health system.

It, in, in many parts of certainly I can speak, working within the English mental health system. Community mental health teams are great at dealing with what's termed severe mental illness, psychosis, bipolar affective disorder, mood disorders, depression, anxiety, but actually they struggle when people present with more complex emotional behavioral problems and self harm unfortunately falls into that.

And if you live in a sort of dense urban area, you're, like London, Manchester, your likelihood of being able to access a talking therapy if you self harm is just increased by virtue of the fact that you're living in a more dense area, there's better resourcing. But actually around the country, and this is certainly the case around the world, access to talking therapy is very much subject to a bit of a lottery depending on the resources locally.

So this will require some investment, but it also requires investment in training in shifting attitudes as well and actually opening up mental health services to more people so they can receive the help they need. 

Gavin: When you were putting the commission together, was there anything during the process that particularly surprised you?

Helen: I was, as I said before, I was surprised by the lack of compassionate care That the lived experience advisors talked about. That really shocked me that in this day and age there was such negative attitudes towards people who self harm, as if they were different. And I think that arises from the stigma, that if you self harm, it's not distress that's causing it, it's it's a very negative attitude.

That really surprised me. I wasn't surprised, but I was really pleased to see that there was an emphasis now on Thinking about developing services in conjunction with people with lived experience and building up different forms of services that people feel would be useful to them as opposed to the services that already exist out there.

Albeit that they also need improvement. Apart from that, I think I was surprised how many people had different views about everything. I was amazed we actually got something that combined the societal the individual, because there was definitely not conflict, but stress and tension around, say, the difference between clinicians and people with lived experience, and the views of Indigenous people, and people who had, attitudes.

Yeah, I think that pretty much sums it up for me. What about you, Paul? 

Paul: Yeah, I know you've summarized it really well. I agree with you about the, it's just surprising and awful to hear about people's experience, people who are suffering and wanting to get help being treated badly. So that, those stigmatizing attitudes and the structural stigma that still persists.

It was reported 20 years ago in relation to self harm is still there. I was shuffling around bottom trying to find some way to pick something that they, Jonathan Pym, the handling editor commissioned a historic piece on this. And he talked about something related to this, which is around the fuzzy, I can't remember the term.

That's what I was trying to find. Self harm is a, it's a messy area of medicine really, because it's the boundaries around it. As we were saying earlier, are. are quite blurry. And I think responding to your question, Gavin, what surprised me with similar to what Helen was saying, the fact that with something that was so messy and blurry, where we had multiple stakeholders with different experiences and backgrounds coming together, and there are over 40 of us in this team, the fact that we were able to pull off something that resembled some form of consensus around key areas, Surprised me, pleasantly surprised me.

Helen: Could I just add too that I think we have to make sure, I'd like to make sure anyway, that the views of the LAMIC societies are reflected. And one of the key things, which is a recommendation actually as well, is that there should be far more research going on in LAMIC countries, which struggle with the burden of self harm.

No, it's something like an estimate of 11 million. Episodes in India, it's again an estimate because there's not very good data being collected on self harm, but there needs to be recognition that what, what's happening in Islamic countries has to be recognized. The research needs to be done to determine the causes and the risk factors and the helpful interventions that might work in those particular countries.

Paul: Yeah, absolutely. That's a good spot to raise that Helen. I think the current state of knowledge and this, we talk about this in our document, it very much reflects a high income country perspective. And so our commissioners, our colleagues from lower middle income countries were very keen to.

To emphasize the fact that just trying to impute that epidemiological knowledge into other settings is probably not the best way to forward That actually we need more descriptive epidemiology and we need interventions which are shaped by Lamic leaders similarly for indigenous peoples You know The research needs to be indigenous led and in lamic countries needs to be led by individuals living and working in those countries So that they're developing appropriate interventions for those settings

Gavin: So there are also profiles of Paul and Helen on the commission page if you'd like to find out more about them. You can find the hub page address in the show notes. It's at thelancet. com slash commissions slash self harm. Thanks so much for listening to this episode of the Lancet voice. If you'd like to check out more Lancet podcasts, you can see the whole range at thelancet.

com slash multimedia. And you can, of course, subscribe to any of them, wherever you usually get your podcasts. Thanks for joining us.