Self-harm is common among young people, and typically emerges during adolescence. Lifetime prevalence rates are estimated at around 17% (Gillies et al., 2018), whilst 12-month prevalence rates are estimated at anywhere between 5% and 28% for young people in Western countries (Muehlenkamp, Claes, Havertape, & Plener, 2012; Skegg, 2005). Self-harm is associated with a range of adverse outcomes, including death by suicide (Borschmann et al., 2017; Duarte et al., 2020; Goldman-Mellor et al., 2014; Hawton et al., 2015; Mars et al., 2014; Wilkinson, Qiu, Neufeld, Jones, & Goodyer, 2018). A range of interventions and therapeutic approaches have been developed with the goal of addressing self-harm.

Resources (for example, see here), and to some extent clinical practice guidelines (National Collaborating Centre for Mental Health, 2012), frequently recommend harm minimisation strategies for people who engage in self-harm. There is, however, little consensus regarding the definition “harm minimisation” in the context of self-harm, or whether or not it is effective.

People with lived experience, academics, and clinicians often express different views on what constitutes harm minimisation; as Rachel Rowan Olive stated in a recent blog post for The Mental Elf, “In a way, all my self-harm is harm reduction: in a particular set of circumstances with the particular thoughts in my head, I am always doing the least harmful thing I can”. Similarly, the ultimate goal of harm minimisation strategies is debated – for example, should these strategies aim to prevent self-harm or should they aim to manage associated risk (Furniss & Biswas, 2020)? One thing that we can all agree on, is that the effectiveness of harm minimisation is under-researched.

Wadman et al. (2020) in this paper report on two studies that aimed to address this research gap. Both studies involved analyses of secondary data. Study 1 investigated whether young people with a history of self-harm reported harm minimisation as a form of self-harm or a form of coping. Study 2 qualitatively explored participants’ experience of using harm minimisation strategies.

Methods

The two studies reported in this paper focus on strategies that replace existing self-harm with safer proxies of the physical sensation (e.g., snapping elastic bands against the skin) or the process or experience of self-harm (e.g., drawing red lines on the skin).

Study 1 was an online survey with 758 young people, aged between 16 and 25, who were recruited both online and through the School of Psychology Research Participation Scheme at the University of Nottingham, UK. Analyses assessed the frequency with which behaviours considered harm minimisation strategies were reported by young people a form of self-harm itself, or as a coping response.

Study 2 was a qualitative study with 45 young people aged between 11 and 21, who were recruited in the East Midlands (UK) from Child and Adolescent Mental Health Services (CAMHS), Children’s Social Care Services and in the community. Participants were asked a series of questions about stopping self-harm and self-harm recovery. If harm minimisation strategies were not spontaneously reported, participants were specifically asked about their experience of using these strategies.

Results

Study 1

Approximately 2% of the total sample reported snapping elastic bands against their skin as a form of self-harm behaviour, and 0.9% reported using harm minimisation behaviours as a coping response.

Study 2

Twenty-nine of 42 participants had used harm minimisation as a proxy for self-harm. The analysis identified three themes:

1. Harm minimisation strategies (as a proxy for self-harm) are perceived to be ineffective;
2. Harm minimisation strategies are helpful (to some limited extent);
3. Harm minimisation strategies as self-harm.

Young people reported that using these strategies “doesn’t work” [ID 29], as they fail to address the underlying distress, and can in fact lead to more severe self-harm. Just two participants spoke about harm minimisation in solely positive terms, finding these tactics helpful. Others had mixed views, reporting negative experiences but also acknowledging that they could sometimes lead to short-term benefits.

Conclusions

The paper ultimately concluded that using harm minimisation tactics is

inadequate as it neither addresses the underlying meanings of self-harm, nor acknowledges the distress experienced.

The authors call attention to the finding that some young people used behaviours and tactics, characterised by the authors as ‘harm minimisation’, as forms of self-harm.

Strengths and limitations

These analyses of secondary data provide important evidence on young people’s views on harm minimisation, which has been critically under-researched. Future research which focuses primarily on this topic is necessary in order to more deeply examine the potential benefits and harms associated with these types of strategies.

No ethnicity information was captured for participants in Study 1, and the majority of participants in Study 2 were White British. As discussed in a recent blog post, research has indicated that individuals from ethnic minority backgrounds are less likely to receive appropriate care for self-harm (Cooper et al., 2010). It is therefore important to ensure that future research includes participants that represent a diversity of experiences and identities.

A beneficial avenue of future research could involve an examination of the perceived aims or goals of harm minimisation strategies. Developing a shared understanding of the intended outcome of these approaches is essential, in order to determine whether or not these approaches “work”, and to set reasonable and realistic expectations for young people regarding the likely outcome of implementation of these strategies.

Implications for practice

The authors assert that:

1. Harm minimisation strategies should not be offered in therapeutic isolation
2. If these strategies are recommended then the impact on young people of their use must be closely monitored
3. For some individuals, these strategies will certainly not be helpful and could even be harmful.

The findings indicate that a more productive strategy for services and clinicians would be to focus on addressing young people’s underlying distress.

Furthermore, new questions emerge as potential future avenues of research:

• Does the recommendation of harm minimisation strategies align with the upholding of best practice and duty of care?
• What role does stigma play in responses to young people’s self-harm?
• What does the evidence tell us about what really does work for young people who engage in self-harm?
• Are current self-harm treatments co-designed with young people?

Statement of interests

No conflicts.

Links

Primary paper

Wadman, R., Nielsen, E., O’Raw, L., Brown, K., Williams, A. J., Sayal, K., & Townsend, E. (2020). “These Things Don’t Work.” Young People’s Views on Harm Minimization Strategies as a Proxy for Self-Harm: A Mixed Methods Approach. Archives of suicide research, 1-18, doi: 10.1080/13811118.2019.1624669.

Other references

Borschmann, R., Becker, D., Coffey, C., Spry, E., Moreno-Betancur, M., Moran, P., & Patton, G. C. (2017). 20-year outcomes in adolescents who self-harm: a population-based cohort study. The Lancet Child & Adolescent Health, 1(3), 195-202.

Cooper, J., Murphy, E., Webb, R., Hawton, K., Bergen, H., Waters, K., & Kapur, N. (2010). Ethnic differences in self-harm, rates, characteristics and service provision: three-city cohort study. The British Journal of Psychiatry, 197(3), 212-218.

Duarte, T. A., Paulino, S., Almeida, C., Gomes, H. S., Santos, N., & Gouveia-Pereira, M. (2020). Self-harm as a predisposition for suicide attempts: A study of adolescents’ deliberate self-harm, suicidal ideation, and suicide attempts. Psychiatry research, 287, 112553.

Furniss, F., & Biswas, A. B. (2020). Ethical and Practical Issues in Working with People Who Self-Injure. In Self-Injurious Behavior in Individuals with Neurodevelopmental Conditions (pp. 111-133): Springer.

Gillies, D., Christou, M. A., Dixon, A. C., Featherston, O. J., Rapti, I., Garcia-Anguita, A., . . . Al Kabir, N. (2018). Prevalence and characteristics of self-harm in adolescents: meta-analyses of community-based studies 1990–2015. Journal of the American Academy of Child & Adolescent Psychiatry, 57(10), 733-741.

Goldman-Mellor, S. J., Caspi, A., Harrington, H., Hogan, S., Nada-Raja, S., Poulton, R., & Moffitt, T. E. (2014). Suicide attempt in young people: a signal for long-term health care and social needs. JAMA psychiatry, 71(2), 119-127.

Hawton, K., Bergen, H., Cooper, J., Turnbull, P., Waters, K., Ness, J., & Kapur, N. (2015). Suicide following self-harm: findings from the Multicentre Study of self-harm in England, 2000–2012. Journal of Affective Disorders, 175, 147-151.

Mars, B., Heron, J., Crane, C., Hawton, K., Lewis, G., Macleod, J., . . . Gunnell, D. (2014). Clinical and social outcomes of adolescent self harm: population based birth cohort study. BMJ, 349, g5954.

Muehlenkamp, J. J., Claes, L., Havertape, L., & Plener, P. L. (2012). International prevalence of adolescent non-suicidal self-injury and deliberate self-harm. Child and adolescent psychiatry and mental health, 6(1), 10.

National Collaborating Centre for Mental Health. (2012). Self-harm: longer-term management. In NICE Clinical Guidelines, No. 133: British Psychological Society.

Skegg, K. (2005). Self-harm. The Lancet, 366(9495), 1471-1483.

Wilkinson, P. O., Qiu, T., Neufeld, S., Jones, P. B., & Goodyer, I. M. (2018). Sporadic and recurrent non-suicidal self-injury before age 14 and incident onset of psychiatric disorders by 17 years: prospective cohort study. The British Journal of Psychiatry, 212(4), 222-226.

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