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MRC Social and Public Health Sciences Unit, University of Glasgow, Scotland, UK
Correspondence: Mr Robert Young, MRC Social and Public Health Sciences Unit, University of Glasgow, 4 Lilybank Gardens, Glasgow G12 8RZ, UK. Email: robert{at}msoc.mrc.gla.ac.uk
Funding detailed in Acknowledgements.
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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Aims To investigate self-harm in young people, prevalence, methods used, motivations for starting and ceasing, service use, and how these are related to gender, parental social class and current labour market position.
Method Population-based survey of 1258 18- to 20-year-olds living in the Central Clydeside Conurbation, Scotland.
Results Both past and current rates of self-harm were highest among those outside the labour market. This group was most likely to want to kill themselves and did not cite specialist mental health services as helpful in ceasing self-harm. Those in full-time education more often self-harmed for a brief time, mainly to reduce anxiety.
Conclusions Current labour market position was a stronger predictor than parental social class or gender for self-harm, and was linked to level of severity, motivation for starting and ceasing, and service utilisation.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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This population-based survey of 18- to 20-year-olds investigated three well-established predictors of self-harm – gender, parental social class and current labour market position – and examined how they relate to reasons for both self-harm behaviour and its cessation, and the use of social supports.
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METHOD |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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Measures
All measures, apart from parental social class – which was obtained
at age 11 – were determined at age 18–20. Questions about
self-harm were asked in a single section of the interview in the sequence
given below.
Lifetime self-harm and method(s)
All participants were asked `Have you ever tried to hurt yourself or harm
yourself deliberately?' and, if yes, what method(s) they had used from the
following list: cutting (on the arm or wrists); cutting (elsewhere on the
body); scratching or scoring; taking dangerous tablets or pills; hitting or
punching self; slamming hands in door; burning (with cigarettes, lighter,
etc); other way (please specify).
Reason for self-harming and age at onset
Participants who had self-harmed were asked `What are/were the reasons for
doing this?' from the following list: to upset others; relieve anxiety;
relieve anger; forget about something; make someone else take notice; punish
myself; kill myself; not sure why; other reason (please specify). In addition,
they were asked at what age they first started to harm themselves.
Current self-harm and awareness by health services and informal networks
Those who reported self-harm were asked whether this was in the past only,
currently (in the past year) only, or past and current. Anyone who had
self-harmed within the past year was asked `Who currently knows about this?'
from a list including: psychiatrist or other mental health professional;
doctor/general practitioner (GP); parents (either); spouse or partner;
friend(s); brother(s)/sister(s) or other close family member; work or college;
most people that know you fairly well; none of the above. Responses were
subsequently collapsed into formal services (GP, psychiatrist and health
professional) and informal networks (parents, family, spouse or friends).
Reasons for stopping
Those who admitted to self-harm but said that they were not currently doing
so were asked the open response question: `Why did you stop?' We categorised
the 65 valid responses into four broad categories that show considerable
similarity to the narratives developed by Sinclair & Green
(2005). The categories were:
one off or temporary phase (e.g. `only happened once, no further thoughts of
self-harm'); coped or felt better or found purpose (e.g. `felt I was coping
better with things and that [there] were better ways to cope'); got
professional help or help from family or friends (e.g. `went to see
psychiatrist'); realised the harm to self or family or the `stupidity' of
self-harm (e.g. `realised what life was worth and how much it hurt the
family').
Service use
To assess service use, participants were asked to select from a list of
services those they had used since age 11. We report use of Scottish services
most relevant to self-harm, namely psychiatric, accident and emergency,
Children's Panel (part of the Scottish Youth Justice System) and social
work.
Parental social class
Parental social class was based on the occupation of the head of the
household (father figure's current or previous occupation if not working or,
in his absence, mother figure's current or previous occupation), mainly
provided by parents during the first wave of the study (when the participants
were aged 11 in 1994). Where missing, these data were supplemented by
information provided by the children themselves, which we have found to be
reliable (West et al,
2001). Occupations were categorised by reference to the 1990
Standard Occupational Classification
(Office of Population Census and Surveys,
1991) into non-manual (occupational classes I–IIInm) and
manual (classes IIIm–V). There were 63 instances in which social class
was unclassifiable owing to either missing or poor information. With the
exception of basic statistics, unclassifiable data for social class were
treated as missing.
Current labour market position
Participants were asked a set of questions concerning education, training
and employment to determine their main labour market position. This was
classified into three broad groups: full-time education (higher or further
education); training or work (either full- or part-time, or on a training
course or scheme); and a non-labour market group, comprising unemployed
(n=86), at home or with care responsibilities (n=37) and
those sick or ill (n=12).
Statistical analysis
Chi-squared or Fisher's exact tests were used, as appropriate, for
categorical data, and two-tailed t-tests to assess differences for
age at onset. Logistic regression was used to test for potential confounding
between parental social class and current economic position. Re-analysis of
data omitting the 12 participants classified as sick or ill did not alter the
results substantially. Owing to the relatively low frequencies and their more
qualitative nature, we report only the raw numbers for some of the more
exploratory analyses of young people's explanations for ceasing self-harm.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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Young women were more likely to report starting to self-harm at an earlier age (females: mean 15.0, s.d.=2.1 years; males: mean 16.4, s.d.=2.3; two-tailed t-test t=2.9, d.f.=84, P=0.004), but there was no significant difference in age at onset according to parental social class or current labour market position.
Methods of self-harm
Table 2 shows rates of
self-harm by different methods within the sample as a whole. Cutting, scoring
or scratching were the most common, followed by taking dangerous tablets;
other (typically overtly violent) methods such as burning or punching self
were relatively rare. A clear gender pattern emerged, with young women more
likely to cut themselves or take dangerous tablets. The only difference
according to parental social class was that those from manual backgrounds used
other, more unusual, methods of self-harm (typically a combination of two
methods). Partly reflecting the fact that those in the non-labour market group
had the highest rates of self-harm, this group were most likely to have cut
themselves, taken dangerous tables, or used other methods.
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Reasons for self-harm
Table 3 shows the reasons
cited by those who had self-harmed. Relief of anger was most commonly
reported, followed by wanting to forget about something, relief of anxiety and
desire to kill themselves. This confirms that the main motive behind young
people's self-harm was to relieve negative emotions, with only a small
minority saying they self-harmed in order to elicit attention and help from
others.
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Significant gender differences were found, with young women just under twice as likely to self-harm in order to forget something and nearly three times more likely to cite relief of anxiety. Parental social class and current labour market position were both related to reasons for self-harm, with those from manual backgrounds (35.9%) being much more likely than those from non-manual backgrounds (6.7%) to self–harm to kill themselves. Those from non-manual backgrounds were also more likely to be unclear about why they had harmed themselves. Those in full-time education were more likely to self-harm to reduce anxiety than those in training or work or the non-labour market group (although not significantly so), and those in the non-labour group were more likely to self-harm in order to kill themselves.
People aware of young person's self-harm
The small numbers of those who were currently self-harming (n=20)
made it difficult to establish statistical patterns. According to the young
people's reports, at least one person or agency was aware of their behaviour
in most cases (17 out of 20). All mentioned somebody from their informal
network, most usually a parent (11 out of 20). Formal services were less
likely to be aware of the behaviour (9 out of 20), with GPs more likely (9 out
of 20) than specialist mental heath professionals (4 out of 20) to know; no
young person had told their college or work.
There were no gender differences with respect to who was aware of the self-harm but, despite the small numbers, we found significant differences in parental social class and current labour market position. Those from households with a manual worker as the head or outside the labour market were more likely to confide in a friend. Those outside the labour market were also more likely to tell a psychiatrist or mental health professional about their self-harm; indeed, none of those in full-time education or in work or training had confided in a psychiatrist or mental health professional (further details available from the authors).
Explanations for stopping self-harm
Table 4 shows the main
explanations given by participants as to why they had stopped self-harming,
according to gender, parental social class and current labour market position.
The most frequent reason was that the young person had realised how damaging
or futile it was to self-harm or how it hurt others (sometimes both). The
second most frequent reason was that the behaviour was a single episode or
represented a transient period of self-harm. This was closely followed by the
development of a better coping strategy, feeling better (either due to
circumstances or events), or finding a purpose in life. The least common
explanation was gaining external help from professionals, close friends or an
unspecified source. Only five young people specifically mentioned
psychologists or psychiatrists.
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Although the overall gender difference for self-harm was not significant, all who stated that they had ceased to self-harm because of professional help or help from friends were young women. There were no differences in relation to parental social class, but current labour market position was strongly associated with reason for cessation, although the small numbers in each category suggest caution in interpretation. Those in full-time education were more likely to attribute their self-harm to a temporary phase, particularly compared with those outside the labour market. Those in training or work were more likely to attribute stopping their self-harm to `coping better'. Half the young people outside the labour market attributed either upset to family, friends or dependants, or realising the futility/stupidity of harm to self as reasons.
Service use
Overall, no gender differences were found in service use, and the only
difference according to social class was that those from a manual background
were more likely to present to an accident and emergency department. Young
people currently outside the labour market appeared to be the highest users of
statutory services, with elevated use of psychiatric, accident and emergency,
Children's Panel and social work services.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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We found that the main motive behind most young people's self-harm was to relieve negative emotions. This is consistent with the few population-based studies, which have suggested that young people who self-harm may have limited coping strategies to deal with emotional difficulties or may be exposed to elevated stress levels. For example, the Child and Adolescent Self-Harm in Europe Study found that the most common immediate reason for self-harm was `to find relief from a terrible state of mind', or `wanting to die', but other, less common, reasons included `to punish self' and to bring their distress to others' attention (Rodham et al, 2004). Similar reasons are also given by clinic attendees (Nock & Prinstein, 2004).
Previous studies have identified gender as an important predictor of self-harm, with a higher prevalence among young women (Hawton et al, 2002; Hawton & James, 2005; Skegg, 2005). Although our study found an excess of females for lifetime self-harm, current rates were similar for both genders. Young women were more likely to state that they would self-harm to reduce anxiety but, counter to traditional gender differences, reducing anger via self-harm was unrelated to gender. In addition, young women were more likely to self-harm by cutting or taking tablets, whereas young men were more likely to use violent methods, as in other studies (Lewinsohn et al, 1996). We found no gender difference in relation to the number of young people reporting that they self-harmed to kill themselves. This contrasts with reported gender differences in suicide rates (Skegg, 2005) and may indicate that gender differences in completed suicides could be partially attributed to gender differences in the lethality of their chosen methods of self-harm. None of the young men said that either professional or more informal help was a primary factor in stopping self-harm, but 8 out of 40 young women said this was the main reason for cessation. One possible explanation is that current professional therapeutic interventions are more tailored towards women, who may find it easier to discuss emotional difficulties than men (van Beinum, 2003; Biddle et al, 2004).
Previous studies have shown that rates of suicide, attempted suicide and self-harm are related to socio-economic factors, although the relationship is by no means straightforward (Platt & Hawton, 2002; Rehkopf & Buka, 2006). In our study, contrary to previous research, the overall prevalence of self-harm was not strongly related to parental social class, although one specific reason (`killing myself') was more often cited by young people from manual social backgrounds. The lack of association with social class is unexpected but is consistent with evidence of equalisation in health among young people in contemporary society (West & Sweeting, 2004). When we compared the relative effect of parental social class with current labour market position, we consistently identified current labour market position as the more important factor for self-harm. Young people most at risk were those who were currently unemployed, sick or outside the labour market. This closely mirrors the results of a previous study of the impact of youth unemployment on suicidal behaviour among 18-year-olds in the same geographical area (West, & Sweeting, 1996).
Other results confirm the greater severity of self-harm among those outside the labour market, with nearly half (10 out of 23) explaining that their reason for self-harm was to kill themselves, and many reporting high service use, particularly of mental health services. However, service use may not have been related solely to self-harm, as this group are likely to have other psychological or behavioural problems that increase their use of statutory services. Few outside the labour market attributed their self-harm to a transitory phase, indicating a chronic problem, and none of the 12 who had ceased to self-harm said that specialist health services were useful in supporting them to stop.
For young people in education self-harm was more likely to be a transitory reaction to specific stress, such as examinations or academic pressures, which have previously been related to psychological distress in this cohort (West & Sweeting, 2003). For many in this group, self-harm might have been an adaptive coping mechanism to deal with temporary anxiety states and not something for which they felt they needed external help. This is compatible with research suggesting that young people who self-harm are less likely to use other coping strategies in times of stress (Evans et al, 2005). This is supported by a recent study which found that young people with anxiety disorders were least likely to use statutory services (Ford et al, 2006). Furthermore, those in our study who were currently self-harming, and who were in education, work or training, tended to be more secretive, nearly always concealing their behaviour from professionals, parents or friends, and not disclosing problems at work or college.
Study limitations
This study is restricted to 18- to 20-year-olds and therefore conclusions
about self-harm in other age groups are not possible. Glasgow has both a
relatively high level of deprivation and a high concentration of colleges and
universities, and this may have boosted the power of this study to detect
differences between students, those employed and those outside the labour
market. Attrition may also be important, since it tends to disproportionally
affect those from disadvantaged backgrounds. However, applying weights to
adjust for this had negligible effects on the results, suggesting it was not a
factor. The study relies on young people's reports of self-harm, but this
itself may be socially patterned. Owing to the relative simplicity of this
analysis there is always the possibility of omitting relevant variables. For
instance, the small numbers did not allow investigation of the impact of
affective and psychotic disorders on self-harm. Similarly, those outside the
labour market were a heterogeneous group but their small numbers did not allow
for a more detailed investigation of possible subgroup differences. However,
despite these limitations, this study represents one of the largest
population-based studies of self-harm in this age group.
Implications
The transient nature of self-harm behaviour found in young people in
employment or education suggests a better clinical outcome for this group,
despite their reluctance to access help. The results reported here suggest
that the most acceptable supports for these two groups would be approaches
that emphasise developing personal coping skills. In contrast, those young
people who are unemployed, sick or not in full-time education are of greater
concern. They are more likely to be engaging in chronic self-harm and to be
actively trying to kill themselves. An important finding was that, in our
study, 45% of young people who had self-harmed were known to their GP,
compared with 4% in Australia (De Leo &
Heller, 2004) and 13% in New Zealand
(Nada-Raja et al,
2003). Therefore, Scottish GPs might be a means of targeting
intervention. However, although a number of respondents said that they had
accessed specialist services, they often had not found them particularly
helpful. More effective interventions for this group of vulnerable young
people are urgently required and, in particular, training and additional
support for GPs. Targeting upstream causes (social disadvantage and chaotic
personal circumstances) are likely to prove more effective than biomedical
interventions alone (Platt et al,
2005).
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ACKNOWLEDGMENTS |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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REFERENCES |
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Received for publication December 5, 2006. Revision received March 6, 2007. Accepted for publication March 27, 2007.
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| Psychiatric Bulletin | Advances in Psychiatric Treatment | All RCPsych Journals |
