People who self-harm: rapid evidence review and survey of practitioner perspectives

Rapid Evidence Review

Methodology

A rapid evidence review was conducted to identify barriers and facilitators experienced by individuals when accessing, attempting to access, and engaging with support for self-harm. Due to time constraints, a rapid evidence review was carried out rather than a systematic review. Therefore, the review does not aim to comprehensively cover all existing research on the topic but rather highlights key themes and insights from recent research. This evidence review provides an overview of research published between 2014 and 2024, with a primary focus on research from the United Kingdom.

Search Strategy

A search of key databases was conducted using search terms developed in collaboration with the Scottish Government Library. The search covered the Scottish Government’s Knowledge and Evidence library (which includes over 60 databases) and Google Scholar. The process began in June 2024 and concluded in August 2024. Grey literature^[1] was also searched using the same terms on OpenGrey, and reference lists of selected studies were hand-searched for additional sources. A SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, and Research type) table was designed to organise the search terms. Full search terms are provided in Appendix 1.

Inclusion and Exclusion Criteria

The following criteria were used to determine which studies were included in and excluded from this review.

Inclusion criteria

• Research focused on people’s experiences of help-seeking for self-harm, including barriers and/or facilitators to accessing and engaging with support from:
  • Formal sources (e.g. primary care, A&E, emergency services, Community Adolescent Mental Health Services (CAMHS), helplines).
  • Informal sources (e.g. peer support, teachers, family members).
• Studies using quantitative, qualitative, or mixed methods.
• Grey literature, including reports, theses, and surveys conducted by non-profit organisations or public sector bodies.
• Research conducted in, or relevant to, the UK or Ireland.
• Research published between 2014 and 2024.
• Studies including any age group.
• Publications available in English.

Exclusion criteria

• Research that does not explore the experiences of people who self-harm in accessing or engaging with support or services.
• Systematic, scoping, or other review articles (e.g. meta-analyses).
• Research conducted outside the UK or Ireland, or not relevant to the UK/Ireland context.
• Research published before 2014.
• Publications not available in English.

Study Selection Process

Study selection followed a two-stage process. Firstly, titles and abstracts were screened against the inclusion criteria. Studies that clearly did not meet the criteria were excluded at this stage, and their full texts were not reviewed. Secondly, the full texts of potentially relevant studies were assessed in more detail. Data were extracted from studies that met the inclusion criteria.

The initial database search yielded 944 results. After the first stage of screening, 83 studies progressed to full-text review, while 861 were excluded. At the full-text stage, 18 studies met the inclusion criteria and were included in the review. Common reasons for exclusion at this stage were that the study did not focus on self-harm or lacked sufficient information to confirm eligibility. An additional 9 studies were identified through hand-searching reference lists, charity publications, and grey literature sources, bringing the total number of included studies to 27.

Overview of Studies Included in Rapid Evidence Review

This review includes 27 studies exploring the views and experiences of people who self-harm when seeking help and accessing services for self-harm. A detailed breakdown of the study characteristics can be found in Appendix 2.

The majority of studies were conducted in the UK, with one exception from Ireland^[2] (Nearchou et al., 2018). Thirteen studies were specifically based in England, with one study each from Northern Ireland and Scotland. The remaining studies did not specify a particular region but were UK-wide. It is important to note that service provision may vary across different parts of the UK, including Scotland, which could affect how findings from other regions apply in the Scottish context.

The majority of studies in this review used qualitative research methods. Twenty studies adopted a qualitative approach, most commonly semi-structured interviews. Four studies used quantitative methods, enabling larger sample sizes. Three studies employed mixed methods, combining qualitative and quantitative data.

Studies primarily focused on the experiences of people who self-harm when accessing support from primary care services or A&E departments, while a few explored experiences within secondary care services. Participants were drawn from a range of settings and contexts, including universities, secondary schools, prisons, care-experienced settings, residential or secure care, voluntary and community organisations, counselling services, and psychological therapy services. One study also explored experiences of accessing support during the COVID-19 pandemic.

The studies varied in the demographic data they reported, with some choosing not to collect detailed information. In some cases, this decision reflected concerns that requesting such data could deter individuals who self-harm from participating, particularly due to confidentiality issues.

Thirteen studies focused specifically on young people, particularly adolescents and young adults. Ten studies included adults across a range of ages, although the average age tended to be below 40. One study concentrated specifically on the experiences of older adults.

Women were overrepresented in many studies, with 15 reporting predominantly female samples^[3]. Two studies focused specifically on women’s experiences, and one on men. Two quantitative studies reported a gender-balanced sample, as did one qualitative study.

There was limited representation of minority ethnic groups, with most participants reported as being White British.

People with disabilities were generally underrepresented. Only one study specifically explored the experiences of individuals with autism.

The inclusion of predominantly qualitative research in this review provides valuable insights into the lived experiences of people who self-harm, which is essential for understanding complex and sensitive topics such as help-seeking and access to services. These studies offer rich insights into the lived experiences of individuals who self-harm and the barriers they face when accessing support. However, there are limitations, particularly in relation to small sample sizes and limited generalisability.

In addition, there was a notable lack of studies reporting on population groups that may be at higher risk of self-harm, such as people from ethnic minority backgrounds, LGBT+ people, and people with disabilities, as highlighted in the Self harm strategy and action plan 2023 to 2027: equality impact assessment. As a result, the findings from this review may not be fully representative or applicable across all population groups.

Key Findings from the Rapid Evidence Review

This section presents the findings from the rapid evidence review, which identified a range of individual and service-related barriers to accessing support and services for individuals who self-harm. The review also highlights several facilitators that can help overcome these barriers and improve engagement with support and services.

Individual Barriers to Accessing Support for Self-Harm

This section explores the individual barriers that may prevent people from seeking help for self-harm. This research defines individual barriers as personal and social factors within or close to the individual that influence their willingness or ability to seek help. The following evidence highlights individual barriers such as fear of judgement or negative reactions, difficulties recognising when support is needed, self-stigma, unhelpful reactions and responses to disclosure of self-harm by close relations, and confidentiality concerns. The review also provides insight into potential age and gender differences in help-seeking for self-harm.

Fear of Judgement or Reaction

The evidence review indicates that fear of judgment or negative reactions can deter help-seeking for self-harm support. Geulayov et al. (2022) conducted a survey involving 10,560 secondary school students aged 12-18 years in England to explore help-seeking behaviours related to self-harm. Of the 1,457 students who reported having ever self-harmed, they found that around a quarter oavoided help-seeking because they did not want the associated stigma, while half were worried about what people might say about them. Long’s (2018) qualitative study of adults with a history of self-harm found that fear of judgement often prevents them from seeking help. Participants described self-harm as a taboo topic, with one stating they were “absolutely petrified of… judgement.” Many felt this stigma was deeply rooted and unlikely to change, and some expressed a desire to stop self-harming but were too afraid to seek professional support.

When discussing seeking professional help (for example, from GPs), young people shared concerns about being judged and feeling ashamed due to perceived stigma which acted as a barrier to seeking support (McAndrew & Warne, 2014). Similarly, Mughal et al. (2021) interviewed young people who had sought support from their GP for self-harm, finding that many anticipated experiencing stigma from health professionals, leading to secrecy and internal shame. Within a UK university setting, students who had self-harmed were interviewed and described sharing stories with other students about their negative experiences with mental health services (such as being unable to get an appointment unless suicidal) which discouraged help-seeking (Tickell et al., 2024).

Anticipating negative opinions from health professionals acted as a barrier to accessing support (Bailey et al., 2019; Cohen, 2019; Mughal et al., 2021). Research found that young people described being worried that disclosing self-harm would make them seem ‘crazy’ and were concerned about what doctors would think of them (Bailey et al., 2019). Prior to their first engagement with GPs for self-harm support, young people feared being hospitalised and being admitted to an inpatient psychiatric unit (Mughal et al., 2021).

Similarly, adult service users shared in interviews and focus groups their fears about how they might be treated by mental health services, including concerns about being ‘locked up’ or held against their will (Cohen, 2019). Bailey et al.’s (2019) study, which included focus groups with GPs, practice nurses, and young people who had self-harmed, found that GPs often hesitated to ask patients about self-harm and lacked confidence in broaching the topic. However, young people in the focus group discussions generally reported they did not mind being asked about self-harm, provided it is done in a non-judgmental manner and accompanied by appropriate reassurance.

Difficulties Recognising When Support is Needed

Evidence from this review suggests that recognising the need for support in people who self-harm can be complex and may only occur when individuals reach a crisis point. Research from England suggests that low help-seeking rates can partly be explained by insufficient knowledge about self-harm risks, as reported in interviews with young people who had sought help from their GP for self-harm (Mughal et al., 2021).

Similar findings come from Camm-Crosbie et al. (2019), who conducted an online survey with autistic adults who accessed treatment for mental health problems, self-harm, and suicidality for the first time. They found that participants often did not recognise the need to seek support for their self-harm until experiencing suicidal ideation. This suggests that acknowledgment of the need for treatment may not occur until distress reaches a crisis point, although the relationship between self-harm and suicidal ideation is often complex and non-linear.

Several studies highlighted the challenges individuals face in recognising their own need for help with their self-harm. For instance, qualitative interviews with young men receiving care from CAMHS in England found that help-seeking often began only after family members, friends, or teachers expressed concern about self-harming behaviours (Hassett and Isbister, 2017). Initially, some participants were confused when encouraged to seek help and did not immediately see their self-harm as requiring external support.

Similarly, Mughal et al. (2021) reported that young people often relied on parents or friends to initiate help-seeking on their behalf or to encourage them to ask for help. For some, speaking to a GP represented the first time they verbalised their engagement in self-harm. This experience was described by some as confrontational and initially uncomfortable. Others felt a sense of relief due to the challenge of articulating their internal struggles associated with self-harm. In Harris’ (2019) interviews with adults who had presented to A&E due to self-harm, some participants described reaching out for help as a significant moment in their lives, requiring considerable bravery.

Self-stigma

Evidence shows that self-stigma can act as a barrier to seeking support for self-harm. It is common for people to see their self-harm as burdensome for those around them. Geulayov et al. (2022) reported that 55% of students they surveyed who had ever self-harmed were concerned that seeking help would make them a burden. This contributed to non-disclosure within friendship groups and families.

Concern about being seen as a burden seemed to be a particular obstacle to seeking professional support for self-harm during the COVID-19 pandemic, due to the widespread understanding of the pressure on the NHS. For some people who self-harmed, the pandemic exacerbated feelings of unworthiness and led to the perception that other health needs were more deserving of treatment (Sass et al., 2022).

Self-stigma, which can be understood as the internalisation of public stigma (Long, 2018), was a finding noted in Quinlivan et al’s (2023) qualitative survey of patients with experience of self-harm. Survey participants also reported feeling unworthy of receiving support from mental health services. Similarly, adults in Long’s (2018) qualitative study of adults with a history of self-harm showed that the internalisation of public stigma reduced individuals’ self-esteem and self-worth. Participants in the study stated that they worried about how society would perceive them, because of their self-harm, and how it may impact their future, including their ability to gain employment or achieve personal goals. Self-stigma can lead to people hiding their self-harm, including by masking emotions in social interactions, physically hiding wounds using bracelets or clothing, and creating ‘cover stories’ (Long, 2018, Edwards-Bailey et al., 2023).

Unhelpful Reactions and Responses to Disclosure of Self-harm by Close Relations

Several studies in the review reported that disclosing self-harm is often difficult, and that negative reactions from close relations may discourage individuals from seeking support. Geulayov et al. (2022) reported that a quarter of the school students they surveyed who self-harmed used their parents as their source of support. However, research also indicates that unhelpful responses from parents can negatively impact their likelihood to seek other forms of support. For example, in interviews with adolescent females who had self-harmed within the last six months, Wadman et al. (2018) found that they were discouraged from ongoing disclosure when parents responded in a dismissive manner or became overly emotional upon discovering self-harming behaviours. Parents’ initial reactions to disclosures of self-harm were found to play a crucial role in whether young people continue to seek their support. Many young people in the study expressed feeling responsible for their parents’ emotions and were reluctant to cause them distress.

As people move into adulthood, the reactions of partners, friends and family members to self-harm become particularly impactful (Edwards-Bailey et al., 2023; Tickell et al., 2024). Edwards-Bailey et al (2023) interviewed UK university students with experiences of self-harm during their studies. They reported that when someone discloses self-harm and is met with a highly distressed reaction, it is often interpreted as pressure to stop engaging in self-harm. If stopping is not possible, this can lead to people feeling guilt and shame, and individuals may conceal their self-harm to avoid causing further distress to others.

Other potentially harmful responses include ignoring the person’s disclosure of self-harm or ignoring the person in general and asking them to cover their wounds. These responses were said to convey pejorative judgement and a misunderstanding of why someone would self-harm (Edwards-Bailey et al., 2023). More positive responses involved being listened to and having family or friends take the time to understand that self-harm was being used as a coping mechanism for anxiety, stress, or low mood (Tickell et al., 2024).

Confidentiality Concerns and Fear of Disclosure

Evidence collated in this review highlights that concerns about confidentiality and the potential consequences of disclosing self-harm can be an anxiety for individuals, as it raises fears about who this information will be shared with and how this might impact other areas of people’s lives.

Several studies reported that young people worried about confidentiality when disclosing self-harm to health professionals. For example, whether family members would be told about their self-harm without their consent, leading to feelings that there was no one they could trust to confide in (Nearchou et al., 2018; Geulayov et al., 2022). Some of these fears can originate from experiences that had been shared by fellow young people who had seen a GP about their self-harm (Mughal et al., 2021).

Tickell et al (2024) reported that university students were hesitant to seek support for self-harm because of concerns about confidentiality and how knowledge of their self-harm may impact their studies or future employment prospects. Some had experienced university staff suggesting that they take time out of university or drop-out completely leaving them feeling as though they had to choose between their studies and addressing their mental health.

Cohen’s (2019) study with adults who attended A&E for self-harm highlighted similar concerns about confidentiality. These concerns were particularly voiced around whether the information they disclosed would mean that social services were contacted and whether this would impact access to their children. In another study exploring the experiences of people presenting to A&E for self-harm, some individuals reported leaving hospital, or disengaging from support, before receiving treatment due to the fear of consequences from disclosing self-harm and who this information would be shared with (Harris, 2019).

Age and Gender Differences in Seeking Support

Some studies in the review suggest that there are variations in help seeking behaviours across age groups. Adolescence was highlighted as a particularly challenging time for help-seeking, due to developmental transition towards a desire for independence and autonomy. Geulayov et al’s (2022) survey of high school students showed that around one in three within their sample had not sought support following engaging in self-harm. Findings from a survey conducted by Nearchou et al. (2018) show that even amongst the adolescent age group (12-18 years), there are age differences in how willing adolescents are to seek help. The older adolescents become, the less likely they are to seek support for self-harm. This may be related to an increased awareness, and concern, about possible stigma associated with self-harm or receiving mental health support (Berger, Hasking & Martin, 2017).

Tickell et al. (2024) suggested that the transition between school and university can also present significant changes for accessing support for self-harm. Students typically have to establish new forms of formal and informal support and may be seeking help from adult mental health services for the first time. This life stage may also be the first time that individuals have to personally seek support, as they are no longer relying on prompting from parents or teachers. This may suggest that older adolescents and young adults can find it challenging to proactively ask for support for self-harm.

A study by Troya et al. (2019) with older adults (60+ years) showed that self-harm is prevalent in this age group but tends to attract less attention. Their findings suggest that self-harm is more hidden in older adults as they often keep their self-harm a secret. Non-disclosure was related to feelings of shame and embarrassment, with one participant stating that being older means that they “should know better”.

As well as age differences, there may be gender differences in help seeking behaviours. Nearchou et al. (2018) found that boys reported being more likely to seek help for self-harm compared to girls. However, this gender difference was not observed in their findings for help-seeking related to depression or anxiety, suggesting that it may be specific to self-harm.

Summary of Individual Barriers

The evidence reviewed has shown that people who self-harm often encounter individual barriers to seeking support. Some individuals may only begin to seek assistance when prompted by others, emphasising their critical role in facilitating access to care.

Findings also suggest that fear of judgment and negative reactions can deter individuals, especially young people, from disclosing their self-harm and accessing support. Additionally, self-stigma, where individuals internalise public stigma, fosters feelings of unworthiness and the perception of being a burden to others, can result in the concealment of self-harm and avoidance of help-seeking.

Research in this review indicates that concerns about confidentiality, such as fears that disclosures will be shared without consent or lead to negative consequences, also discourage individuals from seeking help. Age and gender differences may further shape help-seeking behaviours, according to some studies with older adolescents, young adults, and older adults facing distinct challenges. Finally, unhelpful or distressing responses from close relations appear to reinforce secrecy and shame.

Service Barriers to Accessing Support for Self-Harm

This section of the report explores the service barriers that can prevent individuals from accessing support for self-harm. For the purposes of this research, service barriers are defined as obstacles within the design, delivery, or accessibility of services that restrict access to appropriate support.

Evidence from this review identified several key barriers, including stigma and discrimination from healthcare professionals; distrust in professionals’ ability to support self-harm; lengthy waiting times for treatment; negative past experiences and unmet needs; rigid eligibility criteria that leave some people falling between services; and a lack of tailored services for those who self-harm.

Stigma and Discrimination from Healthcare Professionals

The evidence review highlights that experiences of stigma and discrimination from formal sources of support can act as a barrier to accessing care or services.

Findings from the evidence review show that individuals presenting to A&E with self-harm injuries may encounter stigmatising and discriminatory reactions. Adults in England who attended hospital for self-harm shared their experiences of psychosocial assessments through an online survey (Quinlivan et al., 2021). Many respondents reported feeling stigmatised by healthcare services. Some respondents said they had been told by A&E staff that their attendance was a “waste of time” and that they were “attention-seeking”. In addition, respondents also commented that they had been denied pain relief or treatment in A&E because their injury was self-inflicted, even when suturing was required—or due to assumptions that they would repeat the self-harm or undo any sutures. These responses were interpreted by the respondents as a punishment for their actions. This discrimination and stigmatisation discouraged them from seeking support.

Several studies documented how stigma surrounding self-harm can be compounded for individuals diagnosed with personality disorders, who may encounter dismissive or disbelieving attitudes from healthcare professionals. For instance, one person described A&E staff denying the legitimacy of personality disorders, while another reported being sent home without assessment because self-harm and borderline personality disorder were not viewed as genuine mental health issues (Harris, 2019). Such framing contributes to the stigmatisation of self-harm as a behaviour unworthy of support or intervention. In some cases, repeated presentations to hospital have been met with refusal of care, based on the belief that treatment would reinforce the behaviour (Quinlivan et al., 2022).

Evidence suggests that internalising these stigmatising experiences can lead to self-stigma. Individuals who self-harm shared that they felt undeserving of psychological therapies and became reluctant to ask for help (Quinlivan et al., 2023; Tickell et al., 2024). Examples of this included young people feeling unable to talk about their self-harm because they felt it was ‘demonised’ and deserving of ‘bad treatment’, highlighting the internalisation of discrimination from health professionals towards self-harm (Owens et al., 2016; Tickell et al., 2024).

Distrust in Health Professionals’ Ability to Support Self-Harm

A lack of trust in health professionals’ ability to provide appropriate support for self-harm was identified as a barrier to accessing services in several studies included in the review. In interviews with older adults (Troya et al., 2019) and young people (McAndrew & Warne, 2014), participants expressed doubts about GPs’ capacity to offer adequate help for self-harm. Both younger and older individuals perceived that GPs were more focused on physical health issues than on self-harm. Some felt that GPs were primarily concerned with treating the physical wounds associated with self-harm, rather than addressing the underlying psychological distress. A participant in McAndrew and Warne’s (2014) qualitative study, which involved interviews with young people who had self-harmed, explained that they chose not to disclose their self-harm to a nurse. They stated that while they would have trusted the support provided by a nurse for a physical injury like a broken leg, they would not do so for self-harm.

In Troya et al.’s (2019) qualitative study exploring barriers and facilitators to accessing care within primary care for older adults who self-harm, participants reported that they were typically offered pharmacological treatment rather than psychological support. This was not considered sufficient, with some sharing that medication ‘only masks’ self-harm, and that what they needed instead was the opportunity to talk about what they were struggling with. Similar findings were reported by Mughal et al.’s (2021), with reference to the percived over-medicalisation of treatment for self-harm, and GPs relying on prescribing antidepressants rather than adopting a more holistic approach. This left patients with unmet expectations and that their disclosure of a significant personal concern had been dismissed. Clinicians in A&E being perceived as lacking specific training in responding to self-harm has also been reported in research (Harris, 2019).

Lengthy Waiting Times for Treatment

Findings from this review indicate that long waiting times for self-harm treatment can lead individuals to disengage from support and services. Individuals who self-harmed stressed the urgency of being seen by a healthcare professional as close to the time of self-harming as possible (Mughal et al., 2021; Hulin et al., 2024). However, some individuals who self-harm have experienced a lack of provision of care, unless they were at crisis point, leaving them feeling like they were not a priority (Troya et al., 2019). Similarly, several respondents to an online survey of autistic adults across the UK who had accessed mental health treatment identified long waiting times as a barrier to accessing support (Camm-Crosbie et al., 2019).

Evidence from this review highlighted that people who self-harm can sometimes face long waits for appointments, which can render support ineffective (Samaritans Scotland, 2020; Hulin et al., 2024). Samaritans Scotland’s (2020) survey of people across the UK with lived experience of self-harm found that 15% of respondents did not seek support from their GP surgery because they could not get an appointment quickly enough.

A semi-structured interview study conducted by Hulin et al. (2024) explored the experiences of adults in England who had self-harmed, focusing on their interactions with voluntary, community, and social enterprise services. Several participants described facing long delays and complex pathways to accessing treatment. One individual, for instance, recounted waiting two years for talking therapies, only to discover they had been removed from the waiting list without notification. After contacting their GP, they were prescribed medication and advised to self-refer again. Upon doing so, they were informed of an additional eight-month wait before receiving psychological support.

Some individuals who self-harm use A&E to bridge the gap between the act of self-harming and waiting for psychological assessments and support. Participants described A&E as a “convenient way” to meet their acute needs following self-harm, without engaging in the process of therapy (Cohen, 2019).

Quinlivan et al. (2023) conducted a qualitative survey with patients and carers to explore patients’ experiences of accessing psychological therapies following self-harm. The study highlighted the significant deterioration in mental health that can result from long waiting times. One carer shared that her daughter died by suicide after waiting four months for an initial consultation for psychological support, describing the support as “too little, too late.” Patients also reported increased suicidal ideation, more frequent engagement in self-harm, and a loss of hope and trust in receiving support following long waiting times.

From the perspective of mental health practitioners, the review identified that waiting times can damage therapeutic relationships prior to the first meeting between a patient and their psychologist. A mental health professional working in a psychological liaison team, speaking about people who self-harm and repeatedly attend A&E, described in a semi-structured interview how the experience of waiting for treatment might reduce trust. They explained: “I suppose if I get referred somewhere, and wait and wait, meanwhile self-harm again, and then eventually someone contacts me for something I did such a long time ago. It increases distrust.” (Cohen, 2019).

Negative Past Experiences and Unmet Needs

Based on research in this review, service users have reported negative experiences of engagement and unmet expectations of care across a range of formal and informal self-harm support services.

Holland et al. (2020) used an Audio Computer-Assisted Self-Interview^[4] method with young people, from the East Midlands, to explore their views about the support they received for their self-harm. A key finding from this study was that CAMHS was regarded as both the most and least helpful source of support by many young people for their self-harm. There were no differences in sex, age or whether participants had a history of being looked-after, suggesting there is a polarity in experiences of young people receiving support through CAMHS in this study.

Wadman et al. (2018) interviewed adolescent females about their experiences of self-harm, including accessing support and services. They shared how their experience of CAMHS involved long waiting times, not being offered what they felt were an adequate number of therapy sessions, and inflexible therapeutic strategies. They felt let down at the service level and were left feeling dismissed and unsupported.

Students at a UK inner-city university shared in semi-structured interviews that, while the counselling provided by their university was helpful, the limited number of sessions often meant they were unable to fully address the root causes of their self-harm. Students felt they needed more support and would benefit from longer-term therapy. In these cases, once the six sessions offered by the university ended, students reported being advised to seek private psychotherapy rather than support through the NHS. The financial burden of private treatment for self-harm created challenges for accessibility and led to guilt over having to ask family members for money to receive support (Tickell et al., 2024).

Previous negative interactions with general practice care can result in a hesitancy to seek help for self-harm in the future (Mughal et al., 2021). For example, 14% of respondents in a survey of people lived experience of self-harm reported that previous negative experiences with GPs were a reason they would not seek support from their GP in the future (Samaritans Scotland 2020).

In Cohen’s (2019) qualitative study with service users who self-harm, all of the participants reported negative experiences of accessing secondary mental health services. Traumatic experiences were also reported when presenting to A&E with self-harm, with people reporting feeling dehumanised and that their self-harm was handled insensitively. Other examples of this include people avoiding hospital despite needing treatment (Owens et al., 2016) or because of the negative impact receiving treatment in A&E had on their mental health (Harris, 2019).

In addition to negative past experiences, evidence from this review identified instances where people received what they perceived as inadequate care for self-harm in A&E. Qualitative interviews conducted by Harris (2019) with individuals reporting to A&E in England due to self-harm revealed experiences of staff making errors on forms, staff not following through with care plans, people being given diagnoses that were perceived to be inaccurate, and medication prescriptions being lost by staff. A lack of basic care was experienced by one person who had self-harmed and who did not have their cuts attended to. This resulted in deep scarring and caused ongoing anxiety about the appearance of the scars. Another person in the study stated that the perceived lack of care they received from A&E meant that they no longer felt comfortable seeking emergency treatment for their self-harm, even in very serious circumstances, such as an overdose.

Based on research in this review, some services were found to rely on referring people to A&E for self-harm because this would guarantee that they would be attended to. In Quinlivan et al.’s (2022) quantitave study investigating why some patients who had self-harmed and attended hospital did not receive a psychosocial assessment, both patients and practitioners participated in the survey. Paitents described feeling like no one wanted to help them, while practitioners noted that this may also be frustrating for A&E staff, who are under-resourced and experiencing high levels of stress, leading to compassion fatigue and burnout.

The experiences of people accessing A&E for self-harm treatment suggest that it may not always be the most appropriate form of support. As noted in Quinlivan et al.’s research, individuals sometimes left A&E before being assessed by the psychiatric liaison team due to long waiting times, prioritisation, and lack of information about further mental health support. For those who waited for assessment, follow-ups were rare unless a person’s self-harm was deemed life-threatening (Quinlivan et al., 2022).

In interviews with adults living in England who presented to A&E following self-harm, several participants reported receiving no care plan before leaving hospital, which left them feeling lost and unsure of where to get further support (O’Keeffe et al., 2023). One patient reflected that unless the self-harm was severe enough to be considered nearly fatal or a suicide attempt, people were sent home (Quinlivan et al., 2022).

Research in this review also found that people have had negative experiences in inpatient units, including poor security leading to people being able to continue to self-harm while in hospital and uncertainty about what treatment they could receive and when – these experiences led people to conclude that the experience of being an inpatient may exacerbate self-harm and feelings of helplessness (Cohen, 2019). A qualitative study from England found that children and young people admitted to acute paediatric inpatient units often felt they were placed in environments inappropriate for their needs. Some young people who had self-harmed reported being placed in unsuitable wards, including those for patients receiving end-of-life care (Manning et al., 2024).

Rigid Eligibility Criteria and Falling Between Services

Exclusion from formal support due to rigid eligibility criteria and fragmented service pathways emerged as significant barriers to receiving care for self-harm in several studies.

As illustrated in the following quote from a female patient, participants in Quinlivan et al.’s (2023) qualitative survey of patients with experience of self-harm reported falling into gaps between services because their mental heath was deemed to be to poor for one service to be accepted by one service, yet not unwell enough to be accepted by another: “Too mad for IAPT (Improving Access to Psychological Therapies), not mad enough for CMHT (Community Mental Health Team).” Other participants in the study reported being discharged from inpatient treatment in England for self-harm and subsequently offered no follow-up support, which led to significant psychological distress.

Similarly, in Edwards-Bailey et al.’s (2023) interviews with UK university students who had self-harmed, a participant recounted being removed from the university counselling service’s waiting list because they were deemed ‘too risky’ and were advised to contact community services, which also rejected them.

Bergen et al.’s (2023) case study research, which drew on video-recorded assessments, patient and carer interviews, and medical records, explored the factors underlying decisions not to refer people who self-harm to mental health services. One case study, Ann, exemplifies the impact of rigid service criteria. Ann restricted her eating as a form of self-harm and was experiencing suicidal ideation. She received support through her university counselling service but required a higher level of care, particularly for her eating disorder. Ann was denied a referral to eating disorder services due to narrow eligibility criteria, specifically related to her weight and the fact that she was already receiving support. She experienced significant weight loss before becoming eligible for professional help. Ann reflected that if she had been able to ‘access help sooner,’ she might have avoided such severe weight loss and worsening symptoms. The study also found that some practitioners, aware of these criteria, advised patients not to seek support from certain services, leaving them feeling they had nowhere to go.

Studies included in this review also reported how many individuals who self-harm describe feeling like they fall between gaps in services, leaving them without the comprehensive care they need. For example, research participants described being passed around services like “hot potatoes,” facing referral after referral and long waiting times to initiate treatment (Cohen, 2019; Tickell et al., 2024).

A further barrier to accessing support for self-harm found in this reviews, was findings that decribed how some individuals could only receive treatment from one mental health service at a time. As found by research in this review, this criterion can leave people who self-harm being able to access additional support if they are already on a waiting list for another service, leading some to seek private treatment (Quinlivan et al., 2023). Findings from Bergen et al.’s (2023) case study research found that some mental health practitioners believe individuals should address one need at a time when accessing support from multiple services. This was illustrated by a patient’s experience of being denied referral options while seeking support for both alcohol use and mental health. The patient was denied a referral to mental health services until they reduced their alcohol use, on the basis that starting therapy could destabilise them and worsen both self-harm and alcohol misuse. This decision led to deterioration in both areas, ultimately resulting in the individual falling into a coma.

Lack of Tailored Services for People Who Self-harm

This review found that a barrier to accessing and engaging in support is the reported lack of flexibility amongst services to tailor interventions to individual needs. Hulin et al.’s (2024) online interviews with individuals who had accessed support for self-harm in England highlighted only being offered a group support session, whereas they felt they would have benefitted most from one-to-one support with a mental health professional. Participants in this study viewed group sessions as having practical barriers to accessing them due to inflexible scheduling and trying to fit them around full-time employment, education, or childcare. For older adults in particular, accessibility was key to being able to receive support. For example, services not recognising mobility difficulties and the cost of public transport to attend appointments, which impeded their ability to access support (Troya et al., 2019).

In their interviews with adults actively receiving or attempting to engage in support for their self-harm, Sass et al (2022) found that the shift in the delivery of psychological therapies during Covid-19 pandemic, from face-to-face to online or over the phone, caused a barrier for some people as they felt disconnected and unable to discuss their mental health in as much depth as they had done in-person previously. Some felt unable to discuss self-harm whilst at home, as it was not a safe space. It was also reported that the opportunity to travel to receive support was important to some individuals, whilst it may act as a barrier to others who would prefer remote support.

A related barrier to accessing support is a lack of awareness or clarity around available services. Geulayov et al.’s (2022) survey of over 10,000 secondary school students in England found that among those who had self-harmed, over a third had never received support, and 12% reported not seeking help because they were unaware of where to find it. Similarly, Edwards-Bailey et al.’s (2023) interviews with university students across the UK described the process of seeking support for self-harm as “vague and confusing,” suggesting that even when services exist, they may not be clearly communicated or easy to navigate.

When considering care plans for individuals who present to hospital for self-harm, studies noted that individuals reported how they are often given a generic care plan that fails to consider their specific needs. In O’Keeffe et al.’s (2023) qualitative interviews with adults presenting to A&E following a self-harm/suicidal crisis, two out of five participants received a generic plan that advised they continue with their current support strategies. When asked to reflect on the helpfulness of these plans, participants shared that they were not appropriate, and the plan outlined was unrealistic for them. This left them feeling unsupported and dismissed.

Based on their survey of people across the UK with lived experience of self-harm, Samaritans Scotland (2020) concluded that helplines are an underutilised source of support for self-harm, with as few as 1 in 10 people contacting helplines or online support following self-harm. Participants in Sass et al’s (2022) research with adults living in England, actively receiving or attempting to engage in support as a consequence of self-harm during the first Covid-19 lockdown, reported that they would not contact Samaritans for self-harm support and instead relied on their GP or community nurses. The participants cited several reasons for not using Samaritans, including a perception that helplines are not equipped or knowledgeable about self-harm, concerns about technology failures and barriers compared to face-to-face support, and the inability to refer people to secondary mental health services, which limits the ongoing support they can provide.

Summary of Service Barriers

This evidence review suggests that there are numerous service barriers faced by individuals who self-harm when seeking support and accessing services. Stigma can exacerbate the reluctance to seek help, particularly within healthcare environments where individuals report encountering discrimination, reinforcing feelings of unworthiness and a lack of trust in available services. Rigid eligibility criteria were described in some studies as leaving individuals feeling abandoned between services. Studies also indicate that individuals were often deemed too unwell for one service but not unwell enough for another, delaying treatment until individuals reach crisis point. The restriction to using one mental health service at a time was reported to prevent individuals from accessing more comprehensive care, particularly for those with co-occurring needs. These barriers were compounded by lengthy waiting times, which can lead individuals to disengage from services or attend emergency departments as a temporary solution.

Some individuals who self-harm also described being moved between services without receiving adequate support. In addition, many relied on emergency services, such as A&E, but often left without proper care plans or follow-ups, especially if their self-harm was not deemed life-threatening.

The reported lack of services tailored to an individual's needs contributed significantly to feelings of disconnection and dissatisfaction among those seeking support. Accessibility issues further hindered access to care, while shifts to remote consultations during the COVID-19 pandemic were said to leave some feeling isolated and unable to discuss their self-harm safely.

The findings from the evidence review highlight the need for systemic improvements in mental health and related services to ensure they are flexible, inclusive, and responsive to the diverse needs of individuals who self-harm.

Facilitators to Accessing and Engaging in Support for Self-Harm

This section explores the factors that facilitate help-seeking and engagement with support for self-harm, including the benefit of sharing experiences, the accessibility of support from friends, positive experiences with health professionals, collaborative assessments and co-created care plans, and health professionals seeking to understand self-harm and associated triggers.

The Role of Shared Experience in Recovery

Holland et al. (2020) used an Audio Computer-Assisted Self-Interview method to explore young people’s preferences for support with self-harm. The most common answers included a desire for support from people who have similar experiences, such as peer support or support groups for self-harm. University students in Tickell et al.’s (2024) research reported how it was helpful to discuss their experiences of self-harm with peers who had been through similar experiences, as the sense of relatability facilitated open discussions. More structured forms of peer support (e.g., peer support groups) were also seen as particularly helpful among students and helped prevent triggering conversations.

Evidence from the review highlights the value of different forms of support, including peer, professional, and mutual support. In Troya et al.’s (2019) qualitative study exploring barriers and facilitators to accessing care within primary care for older adults who self-harm, more than half of the support workers interviewed had lived experience of self-harm, which helped the attendees of their support groups feel understood. Young men found reassurance in knowing they weren’t alone in facing mental health challenges and self-harm, especially when someone they respected encouraged seeking help through social connection (Hassett & Isbister, 2017). As well as peer support, mutual support between individuals who self-harm can be beneficial, where individuals agree to stop self-harming and support each other (Wadman et al., 2018).

In a prison setting, women in custody who had self-harmed reported in semi-structured interviews that, while they preferred professional support, they valued peer support while awaiting therapy (Griffiths et al., 2019).

The Role of Friends in Providing Support

Findings from Holland et al.’s (2020) study to explore young people’s views about the support they received for their self-harm found that young people who self-harm considered friends, distraction techniques, and pets to be the most helpful resources. Similarly, Wadman et al. (2018) found that young women who had experienced self-harm generally reported positive experiences with peer support. Friends were also found to be a source of emotional support and can help individuals disengage from self-harm behaviours.

Samaritans Scotland (2020) surveyed people across the UK with lived experience of self-harm and reported that 86% of respondents sought support from their friends for self-harm over the course of their lifetime. When compared to the usefulness of seeking support from family members, friends were seen to be preferable, with 43% of respondents describing support from friends as at least moderately useful.

Geulayov et al.’s (2022) survey of secondary school students exploring help-seeking behaviours related to self-harm reported that friends were used more often as sources of support by school-aged children than professional services. In addition, having support from friends and family enabled young people to take the first step towards receiving treatment for self-harm (Camm-Crosbie et al., 2019).

Positive Experiences with Health Professionals

Harris’s (2019) qualitative study with individuals presenting to A&E for self-harm found that even a single positive interaction with a health professional could encourage engagement with support and shift attitudes towards seeking treatment. In McAndrew & Warne’s (2014) qualitative interviews with young people who had self-harmed, they described the specific characteristics of support they felt was particularly helpful for them, including clarifying confidentiality boundaries and creating a safe space to disclose self-harm. A case study in a women’s prison, using focus groups and surveys with women in custody and prison staff, found that when Therapeutic Community^[5] staff adopted an informal approach and treated participants in a friendly manner, which helped reduce the power imbalance. This created a positive therapeutic experience (Griffiths et al., 2019).

According to Mughal et al. (2021), key elements of a successful consultation with a GP about self-harm, based on their qualitative interviews with young people who sought help from their GP for self-harm, were shared decision making, understanding the best course of action for the individual, and personalising care (Mughal et al., 2021). Young people in Quinlivan et al’s (2023) qualitative survey with patients and carers to explore patients’ experiences of accessing psychological therapies following self-harm suggested that building a relationship with their GP was important to mitigate some uncertainty and distress during long waiting times to psychological therapies, and this process would benefit from longer appointment times and continuity of care to give space to develop rapport.

University students with a history of self-harm shared that, although they initially felt hesitant to disclose their experiences, being asked about self-harm was acceptable when approached with empathy. They described helpful interactions as those where GPs offered reassurance — for example, saying “it’s gonna be ok” or reminding them that “no matter what you’re going through, there is people there that can help” (Edwards-Bailey et al., 2023).

Secondary analysis by Owens et al (2016) of an online discussion forum involving young people who had self-harmed found that engagement in treatment was facilitated when health professionals were considerate of potential triggers. Examples included asking permission before taking blood samples, avoiding requests to roll up sleeves during blood pressure checks, and offering a choice in the gender of professionals. Young people also valued when staff sought to understand the functions of self-harm and showed willingness to learn about their behaviour.

Findings from the review also suggests that good communication between hospital staff and ensuring medical notes are read in advance reduced patient frustration with having to explain their story multiple times to different people. Patients benefitted from being reassured that they acted appropriately by presenting to hospital, combating the shame and guilt some people experience as result of self-stigmatising their self-harm (Quinlivan et al., 2021).

Collaborative Assessments and Co-Produced Care Plans

Evidence identified by this review found that when health professionals work alongside patients to co-produce care plans and utilise collaborative assessment, people who self-harm are more likely to engage in support for self-harm. Harris’s (2019) qualitative study highlighted that when people who self-harm present to hospital for treatment, the initial assessment process can be an anxiety-inducing experience and might be the first time they have disclosed their self-harm. The communication style of the professional conducting the mental health assessment was also considered as important, with active and engaging listening preferred because this helped patients feel listened to and understood. Allowing an adequate length of time for the assessment to take place was also felt to be key to ensuring patients do not feel rushed and can adequately verbalise their experience.

Several studies have found that collaborative discussions and co-produced care plans help reduce patient anxiety and provide clarity about treatment following self-harm. Actionable outcomes and a clear, co-produced plan between patient and support professional for going forward validated patients’ help-seeking (Quinlivan et al., 2021). In O’Keeffe et al.’s (2023) qualitative interviews with people presenting to emergency departments for self-harm, two in five participants considered the care plan they received to be personalised and appropriate, having been co-designed between patient and professional, and resulted from professionals taking time to understand patients’ specific circumstances and history. These plans were perceived to be helpful because they included new information and planning, such as information about a support service that they had not been aware of or accessed before. Helpful care plans were designed in a holistic manner, incorporating options for formal and informal sources of support. This approach meant that patients left hospital with a clearer understanding of where and how they could access support for their self-harm.

Johnson et al. (2017) interviewed young people living in residential or secure care who self-harm about what staff supports they thought were effective and what were counter-productive in order to improve their care. Participants cited a collaborative approach as being helpful. They suggested that staff should focus on calming them down before trying to discuss self-harm, and taking a compassionate approach by asking what they can do to help, finding someone they trust to confide in and offering comfort with a hug, for example.

Waiting Times and Duration of Support

A facilitator to accessing primary care from GPs was reducing waiting times for appointments, due to the urgency of needing support for self-harm at the time of engaging in the behaviour (McAndrew & Warne, 2014). When experiencing long waiting times and the associated distress, some adult participants in Hulin et al.’s (2024) online interviews with people who self-harmed reported that using drop-in services was beneficial because they were available when they most needed the support. An example of this is university students speaking to wellbeing officers while awaiting counselling (Hulin et al, 2024).

Bailey et al.’s (2019) focus groups, which included GPs, practice nurses, and young people with lived experience of self-harm, found that young people felt longer appointments with GPs would improve the support offered for self-harm. Young people specifcally said that a 10-minute appointment was insufficient to disclose their self-harm and to develop a meaningful support plan. When longer appointments were implemented, young people felt less rushed and found the support useful.

Summary of Facilitators

This section highlights facilitators identified in the evidence review for help-seeking and engagement in support for self-harm. Sharing experiences with peers who have similar struggles was described in some studies as a significant facilitator, as young people often found comfort and connection in organised peer support groups. Moreover, the accessibility of support from friends appeared to play a vital role in seeking support for and disengaging with self-harm, with many young people reporting that friendships provide essential emotional support, helping them take initial steps toward professional support.

Positive interactions with health professionals were reported to be pivotal in encouraging engagement with treatment. Characteristics such as creating a safe, non-judgmental environment, active listening, and understanding individual triggers were said to contribute to building trust and rapport. Furthermore, collaborative assessments and personalised care plans were found in some studies to enhance the therapeutic experience, as they validated individuals' help-seeking behaviours and ensure that care is tailored to their unique circumstances. It was suggested that reducing waiting times and providing longer appointments could reduce barriers to accessing support and improve timely access to appropriate support for individuals experiencing self-harm.

Conclusion

This evidence review highlights the multifaceted challenges faced by individuals who self-harm in accessing and engaging with support services. Individual barriers, such as a fear of judgment and negative reactions, were found to play a significant role in discouraging individuals from seeking help. Furthermore, the stigma surrounding self-harm, both publicly and from self-stigma, can exacerbate feelings of unworthiness and isolation. These barriers were found to be further complicated by other service barriers, including rigid eligibility criteria and lengthy waiting times, which often left individuals feeling like they had nowhere to go to receive support and disengaging with services.

This review also highlights key facilitators that may enhance help-seeking behaviours and access to support among people who self-harm. Positive peer interactions and supportive friendships were found to be critical for encouraging individuals to seek professional help, emphasising the importance of relatable support networks. Additionally, constructive experiences with healthcare professionals, characterised by empathy, active listening, and collaborative treatment planning, were found to be important for building trust and ensuring individuals feel understood.