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

Discussion

A rapid evidence review and a survey were conducted to investigate if self-harm can be a barrier to accessing support and services, and what measures can be taken to overcome these barriers. The evidence review examined barriers and facilitators to accessing and engaging with self-harm support, while the survey gathered insights from practitioners about barriers to a broader range of services. Together, the findings suggest that people who self-harm can face a multitude of barriers when trying to access and engage with support and services.

Most of the studies included in the rapid evidence review utilised qualitative methods and involved people with lived experience of self-harm. This resulted in rich, experiential evidence of the many barriers to accessing support and services experienced by people who self-harm, including experiences of mental health services, as well as primary care services like GPs, and emergency care services, particularly A&E. While the review included studies from across the UK and Ireland, it is important to note that service provision may vary regionally, including in Scotland, which could affect how findings from other regions apply in the Scottish context. The studies included in the review also predominantly captured the perspectives of young people and women and girls. Key population characteristics, such as ethnicity, socioeconomic status, disability, sexual orientation, and religion, were often underreported.

While the evidence review investigated the various barriers to accessing support for self-harm, the survey findings indicate that these barriers may also extend to a range of other support services. Individuals who self-harm may experience distinct barriers not only when seeking support and services for self-harm, but also for non-self-harm related support including housing, financial, and educational support.

There was considerable overlap between the barriers identified in the evidence review, and by the practitioners who responded to the survey. The research identified a range of individual barriers to accessing support including the fear of stigma, discrimination, or judgment (Bailey et al., 2019), self-stigma (Long, 2018), and confidentiality concerns around disclosing self-harm (Geulayov et al., 2022). These individual barriers can be further complicated by service-related barriers, including rigid acceptance criteria into services (Bergen et al., 2023), negative past experiences with service providers (Mughal et al., 2021), lengthy waiting times (Hulin et al., 2024), inadequate availability of specialised services (O’Keefe et al., 2023), and inflexible service hours (Wadman et al., 2018). Both individual and service barriers can play a significant role in deterring individuals from seeking help, engaging with services and receiving the support they need.

There were further similarities between the implications of these individual and service barriers reported in the evidence review and survey. For example, some of these barriers may lead to increased frequency engaging in self-harm or feelings of suicidal ideation (Quinlivan et al., 2023), increase the risk of physical injuries or complications (Bergen et al., 2023), as well as other implications such as increased financial stress (Tickell et al., 2024). The survey also illustrated that these barriers may lead to further issues such as not seeking help for non-self-harm related physical health needs, difficulties in maintaining employment or education, and housing instability. These findings underscore the importance of understanding how to overcome both individual and service barriers in order to improve access to support.

The research identified a multitude of barriers, but also highlighted numerous facilitators reported by individuals with a history of self-harm and the practitioners who support them. Accordingly, the remainder of the discussion will examine the barriers uncovered in both the evidence review and survey, alongside strategies that could help address these challenges.

The Role of Stigma, Negative Experiences and Reactions, Self-Stigma, and Confidentiality Concerns on Accessing Support and Services

Stigma and discrimination from service providers emerged as a significant barrier to accessing support, as reported by around half of survey respondents. Respondents described how the people they supported could easily identify various forms of stigma, including service providers having a dismissive attitude towards those presenting with self-harm. Similar responses were highlighted in the review, with individuals who attended A&E for self-harm reporting being denied pain relief or suturing, conveying to these individuals that self-harm was an attention seeking behaviour or they were undeserving of care (Quinlivan et al., 2021, 2022). These stigmatising responses can contribute to perceptions that self-harm does not deserve support and may deter individuals from seeking help in the future.

In addition to the experience of stigma and discrimination, the fear or anticipation of these responses from service providers emerged as a significant barrier to accessing support, as indicated by around two-thirds of survey respondents. Several studies from the review also provided insight into this barrier from the perspective of individuals who have self-harmed. Young people described how anticipated stigma and concerns over what health professionals would think of them led to secrecy and internal shame about their self-harm which hindered seeking help (Long, 2018; Bailey et al., 2019; Mughal et al., 2021). This suggests that, beyond actual experiences of stigma and discrimination, the fear of these types of reactions may further deter individuals from attempting to access or engage with support services. This feeling of anticipated stigma may arise from negative past experiences (Owens et al., 2016), or from hearing about negative experiences of others who have accessed support for their self-harm (Tickell et al., 2024).

Negative past experiences were reported as a barrier to accessing support and services by around four in five survey respondents. Several studies in the review further highlighted how negative past experiences with healthcare services can exacerbate stigma and further deter individuals from seeking help (Mughal et al., 2021). These experiences, along with dismissive or overly emotional reactions from parents, partners and friends, can contribute to individuals who self-harm feeling like they are a burden and become discouraged from ongoing disclosure (Wadman et al., 2018; Cohen, 2019).

Self-stigma was reported to be a barrier to accessing support and services by around two thirds of survey respondents. Evidence suggests that self-stigma can foster a cycle of self-judgment and non-disclosure that hinders individuals from accessing support. For example, self-stigma can contribute to feelings of shame and isolation, which may act as a barrier to help-seeking from services, peers or family (Long, 2018). Some individuals who self-harmed expressed concerns that seeking help would render them a “burden” to others, including friends and family (Geulayov et al., 2022). Self-stigma may also play a role in concerns over confidentiality and sharing information.

Confidentiality concerns were the least frequently reported individual barrier in the survey. Although only a third of respondents identified it as a barrier, evidence from individuals with lived experience underscores its significance. As noted in the evidence review, young people appear to be particularly concerned that health professionals or education staff may share any disclosure about their self-harm with family members, leading them to feeling like they cannot confide in people they are seeking support from (Nearchou et al., 2018; Mughal et al., 2021; Geulayov et al., 2022). As people move into adulthood, confidentiality concerns typically surround the potential impact that their self-harm may have on education and employment prospects (Tickell et al., 2024) or access to their children (Cohen, 2019).

Barriers related to stigma, negative past experiences, and confidentiality concerns may have lasting implications for individuals who self-harm. Repeated exposure to these barriers can lead to reluctance to re-engage with support services, reducing opportunities for care and reinforcing feelings of isolation. The evidence review suggests that these barriers can significantly affect individuals’ ability and willingness to seek help for self-harm. Survey findings further indicate that similar challenges may arise when accessing broader support services, such as housing, education, or financial assistance. Addressing these barriers is therefore essential to improving access and engagement across multiple areas of support.

Improving Understanding and Compassion in Support Services for Self-Harm

Survey respondents often stated that an improved understanding of self-harm among service providers was vital for improving access and engagement with support services. A key component in achieving this was the inclusion of self-harm training across different types of support services—a perspective supported by evidence in the review. For example, if staff were perceived to lack understanding of self-harm this was reported to cause individuals to disengage from support, because they viewed the service provider as being unable to help (McAndrew & Warne, 2014; Harris, 2019). It was considered in the practitioner survey that if professionals across sectors such as mental health, physical healthcare, education, and emergency services (e.g. police) had a better understanding of self-harm, individuals who self-harm could feel more supported within the wider community, rather than relying solely on specialist services. When service providers understand self-harm, they may be more likely to foster a non-judgemental environment where individuals feel listened to, supported, and treated with compassion.

Survey respondents, and individuals with a history of self-harm, whose perspectives were included in the evidence review, identified many similar characteristics of a supportive and compassionate environment. Key characteristics of compassionate support and services included non-judgmental attitudes, empathy, respect for confidentiality, active listening, and reassuring communication that reduces feelings of shame and guilt. Additional elements included fostering trust through informal and respectful interactions, addressing power imbalances, and creating safe environments for disclosure (McAndrew & Warne, 2014; Griffiths et al., 2019; Harris, 2019; Quinlivan et al., 2021).

Importantly, a single positive encounter with a non-judgmental and supportive health professional was reported to significantly shift previous negative attitudes towards receiving support and encourage further engagement (Harris, 2019). This suggests that compassionate support from service providers may help overcome barriers, particularly those stemming from stigma and negative past experiences. However, these facilitators may only be effective for individuals who are willing or able to engage with services. For some, previous negative experiences, such as a lack of care in A&E, may deter re-engagement even in serious situations. Others may struggle to recognise their need for help or lack a supportive network to encourage help-seeking, which is often a crucial first step (Hassett & Isbister, 2017; Mughal et al., 2021).

Personalised and Accessible Support for Self-Harm

Barriers related to the availability of support and services were identified in both the evidence review and practitioner survey. These included a lack of specialist services and person-centred support for self-harm, as well as concerns about staff not having sufficient understanding of self-harm. Survey respondents emphasised that effective support requires recognising the underlying reasons for self-harm, such as trauma or adverse childhood experiences. When individuals encounter services that lack this understanding or fail to offer tailored support, they may feel their needs are unmet, which can discourage engagement.

Several studies highlighted the unmet needs of people who self-harm, particularly in relation to their experiences with GPs. In many cases, individuals reported that their concerns were not fully addressed, with GPs focusing primarily on treating the physical wounds of self-harm rather than exploring the underlying psychological distress (McAndrew & Warne, 2014; Troya et al., 2019). Others reflected their needs being unmet because GPs had an over reliance on prescribing anti-depressants for the treatment of self-harm rather than applying a more holistic approach (Mughal et al., 2021). Additionally, a lack of awareness, particularly regarding conditions like autism, can lead to misunderstandings and further limit the support available to individuals who self-harm (Camm-Crosbie et al., 2019). These findings underscore the need for improved access to specialist services and dedicated practitioners who are trained to support individuals who self-harm within services.

Survey respondents stated that a crucial way to ensure the needs of people who self-harm are met was by adopting a person-centred approach, where support is tailored to an individual's specific needs. As noted in the review, individuals who self-harm strongly prefer personalised support (Hulin et al., 2024) and that a lack of such support can lead them to disengage from services (O’Keefe et al., 2023).

Co-creating care plans was recommended as an effective way to tailor support to an individual’s needs. Survey respondents described how this approach requires staff to build a trusting therapeutic relationship with the individual, helping them to identify and understand their self-harm, explore coping strategies, and collaboratively develop a plan that works for them. Continuity of care with the same practitioner was considered important for co-created care plans because of the value that building a therapeutic relationship can have when receiving care. Evidence from the review showed how co-produced care plans and collaborative assessments enhance engagement with self-harm support (Harris, 2019). Effective care plans are co-designed, patient-centred, and holistic, addressing individual circumstances and incorporating both formal and informal support options (O’Keefe et al., 2023).

Survey respondents recommended that more intensive sessions when individuals seek support for self-harm would also provide the opportunity to explore the underlying issues and causes of self-harm, rather than focusing solely on coping mechanisms. These suggestions were reflected in several studies, where individuals reported that a limited number of counselling sessions or restrictive appointment lengths during GP visits prevented them from addressing the underlying causes of their self-harm and developing a clear recovery plan (Bailey et al., 2019; Tickell et al., 2024).

Providing support that accounts for an individual’s accessibility needs could further help reduce barriers to accessing support. Survey respondents identified that people who they supported encounter a variety of accessibility related barriers, including geographic location, financial barriers (such as the cost of transport), unsuitable appointment delivery method and digital barriers. They suggested that offering support in multiple formats—such as telephone, video, face-to-face, and home or school appointments—could help alleviate some of these barriers. Studies also suggested that there are benefits to offering people varied types of support, depending on the individual (Sass et al., 2022).

Survey respondents also reported on several other accessibility related issues that may act as a barrier to support and services such as a lack of choice regarding the gender of practitioner, limited culturally sensitive services and being unable to bring children or other dependents to appointments. However, there was a lack of evidence in both the review and the survey open text responses that explored the implications of these barriers, or how they could be overcome.

Timely Access to Support Services

Lengthy waiting times can lead to people disengaging with support and services. This barrier was identified by the largest proportion of respondents in the survey. Survey respondents emphasised that quick access to support was critical, particularly when individuals who self-harm experienced a crisis. They noted that if self-harm is not considered “severe” by services then an individual may be placed on a long waiting list which could lessen the effectiveness of support once received. Several studies echoed these findings, for instance individuals who self-harmed stressed that there is an urgency to be seen by a healthcare professional as close to the time of self-harming as possible (Mughal et al., 2021; Hulin et al., 2024). Despite this urgency, some individuals who self-harm have reported encountering long waiting times for NHS support, even when they had experienced a suicide attempt or were actively suicidal (Camm-Crosbie et al., 2019).

Providing a more rapid response approach to support for self-harm was advocated by survey respondents. For example, they recommended more availability of support out of hours, as well as options for self-referrals and same-day appointments. These improvements could enable people who self-harm to receive appropriate support at the right time. Several studies further highlighted the necessity of these suggestions, such as reducing waiting times for accessing primary care, due to the urgency of support following self-harm (McAndrew & Warne, 2014), and the benefits of drop-in services when experiencing long waiting times for formal support (Hulin et al., 2024).

Improving Service Eligibility and Referral Pathways for People Who Self-Harm

People who self-harm are reported to fall between the gaps of different services through restrictive service eligibility criteria and limited referral options. The implications of these service barriers can be particularly damaging for people who self-harm, as demonstrated in both the perspectives of practitioners and evidence in the review from those with lived experience.

Around half of survey respondents indicated that exclusion through restrictive eligibility criteria was a barrier to accessing a range of support and services for individuals who self-harm. It was felt that this could harm recovery, discourage future engagement, and result in inadequate support from other service providers. Survey respondents also expressed concerns that restrictive eligibility criteria and limited referral options could worsen self-harm for those unable to access help. Studies further highlighted the impact of this barrier on individuals who self-harm, with many feeling caught between services due to restrictive acceptance criteria (Quinlivan et al., 2023; Edwards-Bailey et al., 2023). Others described being passed between services with long waits for treatment (Cohen, 2019; Tickell et al., 2024) or feeling they would be dismissed unless their self-harm was life-threatening (Quinlivan et al., 2022). Restrictive service eligibility criteria can require people to address one challenge at a time, which can be particularly harmful for individuals who self-harm and have co-occurring needs, such as substance use. This approach can delay essential care and lead to serious consequences, including worsening mental and physical health, and an increased risk of suicide (Bergen et al., 2023).

Some services may also have a policy of removing an individual from waiting lists following non-attendance to appointments, as reported by half of practitioners. These experiences were noted by some studies, indicating that being removed from waiting lists without proper communication or support can result in significant delays, repeated referrals, and rejection, leaving them feeling unsupported (Edwards-Bailey et al., 2023; Hulin et al., 2024).

Many survey respondents recommended implementing a lower threshold for accessing self-harm care, broadening acceptance criteria for services so that people who self-harm are not excluded from services. Where individuals who self-harm were refused due to eligibility criteria, respondents suggested signposting to alternative services that would not exclude based on self-harm would be valuable, according to survey respondents. Furthermore, follow-up with people after missed appointments, before removing individuals from waiting lists, could provide essential support to those who are most vulnerable and help them avoid losing access to care. Overall, survey respondents strongly supported a "no wrong door" policy, ensuring that if someone does not meet the criteria for one service, they are still guided to a more appropriate option at the initial point of contact.

The Role of Peer and Friend Support in Facilitating Self-Harm Care

The facilitators to accessing support for self-harm identified by survey respondents mainly focused on ways to improve or adapt services to better support individuals who self-harm. However, the evidence review also highlighted the importance of peer and friend support as significant facilitators of care for individuals who self-harm, offering a sense of understanding, relatability, and emotional connection. Peer support helps individuals feel less isolated, encourages open conversations, and motivates them to seek help, particularly when peers or support workers have lived experience of self-harm (Hassett & Isbister, 2017; Troya et al., 2019; Holland et al., 2020; Tickell et al., 2024). Similarly, friends provide accessible, reliable emotional support, assisting individuals in disengaging from self-harming behaviours and taking the initial steps toward seeking treatment. Many young people expressed a preference for this form of support over family or professional resources (Wadman et al., 2018; Camm-Crosbie et al., 2019; Samaritans Scotland, 2020). Therefore, while much of the discussion primarily focuses on service-related facilitators, it is also important to acknowledge the role that peers and friends play in engaging individuals with support and helping them overcome barriers.