Mental health articles

OF mental health care and mentally ill

The relationship between self-harm and suicide

In England, around 5000 people per year kill themselves, and suicide is the most common cause of death in men under 35. It is important to remember that the death of an individual impacts on his community, family and society in general. One of the target groups that the government has identified for reducing suicide rates is the highrisk group of clients who commit suicide in the year following an incident of deliberate self-harm. If this group is combined with people who are currently, or have recently been, in contact with mental health services, it represents almost half of the number of people who kill themselves each year. Bongar suggests that the ‘murky’ discriminations between selfharm, attempted suicide by a non-lethal method, survived and completed suicide attempts, are of more use to the researcher than the clinician. He argues that any act where someone self-harms or states their intention to do so should be treated as a communication of psychological pain, which should be thoroughly assessed. Bonga views suicide as a complex bio-psychosocial phenomenon which includes the death of those who intended to kill themselves and individuals with patterns of deliberate selfharm who accidentally die as a result of their injuries.

The relationship between suicide and self-harm also depends on the client’s understanding of the risk to his or her own life. Stengel defined attempted suicide as follows: A suicidal attempt is any act inflicted with self destructive intention, however vague and ambiguous. For the clinician, it is safer still to regard all cases of potentially dangerous self-poisoning or self-inflicted injury as suicidal attempts, whatever the victim’s explanation, unless there is clear evidence to the contrary. Potentially dangerous means in this context: believed by the attempter possibly to endanger life. Although there is some value in Stengel’s definition in terms of immediate assessment, it has the potential to devalue the client’s own knowledge, experience and reasons for self-harming. Without question, it is important to find out from the client what their intentions were and are, and in fact this could provide the ‘clear evidence to the contrary’ which Stengel seeks. There are grounds for distinguishing between deliberate self-harm and suicidal thoughts, feelings and actions, as many people who self-harm are not suicidal. Someone who feels suicidal may not act in any way to selfharm. However, the meaning or purpose of self-harm will vary from person to person, and it may be more useful to view deliberate self-harm on a continuum with suicide. The self-inflicted damage to the body may be deliberate but without the intent to harm oneself – for example with tattoos, body piercing, plastic surgery or tribal marking/cutting the face. The selfharm can be deliberate and immediate, such as cutting or taking overdoses, or prolonged, such as starvation or poisoning. In turn, the intent of the person who self-harms may or may not be to end their life. Someone may feel suicidal, have suicidal thoughts but not actually make any attempt to kill himself or herself. Often referred to as attempted or parasuicide, the final group that we can nurse are clients who feel suicidal and make an attempt to end their life, but do survive.

When considering clients who self-harm or attempt suicide it is clear that each group has different but overlapping qualities. In defining self-harm and suicide, a relationship between the two phenomena becomes evident. Displayed on a continuum, in Table 28.2, it shows that although the two acts can be separated in terms of the client’s intent, there are many similarities in feelings and actions. Population studies provide the demographic data for identifying whether or not an individual falls into a high-risk group. This does not however inform the clinician of that individual’s risk. Only by assessing the mechanism and the meaning of an act when somebody selfharms or attempts to commit suicide, can a plan of nursing care be made to address the behaviour.

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