What Drives People to Self-Harm and What Does it Mean for Insurers?
When thinking about self-harm, we most associate it with youth. More than half of 11-14 year olds and eight out of ten 18-21 year olds have self-harmed - or know someone who has - according to the results of a UK poll undertaken during 2015.1 The number of children in England and Wales admitted to hospital after self-harming has risen 14% over the past three years.2 Low self-esteem, poor body-image and bullying are obvious causes. However, self-harm is also common among older adults with multiple life problems.
There's no single reason why one person self-harms and another doesn't - and mental health isn’t always linked. Only around 30% of people who repeatedly self-harm have borderline personality or anxiety disorders, depression or post-traumatic stress.3 It frequently begins with no identifiable psychiatric cause. Difficulties with alcohol or in personal relationships, domestic violence, bereavement, work pressures, in addition to isolation and loneliness - all contribute. Many people fail to seek help; rather they hide the evidence of harm or act in secret, meaning it goes unnoticed and untreated.
It is often difficult for others to understand why a person would deliberately harm themselves by cutting, scratching or poisoning with tablets. A critical distinction is made between acts where the person’s intention is to end his or her life and those where they are not. This latter group is called non-suicidal self-injury (NSSI). Individuals in this group self-harm when they are overwhelmed by psychological distress. The pain brings relief from the distress, feelings of anxiety, shame or guilt.
While these groups may appear clearly differentiated, they are linked in complex ways. A 2015 study found that self-harm increased the risk of attempting suicide “seven-fold” and that clinicians should not just dismiss the behaviour as “nothing serious.”4 Individualized clinical support has a key role in suicide prevention. Cognitive therapy is used to build resilience. Antidepressants help to ease anxiety and improve well-being but there are too few trials of other promising interventions to conclude as to their effectiveness.5
Assessing suicide risk is a complex task for clinicians. It involves identifying the presence of intent and mental illness, in addition to exploring the immediate causes of the problems and the more enduring social, psychological and medical issues that the individual experiences. Unfortunately, the formal risk assessment instruments do not perform well, and the risk factors identified in the literature are so common in mental health practice that they rarely help in a given individual. Predicting rare events is difficult.
As a result, people who self-harm present a similar dilemma at underwriting because the majority will not end their lives by suicide. It is important that we not assume the worst outcome is inevitable. Underwriters should look for evidence of suicidal intent, the nature of any attempt (for instance, violent means such as drowning, hanging or jumping), and a diagnosis of mental illness - in addition to the proximal causes of the harm - and always bear in mind that the suicide risk diminishes over time since the last act of harm.
- Townsend, E. et al., Self-harm and life problems: findings from the Multicentre Study of Self-harm in England, Social Psychiatry and Psychiatric Epidemiology, February 2016, v51, issue 2, 183-192.
- Dickstein, D. et al., Self-injurious implicit attitudes among adolescent suicide attempters versus those engaged in non-suicidal self-injury, Journal of Child Psychology and Psychiatry, 2015.
- Gunnell, D et al., Psychosocial interventions following self-harm in adults: a systematic review and meta-analysis, The Lancet Psychiatry Vol 3, No 8 740-750, 2016.