Pharmacy’s role in supporting adults who self-harm

Introduction

The National Institute for Health and Care Excellence ‘Self-harm: assessment, management and preventing recurrence’ guideline was updated in September 2022 to include recommendations that all health and social care professionals should support people who self-harm and that the responsibility goes beyond those with mental health expertise​[1]​. Self-harm can occur at any age and present in any setting. The new guideline sets out the responsibilities of non-mental health specialists when caring for people who self-harm; this includes pharmacy staff (see Box 1). Community pharmacies are the most visited healthcare establishments, and in the Self-harm and Suicide Competence Framework, published by the National Collaborating Centre for Mental Health in 2018, pharmacy staff were recognised as front-line clinical professionals​[2]​.

In this article, the term ‘self-harm’ is used to refer to any act of self-poisoning or self-injury carried out by an individual, irrespective of motivation​[3]​. Self-harm involves a breach of the boundary of the body — either by cutting the skin, or through ingestion of medication or poison. The body boundary connects the external with the internal, the mind and the body, and the self and others​[4]​.

There are several important exclusions that the term self-harm is not intended to cover in this context; these include harm arising from excessive consumption of alcohol or recreational drugs, mismanagement of physical health conditions, body piercing, or starvation arising from anorexia nervosa.

Many healthcare professionals are not educated in risk factors for self-harm and may miss opportunities for detection. It is important for pharmacy staff to be aware that carers, friends or family members of someone who is self-harming may seek help and advice, signposting or acute management. These experiences can be distressing for everyone who is involved.

This article provides a brief overview of self-harm in adults and outlines how pharmacy staff can support people who self-harm. The article also considers the importance of the thoughts and feelings that self-harm may evoke in pharmacy staff and how they should respond.

Types and causes

Self-harm can occur at any age but is most common in young people (individuals aged 8–17 years). Self-harm occurs in all population groups but is more common among people who are socioeconomically disadvantaged, single or divorced and live alone, single parents, or anyone who has a severe lack of social support​[5]​. Most people who attend an emergency department following an act of self-harm will meet criteria for one or more psychiatric diagnoses (e.g. personality disorder, depression and/or psychosis) at the time they are assessed​[6]​. The rate of self-harm is high in people with borderline personality disorder, with estimates ranging from 65–80%​[7]​.

Methods of self-harm can be divided into two broad groups:

• Self-poisoning;
• Self-injury.

The estimated prevalence of lifetime experience of non-suicidal self-harm in the UK is 6.4%; during the lockdowns in response to the COVID-19 pandemic, elevated prevalence was noted among various cohorts of participants surveyed​[8]​. These included women, black, Asian and minority ethnic groups, and people experiencing socioeconomic disadvantage, unemployment, disability, chronic physical illnesses, mental health conditions and a COVID-19 diagnosis​[9]​.

Some estimates suggest there are upwards of 200,000 presentations in England each year for self-harm​[1]​. Studies of attendance at emergency departments following self-harm show that around 80% of people attend following an overdose of prescribed or over-the counter medication, most commonly analgesics or antidepressants​[10]​. A small percentage of overdoses are from illicit drugs or other substances (e.g. household substances or plant material). However, these figures can be misleading because people who self-poison are more likely to seek help than those who self-injure​[5,11]​. General population studies have shown that self-injury may be more common than self-poisoning​[11,12]​. Of those who self-injure, cutting is the most common method​[10,11]​. Less common methods include burning, hanging, stabbing, swallowing or inserting objects, shooting, drowning, and jumping from heights or in front of vehicles. Around one in five people who attend an emergency department following self-harm will harm themselves again in the following year​[13]​.

In England and Wales, 5,583 suicides were registered in 2021; the suicide rate per 100,000 was 5.5 for females and 16.0 for males​[14]​. While there is a link between deliberate self-harm and suicide, deliberate self-harm is not usually intended to end life. Following an act of self-harm, the rate of suicide increases to between 50 and 100 times the rate of suicide in the general population​[3,15]​. Men who self-harm are more than twice as likely to die by suicide as women and the risk increases greatly with age for both genders​[16]​. It has been estimated that a quarter of all people who die by suicide attended an emergency department in the previous year for an earlier self-harm episode​[17]​. In a large, 20-year study, Runeson et al. found that certain methods of self-harm were associated with increased suicide risk. Hanging, strangulation and suffocation were associated with a six-fold increased risk of future successful suicide compared with self-poisoning​[18]​. Around half of people who attend an emergency department following self-harm will have consumed alcohol immediately preceding or as part of the self-harm episode​[10,19]​. For many, this is a factor that complicates immediate management of self-harm because of the effect of impaired judgement and capacity, or by adding to the toxic effects of ingested substances — for example, in the case of paracetamol overdoses​[1]​. Additional information can be found in ‘Suicide: how to recognise the warning signs and deal with disclosure’.

Why does self-harm occur: psychodynamic perspective

Self-harm is a complex act that can have multiple meanings. It involves — more or less consciously — a relationship, external or in the mind. Self-harm can be a way to communicate through actions when words cannot be used; for example, it can be an expression of one’s need for help and care. Those who self-harm may seek to obtain relief from intolerable emotional states or overwhelming situations​[11]​. In many cases, there is a background of previous traumas involving neglect or abuse of the person’s body in infancy or childhood​[4]​.

Self-harm is often viewed in society as deliberately ‘attention-seeking’, a negative behaviour that should be discouraged. Although people who self-harm may be seeking attention, their attention-seeking is a plea for compassion and understanding of their unconscious communications, in which action has taken the place of words​[4]​.

Sutton organised the various meanings of self-harm in patients in a way that may be useful to promote understanding in clinicians (see Box 2)​[20]​.

Supporting patients

As experts in medicines, pharmacy staff are in a position to understand and support patients who might use medication to self-harm. They may be able to identify self-harm, provide psychoeducation and harm reduction, and signpost to appropriate support, including community services​[21]​. These services may include third sector volunteer services, such as the mental health charity Mind UK or NHS mental health services. It is also important to remember professional limitations; for example, that pharmacists are not able to provide social care work or crisis support, but can signpost patients to where they can access these services. When caring for patients who self-harm, pharmacy staff should be able to assess suicide risk; however, Berman et al. explain: “There are no consensually agreed on or valid, reliable risk assessment scales or other instruments that have standardized or simplified the task of assessment. There is no agreed-on strategy for intervening in the life and death decision of the suicidal mind or for treating the suicidal character”​[22]​. This is supported by NICE guidance, which does not recommend the use of risk assessment tools and scales to predict future suicide or repetition of self-harm​[1]​.  However, there are warning signs that should be considered to mobilise concern (see Box 3). High suicide risk may call for action — providing psychological safety, including providing containment, to hold the patient in mind and feel connected can be helpful(see Box 4)​[1]​. 

Management and interventions

NICE states that pharmacological interventions should not be offered specifically for self-harm, based on uncertain evidence, knowledge and experience. While pharmacological treatments do not play a direct role in the management of self-harm or personality disorder, they have a significant indirect part to play in the management of associated conditions. Depression, anxiety disorders and schizophrenia are associated with a higher risk of self-harm, and the pharmacological treatment of these conditions is documented in their respective NICE guidelines​[24–27]​. There have been reports that link lithium treatment with a reduction in suicidal behaviour in patients with mood disorders​[28]​. Other co-existing conditions that may increase the risk of self-harm, such as chronic pain, may also lend themselves to pharmacological treatment​[24]​.

When prescribing drugs for associated mental health conditions in individuals who self-harm, the toxicity of the prescribed drug in overdose should be considered. For example, when prescribing antidepressants, selective serotonin re-uptake inhibitors may be preferred because they are less toxic than other classes of antidepressants. In particular, tricyclic antidepressants are notably more toxic in overdose and should be avoided in people with a history of overdose​[1]​.

There are psychological and psychosocial interventions that can be helpful for self-harm. These interventions vary depending on the individual’s circumstances and readiness for change, with the most appropriate intervention identified following a comprehensive psychosocial assessment. Interventions for self-harm may focus on the behaviour itself or take a more holistic approach by dealing with relationships, cognitions and social factors. If patients are not already engaging with support, pharmacy professionals can support and encourage patients to get in touch with their GP or local mental health community support services. Box 4 provides essential points to remember when supporting people who self-harm.

Supervision, training and self-care

People who self-harm often describe experiencing negative responses from staff in mental health services and emergency departments. This may be linked to professionals’ lack of understanding of the behaviour​[29]​. Patients may also feel that more importance is paid to their physical health, rather than their mental state​[30]​.

“Professionals are often terrified by self-injury. Their normal empathy with others’ distress and their confidence and ability to help often desert them when faced with someone who persistently hurts themselves. This problem reflects a serious and widespread lack of understanding of self-injury, which results in great inconsistency and inadequacies in services” (Arnold, 1995)​[29]​.

Attacks on the body can powerfully offend our usual human sensitivities and mobilise our own anxieties about bodies and vulnerability. In addition, when supporting people who self-harm, pharmacy staff may become the unwitting recipient of the patient’s unwanted feelings. These communications of intolerable feelings are largely unconscious. Feelings of aggression, hatred, hopelessness, desolation, anguish, disgust and despair can be expelled through self-violence or attributing them to someone or something else. Recipients of the patient’s unwanted feelings are paradoxically often the people who are trying to help the patient, as care may be experienced as untrustworthy or even dangerous. This can take a toll on pharmacy staff having to contain the patient’s intolerable feelings, while being persecuted by the patient’s destructiveness and the fear of investigations into the pharmacist’s practice. This can lead to confusion and, if unprocessed, to unhelpful, uncaring and rejecting actions from pharmacy staff[4]. The importance of clinical supervision and other facilitative spaces for pharmacy staff and other professionals involved in the care of people who self-harm must be prioritised. While time is in limited supply, allowing space for supervision, reflective practice and peer discussion is vital in providing good care, reducing burnout, and increasing resilience. Awareness of, and reflection on, thoughts, feelings and responses evoked in the interaction with patients allows pharmacy staff to act more thoughtfully towards the patient and other professionals, rather than becoming defensive or over-reactive; knowing that others have had similar experiences can be helpful.

Case study 1:  A patient tries to buy paracetamol in a community pharmacy

Ben, a man in his mid-40s who has a regular prescription for sertraline, comes into the community pharmacy to buy four boxes of paracetamol. He looks different to usual, less kempt in his appearance. The pharmacy technician remembers the patient bought two boxes of paracetamol yesterday. They explain to him that the pharmacy is only able to sell two packets of paracetamol per day and are curious why he might need so many packets. He is taken aback and uncomfortable by the pharmacy technician’s questions. They ask if he might want to talk with a pharmacist in the consultation space. Ben tells the pharmacist that he wants to have the paracetamol on hand as a “way out” if things get too difficult and he has been drinking himself to “oblivion”. The pharmacist is left feeling very concerned about Ben’s safety. Ben denies that he has any active suicidal plans. He tells the pharmacist that he has overdosed on medication in the past, but did not get any help and still woke up the next day. The pharmacist is worried Ben might harm himself before he is next due to collect his sertraline prescription.

The pharmacist explains to Ben that they cannot sell them the paracetamol knowing his intentions and that they are concerned about his safety. After being told he cannot have the medication, Ben acknowledges that his behaviour is concerning. The pharmacist agrees a safety plan with Ben that he will attend A&E. A few days later, Ben’s partner comes into the pharmacy and tells the pharmacist Ben took an overdose of paracetamol and that he is in hospital recovering. The pharmacist is concerned about hearing the news and worried that they failed to help Ben sufficiently.

The pharmacist should discuss their experience during a team meeting and in supervision, allowing them to process their feelings and reflect on their decision making in a more balanced, less persecutory way. It could be argued that by disclosing his previous suicide attempts directly to the pharmacist, Ben may have been seeking to expel his unacceptable feelings of helplessness and despair on to the pharmacist, to allow him to feel a degree of control. By discussing this in a supportive environment, the pharmacist would be better able to come to terms with their emotional response and use the experience as an opportunity to learn and improve their future practice.

Case study 2: A patient discloses that they are self-harming by cutting to a clinical pharmacist in a GP surgery

The practice pharmacist is undertaking a medication follow up appointment with Gina, who is experiencing side effects on her antidepressant medication after a period of improvement in her mood and anxiety levels. Gina has an established diagnosis of emotionally unstable personality disorder and a history of cutting herself. After talking about some sleep problems, which she attributes to her medication, Gina tells the pharmacist that she is feeling awful, has increased her cutting and is feeling more suicidal than usual. The pharmacist feels concerned and lets Gina know that it would be helpful to ask if one of her colleagues could join. The pharmacist asks the duty doctor, who is new to the practice and busier than usual. Gina tells them the pharmacist is exaggerating and causing a fuss. The pharmacist feels confused about Gina minimising her distress. The duty doctor is annoyed that they have been taken away from their busy clinic unnecessarily and ends the consultation abruptly. The pharmacist feels guilty for disturbing the duty doctor, apologising for taking them away from their clinic.

In a reflective practice meeting, where a colleague from the mental health team joins, the duty doctor should mention the interaction. The team could then piece together the series of responses and feelings to the situation. The pharmacist and duty doctor could hypothesise the reasons why Gina may have reacted in the way she did. It could have been that Gina became scared of any hopeful feelings that she and the pharmacist could have. Perhaps she was worried that feeling better would mean seeing her clinicians less often? The pharmacist’s care was denigrated, and they were left feeling concerned instead of hopeful. The pharmacist’s reaction of concern and her invitation to the duty doctor provoked anger in Gina. By involving the duty doctor, perhaps Gina felt that she was too much to handle. Gina’s anger was subsequently transferred to the duty doctor when she downplayed her distress and the duty doctor felt their time was not being used well. At the time, the duty doctor was unable to reflect on their affective state and instead acted out by chastising the pharmacist and ‘cutting off’ the patient, mirroring the patient’s ‘cutting out’ of intolerable states of mind, which she could only communicate by cutting her body. This left the pharmacist with feelings of helplessness and failure. The reflective practice meeting offers a space for the team to explore and understand these dynamics, repair the team relationship and restore empathy in Gina’s care.