Self-harming and suicidality – red flags and effective responses

The stark reality: understanding the prevalence of suicide and self-harm

The National Confidential Inquiry into Suicide and Safety in Mental Health1 looks at data from the years 2009 to 2019. It is worth considering that the landscape of mental health during the COVID pandemic and in the aftermath, has definitely become bleaker. Factors such as isolation, breakdown of relationships, economic hardship, and other mitigating factors have placed additional stress upon people. We know from research that suicide risks increase with additional factors, such as self-harm, alcohol, drug misuse, autism, and eating disorders. Indeed a few pertinent statistics from the National Confidential Inquiry into Suicide and Safety in Mental Health show that suicide deaths among patients in contact with mental health services within 12 months of suicide accounted for 27% of all general population suicides.

The rise in mental health concerns in young adults is reflected in the increase in suicide by patients aged under 18. During the years 2009-2019, there were 1,093 suicides in the general population by people aged under 18, an average of 99 deaths per year. Of these suicides, we can see the correlation with other contributing factors, such as 13% diagnosed with autism and 5% diagnosed with eating disorders. Other demographics that show at-risk groups are 13% of suicides in the over 65s. One of the highest figures shows that 77% of all suicides were unmarried and that 48% lived alone. Loneliness, though not deemed a mental health condition, is clearly shown as a mitigating factor.

Given that we know self-harming can be a warning sign of suicidal tendencies, with 64% of suicides self-harming before suicide, we have an incredible responsibility to act on the clues that we see when we work with people.

Feeling the weight of responsibility as a therapist

As therapists, we are crucially aware that part of our work is to look out for warning signs of suicidal tendencies. In some instances, it can be impossible to tell and can be an out-of-the-blue event. Sometimes clients will only tell their therapist about their intentions, as one therapist reports: “It is very hard when you are the only one they have told – feels like a big responsibility but also a burden.” Knowing the best response, and the best steps to take after this type of disclosure, is extremely important to maintain open communication with your client. Training that is tailored specifically around supporting those clients with suicidal intentions, can help to give therapists the necessary tools. Often people don’t openly talk about suicide, rather referring to it obliquely using language such as “dark thoughts” which can make it harder for therapists to catch the intention. Given that we know about the association between self-harming and suicide, it can be useful to discuss choices around self-harming, which may be an easier conversation to build trust with a client. Increased trust can lead to further disclosures, which can be crucial for taking preventive steps, or working with self-destructive thoughts.

Self-harming can cover an array of behaviours, to quote one therapist: “I struggle most with behaviours that are just on the cusp of being self-harm or somewhat socially acceptable e.g. alcohol use, cosmetic enhancements, tattoos, etc. might not seem like self-harm but the function of the behaviour is linked to punishment.” This is an important distinction, as it is to do with the intentionality of the action, rather than the action itself. Enjoying a chocolate bar as a conscious pleasure is different from binge eating the chocolate bar, inducing feelings of guilt or shame. The presenting action may be the same, but as therapists, it is important that we understand the motivation. A tattoo may be a socially acceptable form of self-harm or an expression of self-love. The choice point will help you work with your client to discover whether this is an away or a towards move.

Using the choice point for safety, relapse prevention, or crisis-coping plan

In chapter one of his excellent book ACT Made Simple2, Russ Harris talks about using the choice point as a valuable tool with clients. Even if you do not regularly use the choice point tool with your clients, the concept of moving towards or away from values can be an extremely useful guide to help with safe decisions. The choice point consists of two arrows forming a V-shape. The left arrow is the away direction, so anything that takes someone away from behaving like the person they want to be. The right arrow is the towards direction and represents anything that moves a person towards the person they want to be. At the bottom is the choice point.

Triggers will magnify the risk of a person moving into away behaviours, whether this is self-harming or suicidal thoughts. The towards arrow represents all the actions we can take to help a person move towards their values: a. helpers, b. skills, c. safe environment, and finally d. emergency. These steps will help reduce the risk caused by the trigger. Helpers can be reasons to live, people, or underlying beliefs. Skills include the skills that we learn through therapy such as mindfulness, self-compassion, and problem-solving. A safe environment can include both removing the dangerous, such as alcohol or drugs, and introducing the good, such as a friend, or a pet. In some circumstances changing the environment may be necessary to ensure safety. Finally, emergency, which lays out the contact details for an emergency, a trusted friend or family member, or professional crisis support.


  1. The National Confidential Inquiry into Suicide and Safety in Mental Health. Annual Report: UK patient and general population data, 2009-2019, and real time surveillance data. 2022. University of Manchester
  2. ACT Made simple – Chapter 1