Evidence
Alert

Low rates of self-harm do not mean low levels of distress in a disadvantaged London community

Some highly deprived areas of London have unexpectedly low rates of self-harm. New research explored why hospital data implies that self-harm is less common than expected. The study was carried out in an ethnically diverse community exposed to multiple long-term stressors such as insecure employment, poor quality housing, and high levels of crime.

The study found that the impact of stressors was partially offset by community solidarity and a culture of toughness and self-reliance. But this is not the full story. Within this community, identifying as mentally ill through self-harm was regarded as highly risky. It was thought to make people appear vulnerable, damage their social status and increase the chance of being detained or becoming involved with social services. 

Consequently, local people tended to hide distress and respond with other behaviours such as misusing substances, disordered eating or putting themselves at risk of violence or sexual harm. They actively avoided mental health services. 

The research uncovers new complexities in the relationship between deprivation, self-harm and mental health. It may help explain the paradoxically low rates of self-harm rates in some communities – and how people’s experiences of mental health services may shape how their distress is expressed. If the same results are found in other communities, they could improve understanding of this major public health issue. They could inform local policies for tackling mental health inequalities in disadvantaged communities. 

What’s the issue?

The National Institute for Health and Care Excellence (NICE) defines self-harm as 'self-poisoning or self-injury carried out by a person, irrespective of the apparent purpose of the act'. Self-harm is a risk factor for suicide; more than half of those who die by suicide have previously self-harmed.

The levels of self-harm vary across different areas of England. In general, hospital A&E admissions for self-harm are twice as high in the most socioeconomically deprived neighbourhoods compared to the most affluent. But there are some exceptions, such as London, which has higher than average levels of deprivation but low rates of self-harm.

Hospital admission data from 2009 to 2016 for South London suggest that these patterns cannot be explained by local levels of deprivation. Some deprived inner-city areas have paradoxically low rates of self-harm.

Local cultures and relationships between communities and mental health services shape the way people understand and respond to stressors. Hospital admission for self-harm may be lower than expected in areas of deprivation because of this. But this does not mean there is a reduced need for mental health services.

Developing public mental health policies to ensure access to mental health support for vulnerable populations living in deprived areas is important. Failure to develop these policies and to commission mental health services may lead to further widening of mental health inequalities in the UK.

What’s new?

The study took place in a specific area of inner South London where the rates of self-harm are low compared with the surrounding city. The area has high levels of deprivation, and a reputation for crime, drug-dealing and use, and gang-related violence. More than half the population is born outside of the UK; only one-sixth identify as White British. Approximately half are Black, equally split between African and Caribbean groups. 

Between October 2018 and June 2019, 26 people living and working in the area participated in interviews or focus groups to share their insight on issues relating to self-harm.

Five main themes emerged.

  1. Stressors affecting the community: finances, welfare benefits, employment, housing, and migration status were common stressors. Violence, drug and alcohol abuse made living in the area, a stressor. The cumulative effect could be overwhelming and led to the community feeling uncared for by others and by local and national government. 
  2. Community solidarity: participants said the community responded to stressors with self-reliance and solidarity, which gave a sense of belonging. But the recent influx of wealthier White people and a new migrant community had undermined the established population’s strong sense of solidarity. 
  3. Individual self-reliance: people were expected to respond to stressors with self-reliance. Some suggested that experiences build resilience and help protect mental health. A tough, self-reliant persona helped to protect against being seen as vulnerable, which could make people a target for abuse or exploitation.
  4. Risk of being identifiably mentally ill: self-harm was seen as clearly linked to mental illness, a weakness that reduced a person’s credibility. Many described other harmful behaviours as more usual responses to distress - including substance misuse, provoking or putting yourself at risk of violence, disordered eating, sexual and other risk-taking, neglecting or isolating yourself. 
  5. Harm from mental health services: all participants felt that local people who self-harmed would be unlikely to seek help from mental health services. Some would not want to be known to have a mental health problem. Others emphasised the risks of engaging with services that did not understand their culture: misdiagnosis, misuse of medication, involuntary treatment. Services were not trusted. They were seen as part of a wider, interconnected system and any engagement could have difficult consequences for people. 

Why is this important?

Self-harm is an important indicator of mental health in the general population. But this study found it does not reliably flag distress in a disadvantaged community. 

    • This vulnerable population is being missed in current records on self-harm. The statistics appear to show low levels of self-harm but this is not the full picture. People in the study area who self-harmed were less likely than others to present to hospital and were therefore not all included in routine admission data. This is not a sign of the effectiveness of services but stems from the community’s lack of confidence in them. 
    • High levels of stress were linked to many other types of harmful behaviour than those clinically defined as self-harm. These behaviours may be more common responses to stress because the community was less likely to link them to mental illness.

What’s next?

Black communities in the UK experience more compulsory involvement with mental health services than other groups. This may partly explain the lack of trust in services shown in this study. Mental health services need to address the differences in experience for ethnic minority groups and those living in deprived areas. It can lead to a lack of confidence in health services and reduced access. 

Public mental health policy, and health and social care professionals, may also need to consider a wider range of harmful behaviours as indicators of stress and distress. These behaviours may signal a need for intervention. This way of thinking could improve access to mental health support for ethnic minority groups and those living in deprived areas.

You may be interested to read

The full paper: Polling C, and others. “There is so much more for us to lose if we were to kill ourselves”: understanding paradoxically low rates of self-harm in a socioeconomically disadvantaged community in London. Qualitative Health Research. 2021; 31:1 

The Mental Health Foundation, which promotes good mental health for all

Information about self-harm, including possible causes and how to access treatment and support, from Mind, the mental health charity.  

NICE Quality Standard on improving the quality of care provided or commissioned for those who self-harm. This standard (QS34) covers the initial management of self-harm and the provision of longer-term support for children, young people and adults

Public Health England Evidence Briefing 2018: Does self-harm prevalence and admission vary across English regions or local authorities, and if so, what might be the reasons for this variation

 

Funding: This research was supported by the NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King’s College London. Catherine Polling (Lead Author) is funded by a Wellcome Trust Research Training Fellowship.

Conflicts of Interest: The study authors declare no conflicts of interest.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Commentaries

Study author

It was striking hearing some of these voices describing exactly what makes people so afraid to encounter mental health services. This often gets expressed as cultural attitudes or stigma, but it was much more practical than that – knowing how others had been treated, understanding how big the power differential was between them and services, and concluding that it was a very risky thing to go and ask for help. 

The study was a wake-up call for what it means to be providing a service for a community that doesn’t want to go anywhere near it. We need to find ways to increase understanding among mental health professionals about the communities they’re serving – and how we can make changes to our practice in ways that would make it easier for people to use our services and to work with us.

Catherine Polling, Wellcome Research Training Fellow, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London  

Study participant 

I went to school with some really nice middle-class girls. And a few of them took overdoses and their parents then sent them to the south of France to rehab, and stuff like that. Whereas we’d get none of that. We’d get our children taken away from us, would have to go through social services craziness, we’d probably have to go and do some parenting course, we’d have to go to court, we’d probably lose our flats. There is so much more for us to lose if we were to kill ourselves.

Participant interviewed as part of the study 

Mental Health Foundation 

This study reminds us that there is a substantial difference between rates of diagnosis and mental health needs. We cannot afford to leave addressing those needs to our mental health services. It highlights the need for more attention to be placed on the social determinants that increase harmful behaviours, and should  discourage us from using diagnoses as proxies for need.

It is also a stark reminder that a psychiatric diagnosis can still lead to discrimination and disadvantage. The work done to date has done little to reduce this discrimination, particularly in areas of high deprivation. This discrimination carries a high cost for people already disadvantaged.” 

David Crepaz-Keay, Head of Applied Learning, Mental Health Foundation

Consultant in Public Health 

Ethnic minority groups have specific unmet needs. The study opens up new ways of understanding how mental health services may unwittingly marginalise and stigmatise some communities. This is especially important given the widening of mental health inequalities in the UK.

This paper could act as a catalyst among those working in the field of self-harm and suicide reduction. It shows deprivation, mental health, coping, and resilience are not related to self-harm and suicide in the straightforward way we often assume. Professionals now need to consider the possible buffering effect of community solidarity. Also, hiding mental distress may lead to a paradoxically greater burden of suffering.  

The findings are some of the most significant in self-harm and suicide in recent years. Despite the small numbers, they are consistent and credible. They need to be tested in a larger population but have the potential to improve our understanding of this enduring and global health problem.

Andy Beckingham, Independent Consultant in Public Health and Research Fellow, Hyderabad, India 

Public contributor

This study should impact on the processes health and social care staff use to evaluate and diagnose patients. It should inform decisions on the funding of local support services and highlight the need for different approaches – one size does not fit all. Public mental health needs to reflect the clear cultural and socioeconomic differences in how mental health issues manifest and how different communities perceive diagnosis and support.

Rebecca Bayliss, NIHR SPHR Public Mental Health Network Coordinator, UCL