The functions of self‐harm in young people and their perspectives about future general practitioner‐led care: A qualitative study

Abstract Background Self‐harm in young people is a serious concern but a deeper understanding of the functions of self‐harm in young people can tailor care and inform new clinical interventions to reduce repeat self‐harm and suicide risk. General practitioners (GPs), as frontline healthcare professionals, have an important role in managing self‐harm in young people. This study aimed to explore the functions of self‐harm in young people and their perspectives on future GP‐led care. Methods A qualitative study using interviews with young people aged between 16 and 25 years with a personal history of self‐harm was conducted. Interviews were transcribed and analysed using reflexive thematic analysis. Findings Four distinct functions were identified: (1) handling emotional states; (2) self‐punishment; (3) coping with mental illness and trauma; and (4) positive thoughts and protection. Young people valued GP‐led support and felt future GP interventions should include self‐help and be personalised. Conclusions These findings support clinicians, including GPs, to explore the functions of self‐harm in young people aged 16–25 in a personalised approach to self‐harm care. It should be noted that self‐harm may serve more than one function for a young person and thus interventions should recognise this. Patient and Public Contribution A group consisting of young people with lived experience of self‐harm, carers, the public, and those who work with young people who harm themselves conceived this study idea, informed recruitment methods and the interview topic guide, and supported the interpretation of findings.


| INTRODUCTION
Self-harm is defined as self-injury or self-poisoning irrespective of suicidal intent, and in young people, self-harm is a growing concern of international importance. 1,2 Self-harm in young people is associated with repeat self-harm, anxiety, and depression, 3 and self-harm is the strongest risk factor for death by suicide. 4 In young people suicide is a leading cause of death. 5 Around one in four young people, aged 10-24 years in England, have previously harmed themselves, 6 and in young people who die by suicide, over three quarters had a history of self-harm. 7 In the United Kingdom (UK) one in five young people who selfharm in general practice, repeat self-harm the following year. 8 Risk factors for self-harm in young people include bullying, family discord, and mental health difficulties. 2,9 In young people, cutting is the most common method of self-harm with medication overdose next, but many young people report multiple methods of self-harm. 10,11 Young people in the UK have described their self-harm to have started 10 years before the recent repeat self-harm. 10,12 In 1989, Favazza described why some patients harmed themselves and this included control of sexual desires, establishing control, and relief from alienation. 13 The functions of self-harm have been discussed in substantial reviews. 14, 15 Nock proposed a fourfunctional model informed by behavioural psychology: intrapersonal negative reinforcement (reduction in unhelpful thoughts), intrapersonal positive reinforcement (increase in satisfying thoughts), interpersonal positive reinforcement (increase in social attention), and interpersonal negative reinforcement (reduction in undesired social demands). 15 In a meta-analysis, intrapersonal functions of selfharm were found to be more common than interpersonal functions, in young people aged 9-14 years. 16 In a systematic review, Edmondson et al. presented a descriptive framework incorporating past literature (Suyemoto and Nock) and identified 15 functions of non-suicidal self-harm in people aged 10-92 years across three broad themes: responding to distress, self-harm as a positive experience, and defining the self. 17 In a meta-synthesis of experiences of self-harm in 12-18-yearold adolescents, four themes were identified: self-harm to obtain release, controlling challenging feelings, representing unacceptable feelings, and connecting with others. 18 When considering the effect of interpersonal stressors on young people's self-harm, worries about family breakdown, parental responses to self-harm, and bullying from peers, were all described as contributing to self-harm behaviour in young people. 10 Reasons for self-harm in young people can be multiple, complex, and often contradictory, with explanations and motivations for selfharm changing with time, place, and social context. 12,17 It is challenging for young people to convey, in turn, this complexity and explain why they self-harm, and for clinicians and health professionals to understand self-harm, and therefore tailor interventions to young people. 19 The National Institute for Health and Care Excellence (NICE) self-harm clinical guideline recommends research exploring what self-harm means to people. 1 Reducing rates of selfharm in young people is an international priority. 20 Functions of selfharm have been described-as highlighted above-in adolescents and adults but have yet to be explored in young people aged 16-25 years explicitly. A deeper understanding about the functions-what selfharm means and its purpose-of self-harm in young people [16][17][18][19][20][21][22][23][24][25] years through qualitative methods can lead to nuanced new meanings of self-harm in these young people to tailor care and inform the development of clinical interventions, to reduce further self-harm and improve the quality of life in this vulnerable group of patients. 21,22 This would also address the above-mentioned NICE research recommendation.
Young people, aged 16-25, often first seek help from family physicians and general practitioners (GPs) with a history of self-harm and these clinicians can identify and intervene early to prevent repeat self-harm in young people. 23 GPs/family physicians have an important role in the management of self-harm in young people and they can deliver holistic care, focusing on the function self-harm has, for individual young people. 23,24 GPs are however limited in what they can offer to young people who have self-harmed in the consultation, especially in the context of a lack of accessible effective interventions which is a missed opportunity for early intervention. 25

| METHODS
This qualitative study was conducted from April to November 2019, and we used in-depth semi-structured interviews to explore young people's reasons for self-harm and thoughts about GP-led support for self-harm. This study is reported according to the Standards for Reporting Qualitative Research. 27

| Participant recruitment
We adopted an inclusive approach to self-harm research, encouraged by the study's patient and public involvement (PPI) advisory group, where all types of self-harm (e.g., self-poisoning, cutting, burning, pinching) were included, irrespective of suicidal intent. Young people would be eligible to participate if they were 16-25 years old, had harmed themselves previously, lived in England, and were able to provide informed consent and be interviewed in English.
A diverse sample of young people from England was targeted through social media (Twitter), community recruitment, and national self-harm third-sector organisations. Tweets were drafted and refined with input from the study's PPI group and were shared on the lead author's (F. M.) personal Twitter account to generate participant interest in the study. The study recruitment poster was displayed on university campuses and college settings and in libraries.
A list of self-harm third-sector services and groups in England was compiled from an internet search and knowledge of PPI group members. Organisations were contacted by email with a description of the study and asked if they would be willing to share the recruitment poster within their services. Table 1

| Data collection
In-depth semi-structured interviews with participants were conducted; and allowed for the exploration of participants' perspectives, guided by an interview topic guide (see Table 2), while remaining flexible to participants' accounts enabling exploration of unexpected areas. 28 The interview topic guide was informed by the literature, input from members of the PPI group, and the research team.
Potential participants were given the option of a telephone or face-to-face interview. Face-to-face interviews were conducted in private university meeting rooms. At the start of the interviews participants received a 'Staying Safe Sheet' which listed support services for self-harm. All interviews began with the researcher asking the young person how long they have been harming themselves, and this allowed participants to reply in as much detail as they wished, supporting rapport building. 29 All interviews were conducted by the lead researcher (F. M.) who declared his professional identity: a GP with clinical and research expertise in self-harm in young people, to all participants. Interviews were digitally recorded and transcribed verbatim by F. M. or a professional company. Transcripts were pseudonymised with consent.
Data saturation (the degree to which new data repeats what was previously expressed in past data at the transcript level) was achieved after 13 interviews, 30 and data collection therefore stopped.

| Data analysis
We analysed interview transcripts through reflexive thematic analysis. 31 Reflexive thematic analysis was guided by the six stages of thematic analysis by Braun and Clarke, 31 and placed researchers' subjectivity central to knowledge production, requiring a more active, flexible and collaborative approach to coding, and generating themes within a fluid and recursive analytical process.
FM led the analysis and coding of all transcripts, reading and rereading transcripts for familiarity. Each transcript was independently coded twice across research team members. Recurring codes across transcripts informed wider categories within an analysis framework that included relevant data extracts on which all research team members commented and helped to refine. Higher level recurring themes were then agreed upon within the research team.
Analysis was undertaken in Microsoft Word and QSR NVivo 12. 32 The researchers reflected, during study meetings, on how both their disciplinary and personal backgrounds influenced their assumptions and perspectives about self-harm, and on the interpretation of data and findings.
T A B L E 1 Third-sector self-harm organisations contacted. Young people provided their first ages of self-harm which ranged from 8 to 23 years. Cutting was the most common (92%) method of self-harm in participants and more than half (54%) of participants had experience with more than one method of self-harm. Self-poisoning was mentioned by three participants. Participant demographic characteristics, disclosed ages of first self-harm, and types of selfharm are stated in Table 3.
We generated four higher-level themes representing the functions of self-harm in young people: handling emotional states, self-punishment, coping with mental illness and trauma, and positive thoughts and protection. These functions are listed and described in  The above data extracts highlight that managing emotions serves as a key purpose for young people's self-harm, but often emotions experienced differ for different young people. This variation in experiences among young people needs to be taken into account when consulting young people who present with self-harm to clinical services.

| Coping with mental illness and trauma
Some participants described how self-harm helped them cope with mental illness and trauma:

| Positive thoughts and protection
Young people stated that a key function of self-harm was to feel in control amid the difficulty of changing and overwhelming emotions: 'Erm it was something that was mine, I know that sounds very strange but erm like it wasn't something someone could take away from me… so I guess controlling I guess a control mechanism kind of thing' (P13, 19 years).
There was a therapeutic function to self-harm: 'for me stopping was not an attractive solution as it was helping me cope with other things like suicide and… thoughts and… stuff' (P1, 24 years).

| Valuing GP support and thoughts on GP interventions
In response to being asked about GP-led interventions, young people shared that they would value GP support and intervention, immediately in the consultation, and regularly while being placed on waiting lists for specialist support. They recognised that when seeing a GP, it is 'a good space… and good time to be offering an two of the functions found in our study of slightly older young people; but they also described an addictive element to self-harm in young adolescents which we did not discover. 34 The four functions we identified would be classified according to Nock, as intrapersonal functions as opposed to interpersonal functions, suggesting that relationship triggers don't play a substantial role for these young people. 15 In people with an age range of 19-57 years and history of In the context of Favazza's early finding (1989) that self-harm can be a means of regaining control for an individual, this purpose has appeared to have continued over time and remains a means for some [16][17][18][19][20][21][22][23][24][25] year olds, but we found no evidence of self-harm as a means of controlling sexual urges. 13 Young people have previously suggested that self-help materials from GPs would be helpful and this aligns to our findings, however concerns about time in the consultation were noted. 36

| Strengths and limitations
While functions for self-harm have been explored in adolescents and adults, to our knowledge this is the first study to identify functions of self-harm in young people aged between 16 and 25 years specifically.  39 We asked participants about reasons for self-harm in the context of all their self-harm episodes, recognising motivations for self-harm often change; we did not seek to understand motives for individual self-harm acts, which could include different methods, and in turn, were unable to link motives to the chronology of self-harm methods and episodes.