Self-Harm and the Implementation Gap

In February 2025 I invited ‘unanswered questions’ about self-harm and throughout 2025 and beyond I will be responding to these questions in a series of blogs. In these blogs I draw on my personal and professional experience, as well as survivor and academic literature. The purpose of these blogs is to bring together a range of perspectives and pose ideas and questions for further reflection. I welcome feedback and questions – thanks for reading!

The Unanswered Question(s):

What do we need to better understand from research about self-harm and self-injury and what are the best methods for accessing and sharing new knowledge?

There’s so much research out there about self-harm it can sometimes feel like we’re drowning in it, and yet despite this abundance frontline practice and the experiences of people seeking support for self-harm have not seen significant steps forward in recent years. 

It’s well-established that the average time for research to impact frontline practice is around 17 years, and a recent paper has highlighted both the substantial evidence base and ‘implementation gap’ in self-harm care and treatment.

Research shows that despite the introduction of clear, research evidence-based guidance in the UK in 2004, this has not resulted in significant changes in frontline practice, so it would be hard to believe that additional research has impacted either.

I can’t deny that the experience of being involved in research on self-harm as a non-academic has often been a frustrating one. Bringing the experience of using and running self-harm support services which focus on the narratives and needs of each person can be at odds with spaces focused on distilling ‘the’ reason and ‘the’ answer in relation to self-harm. 

In particular, I have spent countless meetings explaining that measuring people not returning to A&E for self-harm treatment only tells you that they have not come back for whatever reason and gives us no information whatsoever about whether people have self-harmed again. And the idea that living a fulfilled life while still self-harming is a very hard sell in a quantitative and outcome focused world.

Clinically Driven Research Focus

Self-harm research covers a multitude of areas including models with increasing complex names, metrics focused on risk and protective factors, uncountable studies asking people about their reasons, nuanced work on self-harm and embodiment and more recently a focus on defining harm minimisation and exploring the ‘acceptability’ of peer support for self-harm. All these areas of research and more have yielded useful, insightful and interesting additional knowledge to add to our understandings of self-harm. 

But equally there is much research that is very embedded in high-level cognitive processes, is repetitive of previous research or co-opts important concepts developed by people who self-harm. Intellectually interesting as some of this work might be, arguably it has little connection to or impact on people using and delivering frontline support on a daily basis. And on an ethical level it is definitely questionable to ask people to talk about potentially vulnerable and painful experiences to conduct research which merely duplicates what has gone before.

Diverging Priorities

In 2020 I was part of a group which explored the outcomes from clinical trials on self-harm treatment which are most important to people who self-harm and compared them to the focus of research in this area. As this paper points out, despite an extensive body of research existing, there remains a scarcity of evidence supporting one specific route as best practice. This in itself might suggest that a rethink is needed around research in this area, which frequently focuses on reduced repetition of self-harm and improved scores on standardised rating scales measuring common mental health conditions as measures of success.

This research showed that for people these research participants, repetition and mental disorder measures were far less important than their ability to function day to day and their ability to maintain social connections and engage with support. They also discussed seeking medical help for self-harm as a sign of improvement in their ability to engage with help, rather than a negative indicator it has been framed as in much previous research.

So, what do we need to better understand from research on self-harm and self-injury? For me there are four key things:

First and most importantly, research outcomes and parameters need to be set by people who self-harm. 

Part of this will involve embedding genuine co-production into self-harm research, where people with personal experience are involved from the outset of any research, rather than just asked for their views once topics and protocols have been set. As outlined in the 2020 paper, part of this process also needs to focus on examining previous research and teasing out what information is useful and impactful for people who self-harm and what information is really for the benefit of services and systems. Cessation is frequently seen as the main or only goal of support and treatment, and there is a focus on creating cognitive models that can map onto all experiences of self-harm. Focusing on cessation, means that anything less can feel like failure. In my experience of running and using peer support spaces, what is important to people who self-harm in terms of support and short and long-term outcomes, is feeling validated, understood and connected. What makes a difference is wide ranging, and recovery doesn’t always mean cessation. However, people do report that this can be an outcome of validating, holistic support, even if it is not the focus.

Second, we ned to understand the impact of support which is received outside of medical and clinical settings and parameters. 

Recent research has shown that people receiving support for self-harm generally favoured the approaches and support provided in the voluntary and social care sector. There has been some work looking at online forums and peer support groups, but much of the support for self-harm happens in community-based, non-clinical settings, often given either by peers or people who have very little specific training in this area. Certainly, when I deliver training, the room is filled with people working in housing support, youth work and a range of other community organisations, often doing amazing work offering compassionate support and conceptualising self-harm in ways which is not captured by current research. Although medical and clinical treatment for self-harm will always be necessary for some people, many people will never seek support through ‘traditional’ routes.

Third, research needs to be more politically engaged.

The experience of self-harm – who, why, how, help seeking and more – is not homogenous. Oppression, discrimination and social deprivation have all been shown to lead to higher rates of self-harm, yet clinically focused research often frames self-harm as an individual issue, often ignoring the social and political aspects. Although there is research highlighting specific, discrete groups as being statistically more likely to self-harm, less attention has been paid to the impact of intersectionality and how multiple adverse experiences relate to how and why people self-harm. In particular different cultural backgrounds, age, disability, sexuality and gender identity can all significantly impact on why people self-harm and where they may or may not seek help. ONS data shows that rates of self-harm are rising over time, but without these critical understandings of the range of experience and needs of people who self-harm, it is almost impossible to offer meaningful, person-centred support.

Fourth, we need to understand why things aren’t changing.

I’ve been working in this area for nearly 20 years and sadly, although self-harm is talked about more and is seen as a public health concern, I can’t say that there have been substantial shifts in attitudes and access to timely, supportive care and treatment. This is in spite of extensive research, evidence-based guidelines and increased awareness. So, whatever is happening now is not the answer, or at least not the whole answer, and without better understanding why this might be the case, the chances of making progress are significantly reduced. There have been various studies on clinical staff attitudes to self-harm and a smaller number on the impact of training, but to make a difference at scale we are looking at culture change which is a much more complex beast. For some time now, I’ve been reflecting on whether one-off training is of much value and what could be piloted instead. I don’t have the answers – it’s a much bigger question than I can answer alone – but we do need to consider whether people can be trained, and culture can change around such a complex topic through piecemeal training sessions. Spoiler alert: I’m pretty sure the answer is no.

So, ultimately what are the best methods for accessing and sharing new knowledge?

That’s a very tough question, without a simple answer, but my feeling is that two things are key:

First, mandated in-depth education which draws on research and user experience in all health and social care professional training courses. This is my retirement goal (so I’ll be working a long time yet…), to see grounded and practical education that is embedded in all health and social care role that starts with the idea that you will probably come across someone who self-harms, it’s part of the role, here’s what you need to know. An approach like this could go a long way to shifting cultural attitudes that see self-harm as not ‘part of my role’ or significant in the wider health and social care system.

Second, multi-faceted approaches to making information and training available to anyone who needs it, with options for ongoing reflection and accountability. Training sessions are all well and good, but budget, time, rota and seniority constraints will always mean that many people will struggle to access training. In the modern world, I’m a strong believer that the podcast can address a lot of these issues – easy to access, free, short-form, everyone gets the same information, and you can listen over and over. Obviously, this is not the only solution, but it can be a useful starting point. I’m also seeing very positive things come out of ongoing Communities of Practice where people working in a specific area get together to share challenges and achievements and support each other to work on individual goals and projects. In the area of self-harm, I feel there’s huge potential for this type of group which would offer ongoing learning and support that’s not currently available.

Research in this area can feel so broad that it’s hard to know where to start, but by embracing the complexity of self-harm we can move away from the idea that in researching self-harm there’s one single answer that’s just tantalising out of reach and focus on all the things that are very much within our grasp.

Sources of Support

https://selfinjurysupport.org.uk

https://battle-scars.org.uk

https://harmless.org.uk

https://selfharm.co.uk