Responding to Self Harm

1. Responding to Self Harm Anne Peake Educational Psychologist

2. Self Harm Deliberate self harm is intentional self-poisoning or injury, irrespective of the apparent purpose of the act, (www.nice.org.uk). Self harm is an expression of personal distress, not an illness. This can involve: • Cutting, burning, biting • Substance (alcohol, drugs, legal highs) abuse • Head banging and hitting • Taking personal risks • Picking and scratching • Neglecting oneself • Pulling out hair • Disturbed eating • Over-dosing and self-poisoning

3. Risk Factors Individual factors • Depression/ anxiety • Poor communication skills • Low self esteem • Poor problem solving skills • Feelings of hopelessness • Impulsivity • Drug or alcohol abuse

4. Risk Factors contd. Family factors • Unrealistic/ unreasonable expectations • Abuse - neglect, physical, sexual, emotional, past or ongoing • Domestic abuse • Difficult relationships/ arguments with parents/ carers • Depression/ mental health difficulties/ self harm/ suicide in the family • Drug or alcohol misuse by family members

5. Risk Factors contd. Social factors • Difficulties making and sustaining relationships, loneliness • Persistent bullying or peer rejection • A peer group which uses self harm as an expression of feelings • Access to drugs/ medication/ other methods of self harm

6. Risk Factors contd. Social groups • Residential settings • Young people with mental health difficulties • Lesbian, gay, bisexual, transgender young people who feel isolated and unsupported • Use of internet sites which promote or normalise self harm

7. Triggers • Family relationships, parental physical/mental health difficulties • Young carer role • Difficulties with peer relationships • Bullying/ cyber-bullying/ sexting/ racist or homophobic threats • Significant trauma: past/ ongoing abuse • Self harm by other young people (contagion effect) • Difficult times of the year - bereavements and anniversaries • Being in trouble in school, or with the Police • Feeling under pressure from family/ school/ peers to conform • Exam pressures • Times of great change (parent separation/ divorce/ new partner) • Self harm reported in the media, or displayed by role models • Child drug/ sexual exploitation

8. Warning signs • Changes in eating/ sleeping habits • Increased isolation from family or friends • Changes in activity and mood (eg. more aggressive than usual) • Lowering of academic grades • Talk about self harming or suicide • Abusing alcohol or drugs • Becoming socially withdrawn • Expressing feelings of failure • Giving away possessions

9. What keeps self harm going? Self harm once established is difficult to stop, it has a number of functions: • Reduction in tension (a safety valve) • Distraction from problems • A form of escape • A means of eliciting care • An outlet for anger and rage • Opportunity to feel physical pain, to distract from emotional pain • It may be a way of punishing oneself or others • It can feel like a way of taking control • A means of identifying with a peer group • Non verbal communication (eg. of abuse) • It can also be a suicidal act

10. The cycle of self harm When a person inflicts pain on himself or herself, the body responds by producing endorphins, a natural pain reliever that gives temporary relief or a feeling of peace. The addictive nature of this feeling can make self harm difficult to stop. Young people who self harm still feel pain, but some say the physical pain is easier to bear than the emotional/ mental pain that initially led to the self harm.

11. Slide by Jeremy Day

12. Large quantities of content Detailed instructions Validation/ encouragement Novel/fresh content Planning/rehearsing Accessing safety and/ or instructions Looking at others self harming, inspo Elevates tension Disrupts sleep Supports dissociation Erodes inhibitions Revisiting/replaying Imagined expectations of online friends Comparing self to others Reading/creating dark or negative content Intensifies experience Records and observes Encourages and cheers Cares and supports Attention/ approval Fame, notoriety Belonging Abuse, trolling Cyberbullying Aggression Encouragement Slide by Jeremy Day

13. Positive: Strengthening coping The chance to be different and better Facebook friends The Mix Childline People who understand me Playing Minecraft Uplifting playlist Make-up tutorials Fashion blogs #Happy hashtag Real life experiences Chatting to friends Watching calming videos Doing my online CBT Reading poems Slide by Jeremy Day

14. The perspective of a young person ‘The first time I cut myself, I was 16 years old and at an awkward, unattractive stage, physically and mentally. My parents reacted to my moodiness and acts of rebellion by imposing Victorian limitations on my freedom: explosive arguments occurred almost daily...….One day I dragged the point of a pen lid over the back of my hand. The frustration and violence I felt within me had suddenly found a target. The immediacy of the pain focused my thoughts brought instant calm and euphoria……. The cutting became a habit……When my parents saw the scars they threatened to send me to a psychiatrist……..People at school were disparaging and insulting, dismissing me as a freak and a drama queen….. People saw cutting myself as a sign of weakness and juvenile attention seeking……. I viewed it as a logical means of dealing with emotional chaos, allowing me to function day to day’.

15. The impact on parents and the support they need ‘Most parents react by denying what is happening, by expressing outrage and shock, and telling their child not to do it again……….. We were plunged into constant worry. I would wake up every day wondering what the day held and whether she would harm herself again and what I could do to make sure she didn’t………….Our social life disappeared, some friends understood, but there were those who didn’t, who thought we should tell her to pull herself together and to force her to stop. It is not something you can talk about to other people………Soon there was very little humour or fun in the house, it was as if the life had been sucked out of us……..My mother was so upset’.

16. Findings • Most adolescent self harming behaviours resolve spontaneously • However, young people who self harm, may have mental health problems that might not resolve without treatment • During adolescence, self harm is independently associated with depression and anxiety, antisocial behaviour, high risk alcohol use, cannabis use, and cigarette smoking • There is a strong link between adolescent anxiety and depression, and an increased risk of self harm in young adulthood • The treatment of mental health problems during adolescence could be important factor in suicide prevention in young adults.

17. Self Harm Guidelines Guidelines for staff within school and residential settings in Oxfordshire

18. Responding Given the nature of self harm, an assessment of risk is a priority. Frontline professionals are expected to always ask parents and children/ young people about self harm.

19. Resilience Risk Assessment Framework: Self Harm • It is intended foruse by teachers, Hub workers and staff in residential settings, who are in daily/frequent contact with young people and their families, it is a useful basis for a consultation/ referral to CAMHS or Social Care • It is holistic in that it sets self harm in the context of what is known about the child: special needs, the family, the school, social networks, life events, and the work of the professional • An assessment is only as good as the rapport with the young person, the questions asked and the support offered, it should never be about the control of the young person • The involvement of the family, whenever possible, is key • It depends on a commitment to safeguarding and multi agency working • When there are heightened concerns, the dual focus on resilience and risk provides ideas for work to reduce risk and minimise harm

20. How to helpThere is no substitute to listening and understanding • Be aware: Staff training; Information/telephone numbers for crisis services that are available for young people; Self Harm Guidelines for staff; there is clarity about staff roles; and support for staff. • In a medical emergency, follow First Aid Guidelines, advice must be sought from a medical professional with regard to any overdose of tablets. • Identify a key member of staff for the young person, having ascertained to whom they would be willing to talk. Talking should begin straight away, with any mention of suicidal thoughts/plans being carefully noted. • Meanwhile, staff build up a picture of the young person from all that is known, in particular their strengths and vulnerabilities. • Decision making should be managed by Senior Staff, usually the Designated Safeguarding Lead.

21. Discuss with the child the need to tell parents, and listen to any fears they have. Parents should be informed unless there are specific reasons not to, and/or it would be unsafe for the child. • When parents are contacted, they need to know the concerns about the young person, and be given information about Self Harm, so they can be supportive and get further help. • Complete the Resilience Risk assessment Framework and consider a referral to the School Counsellor, or to CAMHS, or Social and Health Care. If what the child says or does raises Safeguarding concerns, then you may need to make a referral to MASH (Multi Agency Safeguarding Hub). • Record who you talk to, the time, date, and any advice you are given. • If you feel that the young person’s future health and development are at serious risk, then discuss this with colleagues in the Children and Families Assessment Team. • It may be appropriate to consider providing ongoing help for the young person. • There needs to be support for staff too.

22. Resources Self Harm Networks • Representatives of schools, statutory, and voluntary agencies • They meet three times a year, in the North, City, and South • Promote the Self Harm Guidelines, the sharing of information vital for early intervention and safeguarding procedures • Address concerns about casework and systemic issues, with no names consultation for emerging concerns if needed • Can develop responses and resources for specific needs, the play “Under my skin’ has been performed to over 20,000 pupils • Can undertake pieces of work or form subgroups as necessary • Steering Group which oversees and develops the Networks • Monitor data about self harm in community settings, which is passed to Public Health • Networks report to the Oxfordshire Safeguarding Children Board

23. Resources • There are national standards for self harm (www.nice.org.uk). The guidelines make recommendations for the physical, psychological and social assessment and treatment of people in primary and secondary care in the first 48 hours after having sel harm • The National Self Harm Network has advice about self harm and resources which can be accessed by young people, families and professionals (www.nshn.co.uk) • Samaritans24 hour helpline 08457 90 90 90 • Out of hours emergency referrals (24/7) 01865 741717 (www.oxfordhealth.nhs.uk)

24. Finally Self harm is an expression of personal distress, not an illness