Young People and Deliberate Self Harm Contemporary Policy and Society

Definitions Other terms used to describe self harm - n Deliberate self harm n Intentional self harm n Para suicide n Attempted suicide n Non-fatal suicidal behaviour n Self inflicted violence n Self poisoning n Self injury n Self mutilation NICE 2003 Intentional self-poisoning or injury, irrespective of the apparent purpose of the act.

What is self-harm? n cutting or burning - the most common forms of self-harm n taking overdoses of tablets or medicines n punching themselves n throwing their bodies against something n pulling out their hair or eyelashes n scratching, picking or tearing at their skin causing sores and scarring n inhaling or sniffing harmful substances n swallowing things that are not edible n inserting objects into their bodies

n Some young people self- harm on a regular basis, others do it just once or a few times. n For some it is part of coping with a specific problem and they stop once the problem is resolved. Other people self-harm for years whenever certain kinds of pressures or feelings arise.

How Do People Self Harm? 2 broad groups n Self poisoning - more likely to seek help n Self injury - cutting by far the most common means. Other methods include burning, shooting, jumping and insertion 80% or people who attend A&E having self harmed will be due to self poisoning. However, in the population self injury is more common

How common is self- harm? n Self-harm is more common than people realise. It's impossible to say exactly how many young people self- harm because: n Many young people hurt themselves secretly before finding the courage to tell someone. n Many of them never ask for counselling or medical help.

How common is self- harm? n There is no standard definition of self- harm used in research. n There are no national statistics on self- harm currently available. n Self-harm is most common in children over the age of 11 and increases in frequency with age. It is uncommon in very young children although there is evidence of children as young as five trying to harm themselves.

How common is self- harm? n Self-harm is more common amongst girls and young women than amongst boys and young men. Studies indicate that, amongst young people over 13 years of age, approximately three times as many females as males harm themselves. Why?

How common is self- harm? n A study in Oxford found that approximately 300 per 100,000 males aged between 15 and 24 years, and 700 per 100,000 females of the same age, were admitted to hospital following an episode of self-harm during the year n Community based studies report higher rates of self- harm than hospital based studies.

How common is self- harm? n A national survey of children and adolescents carried out in the community found that 5 per cent of boys and 8 per cent of girls aged said that they had, at some time, tried to harm, hurt or kill themselves. n In the same national survey, rates of self-harm reported by parents were much lower than the rates of self-harm reported by children. This suggests that many parents are unaware that their children are self-harming. n A study carried out in schools in 2002 found that 11 per cent of girls and 3 per cent of boys aged 15 and 16 said they had harmed themselves in the previous year.

Demographics n Male to Female ratio changing - currently about equal. Although in adolescence, girls are 3 times more likely to self harm n Mean age 32 years n Peak ages (female), (male) n Divorced, separated, single. n Inverse relationship with social class. n Strongly associated with unemployment. n Greater in inner cities.

Why do young people harm themselves? n Difficult or painful experiences or relationships. These may include: n Bullying or discrimination. n Losing someone close to them such as a parent, brother, sister or friend. n Lack of love and affection or neglect by parents or carers.

Why do young people harm themselves? n Physical or sexual abuse. n A serious illness that affects the way they feel about themselves. n Problems and pressures of everyday life. From family, school and peer groups to conform or to perform well (e.g. in getting good exam results). n Low self-esteem, linked to poor body image, eating disorders, or drug misuse. n Peer pressures - young people may find themselves among friends or other groups who self-harm and may be encouraged or pressurised to do the same.

Why do young people harm themselves…. n When the level of emotional pressure becomes too high it acts as a safety valve - a way of relieving the tension. n Cutting makes the blood take away the bad feelings. Pain makes them feel more alive when they feel numb or dead inside.

Self-harm as a way of coping! n Punishing themselves relieves feelings of shame or guilt. n When it's too difficult to talk to anyone, it's a form of communication about their unhappiness - a way of saying they need help.

Self-harm as a way of coping Extreme feelings of fear, anger, guilt, shame, helplessness, self-hatred, unhappiness, depression or despair can build up over time. When these feelings become unbearable, self- harm can be a way of dealing with them. n Self-harm is something they can control when other parts of their life may seem out of control.

n To communicate distress n To obtain temporary respite from intolerable issues n To effect change in the behaviour of others n As a way of expressing emotion e.g. anger n Self punishment n To gain control n To commit suicide n To prevent suicide Why do people self harm?

Factors Associated with Self Harm n Socio-economic factors –Poverty –Homelessness –Multiple adverse life events –Relationship breakdown n Abuse in adult/childhood n Mental disorder - around 70% of those attending A & E would meet the criteria for mental disorder. (For most this will be reactive and short lived depressive episode) n 50% of people diagnosed as having schizophrenia will have self harmed at some point. n Drug/alcohol abuse - 50% of people attending A&E will have used drugs or alcohol immediately prior to, or during the act of self harm.

Vulnerability Factors Long Term - Early Loss or Separation From Parents. Difficult Relationships With Parental Figures. Abuse. Short Term - Relationship Problems, Social Isolation, Drug/alcohol Misuse. Precipitating Factors - Relationship Problems, Financial Worries, Loss. Likely to Have Occurred in the Prior Few Days.

Difficulty with engagement Hostility Internalised Anger Anxiety/irritability Poor coping strategies Poor problem solving capability Dichotomous thinking Autobiographical memory defecits Poor impulse control Hypersensitivity to rejection Poor self image Ambivalence % involves alcohol Psychological Characteristics

Attitudes to Self Harm n Attitudes of health and social care professionals towards self harm tend to be more positive if the individual is seen as being seriously mentally or physically ill. n Depression is viewed more favourably than manipulation as a cause of self harm.

Attitudes to Self Harm n Individuals who self harm without the intention of dying viewed less favourably than those who were attempting to commit suicide n Repeated acts of self harm lead to particularly negative attitudes n Workers often talk in stereotypes such as - genuinely suicidal, mad, silly girls, personality disorder, manipulative

Consequences of Negative Attitudes n Feelings of anger/frustration can lead to avoidance or withdrawal of treatment n Detachment n Some staff over compensate becoming overly proactive n Inconsistency can lead to confusion and uncertainty. Can mirror inconsistency and abusive responses they experienced in dysfunctional relationships

Why Negative Attitudes? n Self harm can be a challenge to our personal/professional beliefs n Fear n Perception of incompetence n Transference counter transference

So What Can We Do? n Risk assessment n Psychological interventions n Clinical interventions n Pharmacological interventions

Risk of Repetition n Risk of repetition 16% will repeat within a year. n Repetition occurs early 25% within 3 weeks 50% within 12 weeks n Factors associated with repetition: Previous history of self-harm Psychiatric history Unemployment Lower social class Alcohol or drug problems Antisocial personality Lack of co-operation with treatment Hopelessness High suicidal intent

Risk of Suicide n 1% will commit suicide within the following year n 3% at 5 years n 50% of suicides have previous self harmed. n Factors associated with suicide: Older age Male Previous history of self harm Psychiatric history Unemployment Poor physical health Social isolation Individuals who self discharge from A&E are three times more likely to repeat self harm or complete suicide.

Hazards Which May Mislead the Assessment and Management of Suicide Risk n Deliberate denial of suicidal ideas n Variability in degree of distress n Misleading improvement

Hazards Which May Mislead the Assessment and Management of Suicide Risk n Anger, resentment (national confidential inquiry: 33% of suicides have previous history of aggressive behaviour) n Un-cooperative and difficulty behaviour n Malignant alienation n Assuming that the service user is manipulating with empty threats

Risk Management Cycle Identify Risk Rate Risk Assess Risk Review Monitor Interventions Risk Management Cycle

Assessment: Basic Skills n Due to lack of effectiveness of risk factors we have to conclude that face to face skills are of primary and paramount importance in our approach to suicide risk. n Need to establish good rapport. n Progressive focussing down on specific suicidal ideas. Useful to begin with more general issues.

Assessment: Basic Skills n Acknowledgement of suicidal ideation often associated with emotional catharses.Process should not be an interrogation. Use open ended questions at a speed individual is comfortable with. n Occasionally necessary to use more direct questioning. n Be prepared to ask directly about suicidal intent as you are unlikely to implant suicidal ideas in individuals. n Impatient challenging due to frustration may provoke high-risk acting out in response.

Psychological Interventions n Problem solving therapy n Cognitive behavioural therapy n Psycho-dynamic interpersonal therapy n Dialectical behavioural therapy

Strategies for Working With Self Harm n Delaying strategies n Restoring hope n Therapeutic activism n Use of short term no self harm contract

Strategies for Working With Self Harm n Alternatives to self harm n Hospitalisation n Reduce access to means Underpinning all of the above is the importance of the therapeutic alliance formed with the individual

Helpful Responses n Show you are concerned n Dont see stopping self harm as the most important goal n Make it clear that its ok to talk about the injury n Convey respect for the persons efforts to survive n Encourage new ways of expressing feelings n Help develop support networks