Deliberate Self Harm by R. Rayner/HOPE Project 2018

hopeproject2016@outlook.com Rachel: 07962 229 206 @hopeproject2016

Understanding self-harm in young people

What you will gain from today's training:

• To know what self-harm is and isn’t

• An understanding of self-harm – self-harm statistics; who does it & understand why young people self-harm

• Knowledge of how to help young people keep themselves safe using good practice guidance and evidence-based strategies

• Increase knowledge about alternative coping strategies for young people

• Resources

PUBLIC HEALTH WARNING: Sensitive material

Activity:

Think about:

• What is self-harm?

• What it isn’t

• What are the debates?

What is Self-Harm?“The term self-harm is used in this guideline to refer to any act of self-poisoning or self-injury carried out by an individual irrespectiveof motivation. This commonly involves self-poisoning with medication or self-injury by cutting.”

“There are several important exclusions that this term is not intended to cover. These include harm to the self arising from excessive consumption of alcohol or recreational drugs, or from starvation arising from anorexia

nervosa, or accidental harm to oneself.” NICE CG133 2011

It is NOT self harm if primary purpose is: Sexual pleasure / body decoration / spiritual enlightenment via ritual / fitting in

“Any act which involved deliberately inflicting pain and/or injury to one’s own body, but without suicidal intent. ” (Arnold & Magill, 1996)

“Paradoxically, damage is done to the body in an attempt to preserve the integrity of the mind.” (Sutton & Martinson 2003)

Examples of Self Harm

• Cutting skin – 72%

• Burning – 35%

• Self-hitting or head banging – 30%

• Interference with wound healing – 22%

• Hair pulling – 20%

• Bone breaking – 8%

• Multiple methods from above – 78%

http://www.inourhands.com/free-resources/

Prompt questions:• Are the YP suicidal?• Would you be worried about these CYP?• How did the clip make you feel?• How can you help CYP show their emotions?

Understanding Self Harm

What is Self-harm continued…

Self-harm (US & UK) is also called:

Self-injury (SI)

Deliberate self harm (DSH)

Para suicide

Self-inflicted violence (SIV)

Self-mutilation

Self-abuse

Features:

Deliberate – DISCUSS. Is it deliberate or spontaneous? Premeditated or done with little thought/awareness?

More than once, often on a regular basis

To end disassociated (unreal-unfeeling) state

It is usually a way of coping with difficult or painful emotions

Deliberate Self Harm by R. Rayner/HOPE Project 2018

hopeproject2016@outlook.com Rachel: 07962 229 206 @hopeproject2016

Who & When?• U.K. has acquired the distinction of being one of the self-harm

centres of Europe• Panorama reported that 1 in 5 teenagers self-reported they had

self-harmed

• 1 in 3 school-age girls (Affinity Healthcare 2008)

• High risk groups:

• Looked after children

• Boarders

• British Asian (3x higher c.f. white British)

• LGBT (1 in 2 DSH, 44% report suicidal thoughts)

• Learning disabilities

Causes and Reasons for Self-Harm

• Bullied

• Poor relationship with parents/other family

• Stress & worry about school work/exams

• Feelings of isolation or social rejection

• Family breakdown

• Bereavement

• Unwanted pregnancy

• Self punishment

• Gives a sense of control

• Abuse in earlier childhood

• Current abuse

• Suicide of a close relation/friend

• Problems with sexuality

• Difficulties with race, culture or religion

• Low self-esteem

• Unmanageable pressure as perceived by person

• Expression of emotional pain

“…to get out the hurt, anger and pain”

Myths and Reality1. Young people who DSH are

attempting suicide

2. DSH is attention-seeking

3. Don’t approach a “self-harmer”, send them to the GP/CAMHS

4. You will know someone is self-harming by cuts on their arms

5. DSH is a fad/fashion that young people will grow out of.

6. DSH is a mental illness

7. Part of a sub-culture e.g. emo/goth

1. It is a ‘cry for help’; it is often done in secret, negating the idea it is attention-seeking

2. Take time to ask, listen & give permission to talk about DSH.

3. You may not know who self-harms. Consider alternative forms of DSH

4. DSH is an “equal opportunity” behaviour. It is not a ‘trend’. It is a sign something is wrong.

5. DSH is a way of coping with life rather than escaping it through death

Why does Self Harm stop?

Study in 2015 highlighted 3 big reasons:

• 40% self awareness – realising they could handle difficult feelings for a while or emotions would pass

• 24% because they felt someone loved or cared for them

• 27% said they simply ‘grew out of it’

Self-Harm and Suicide• Around 13% (11-16 y/o) may try to hurt themselves at some point

• In 2014, a reported 70% increase in 10-14y/o’s attending A & E for self-harm

Estimates around 1,760,000 (adult)(1) Cutting (2) self-poisoning

220,00 (adult) in 2011Mostly self-poisoning

1,103 deaths in 2011(1) hanging, (2) poisoning (3) jumping(2) 844 male 249 female597 Deaths by suicide in YP aged 10-24 y/o 2014

Figure 1: Representation of the relative prevalence self-harm and suicide in young people (Hawton et al, 2012)

Suicide: What is it? (“SUI” = suicide)Common:

• SUI thoughts - 20%- 45% of older adolescents had suicidal thoughts at some time (Hawton, 2005)this does not always = an attempt.

• But…Someone who has thought about suicide in the past, however vaguely or rarely, is more likely to resort to it as a means of coping when life becomes stressful (Samaritans).

• SUI attempts - at least 24,000 each year. More common among young females; peak 16 -18 yrs(Gould, 2003)

• Attempts can be impulsive (drunk, distressed, angry) or planned (premeditated) • SUI death - those aged 15-24 years - suicide is the second biggest cause of death after RTAs

(Samaritans). Death is more common in young males. • Most common methods in UK is (1) hanging (2) self-poisoning (overdose) & (3) jumping from a

height Suicide behaviours (All) Suicide behaviours (YP)

140,000 attempts 24,000 attempts (aged 10-19 years)

6,045 deaths by suicide 1,103 deaths by suicide (aged 15-29 years)

ONS Suicide rates, 2011 in those over 15 years

Deliberate Self Harm by R. Rayner/HOPE Project 2018

hopeproject2016@outlook.com Rachel: 07962 229 206 @hopeproject2016

Risk factors for Suicide. Biological: Genes, brain structure & chemicals• Being young: neurodevelopmental stage of adolescence? Impulsivity higher

(Hawton, 2012) Risk increases with age 15-35 • A family history of suicide: Family bereaved by a suicide are at increased risk of

MH problems & suicide themselves (HMGovernment, 2012)

• Family MH: Children of depressed parents are more at risk of suicidal thoughts (Valenstein et al, 2012)

• Prescription drug side effects; some drugs, such as SSRIs, have suicidal thoughts as a side effect. This is especially true in young people.

• Physical illness and long-term conditions; PI is a significant risk factor for suicide independent of other factors (Qin et al, 2013) some LTC are associated with an increased risk of suicide: epilepsy, cancer, coronary heart disease = higher suicide risk (Web et al, 2012)

• Hormonal & genetic factors; dysfunction of hypothalamic-pituitary-adrenal axis & genes might be linked with impulsive aggression (USPHS 1999)

Risk factors for Suicide. Psychological: our upbringing, how we deal with things• People who self-harm are at increased risk of suicide (although this is not intentional)

• Personality traits: social-perfectionism & self-criticism = higher risk (Samaritans, 2012), Antisocial behaviour traits , esp in women (Evans, 2004) impulsive, poor problem solving ability or coping

• Psychiatric difficulties; ppl with serious MH problems are about 10 times more likely to attempt suicide. E.g. bipolar disorder (10-15% die by SUI), schizophrenia (4% die by SUI) depression, ADHD or personality disorders.

• Past attempts indicate risk; ½ of those who take their own life have tried before.

• Masculinity: suicide = expressing or regaining control in the face of depression (Samaritans, ‘12)

• Alcohol & drugs: 1/3 adolescent sui’s used alcohol at time (Houston, ‘01) binge drinking (Hawton et al, 2012)

• Traumatic events (bereavement, end of a relationship, unplanned pregnancy, domestic abuse, childhood abuse or bullying) can = distress = trigger.

• Critical life event which causes a big change (redundancy, failing exams, changing schools) can = distress = trigger.

Risk factors for Suicide. Environmental: our social lives, environment, friends• Certain occupations - doctors, nurses, vets, farmers and agricultural workers - access to lethal

means? (HMG, ’12). High in male construction workers, plant and machine operatives and female health workers (HMG,’12)

• Environmental risk factors for men = unemployment; family & relationship problems -marital breakup and divorce; social isolation and low self-esteem

• Suicide is more common if unemployed and in lower social class bands.

• Those with a disrupted family background: parents who attempted suicide, broken family relationships or violent abuse at home. Suicidal young men are more likely to have an absentfather (Samaritans.org).

• Those people isolated from more ‘mainstream’ society are at higher risk; the homeless, immigrants and refugees, LGBT groups, students and prison system.

• Exposure to others who have died by suicide (in real life or via the media); there may be a risk of copycat suicides in a community, particularly among young people, if another young person or a high-profile celebrity dies by suicide

• Living apart from parents (Evans, 2004)

• Influence of Social media?

Fears of Young People – why they do not seek help and Self-Harm

• Thought it was going to stop

• Thought they could cope on their own

• It [DSH] was the only coping mechanism they had and feared that it would be “taken away from them”

• Stigma, what will others think about me?

• No understanding of how DSH could become a habit

• No one to talk to

• No idea who to turn to/how to contact support services

• Concerns about DSH affecting future career choices

• No control of the information once it was “out there”

Activity: Letter from Sally (Samaritans)

• How is Sally feeling?

• What underlying issues are going on in her life?

• Is she attention-seeking?

• Could she be suicidal?

• If you asked about the marks on her wrists what might she say to you?

• If you asked about her parents splitting up do you think she would like to talk about it?

Is this a good thing to say to Sally and why?

1. “Eughh! That’s gross.

2. “Oh no, you should go to a doctor or the school counsellor knows about this sort of stuff”

3. “You’re crazy, cutting yourself like that. Just pull yourself together and stop doing it”

4. “You wanna be careful, those cuts will get infected you know.”

5. “If you tell me what’s wrong I swear I won’t tell anyone.”

6. “How are you feeling?”

Exploring the Risk of Suicide

Be sensitive but direct and clear.

e.g. Have you got any thoughts about ending your life?

Do you think about ending your life?

Have you tried to harm yourself before?

Do you have ideas or a plan about how you would hurt yourself or end your life?

How/when would you do this?

Asking about self-harm or suicide will not “give an idea” and will not make it happen

Deliberate Self Harm by R. Rayner/HOPE Project 2018

hopeproject2016@outlook.com Rachel: 07962 229 206 @hopeproject2016

StrategiesAlternative coping methods

Also known as “HARM REDUCTION”

Activity: Discuss what you have done to help someone that was self harming. Do

you think it help? What would you do in future?

Trigger Diary

Distractions

https://www.youtube.com/watch?v=BjKkD1s9KBA

What not to do…

Don't panic!

No blame

Don’t jump to assumptions

Don’t try to force them to stop self harming

Don’t ask the young person to promise not to self harm. This does not work

Don't reprimand or punish the behaviour

Don’t be punitive

How to Help (Think of P.A.C.E.) CONFIDENTIALITY; State boundaries at the beginning. Ensure

any agreement with the child is well documented. Follow professional and agency guidelines

ACCEPTANCE; of the deliberate self harm in a non-judgemental manner

CONCERN; Show your concern for the distress which lies behind the person's self harm behaviour

CURIOSITY: Be interested in knowing how the YP opted for this particular form of coping and what else they considered?

UNDERSTANDING; Show an understanding of the behaviour. There can be a number of underlying causes and many use it as a coping strategy.

How to help some more RESPECT & REASSURANCE; acknowledge that the deliberate

self harm is one way of coping with very difficult circumstances for that young person.

HOPE; that they are not alone and people are available to help and support.

GENTLE INQUIRY; It may be appropriate to invite the young person to talk about their feelings. However be aware of not leaving the young person vulnerable and upset by not having enough time/ resources/ skills to respond to their difficulties.

If you cut to expresspain and intense emotions

Paint, draw, or scribble on a big piece of paper with red ink or paint

Express your feelings in a journal

Compose a poem or song to say what you feel

Write down any negative feelings and then rip the paper up

Listen to music that expresses what you’re feeling

If you cut because you feel disconnected and numb

Call a friend (you don’t have to talk about self-harm)

Take a cold shower

Hold an ice cube in the crook of your arm or leg or rub ice where you would normally cut

Put rubber bands on wrists, arms, or legs and snap them instead of cutting or hitting

Chew something with a very strong taste, like chili peppers, peppermint, or a grapefruit peel.

Go online to a self-help website, chat room, or message board

Deliberate Self Harm by R. Rayner/HOPE Project 2018

hopeproject2016@outlook.com Rachel: 07962 229 206 @hopeproject2016

If you cut to calmand soothe yourself

Take a bath or hot shower

Pet or cuddle with a dog or cat

Wrap yourself in a warm blanket

Massage your neck, hands, and feet

Listen to calming music

The *Five-minute rule; see if you can wait five minutes when you have the urge to self-harm. If you do, see if you can wait longer. Continue until the urge is over. Deep breathe

* Sometimes this needs to be reduced to 1 minute*

If you cut to release tension or vent anger

Exercise vigorously—run, dance, jump rope, or hit a punching bag

Punch a cushion or mattress or scream into your pillow

Squeeze a stress ball or squish Play-Doh or clay

Rip something up (sheets of paper, telephone book, a magazine)

Make some noise (play an instrument, bang on pots and pans)

Tools to Help Assess Risk

• STORM – Risk Assessment and Care planning for Self Harm and Suicide

Activity: Complete STORM (or other worksheet) in small group/s. Which do you like to use?

When to contact a Mental Health Specialist

If there is sufficient concern around the person's safety, either by extent of injury or suicidal thoughts or if there is evidence of depression:

The young person may be referred to the specialist CAMHS team, GP, A&E department or First Response (if the underlying cause of the self harm could be sexual, physical or emotional abuse)

Where confidentiality cannot be kept, in relation to risk, any referral should be done transparently and with respect. Keeping the child or young person informed of the process is very important.

Ideas and Resources

• selfinjurysupport.org.uk/tess-text-and-email-support-service

• sssft.nhs.uk/service-users-carers/self-help-leaflets

• http://www.inourhands.com/free-resources

• www.nshn.co.uk

• www.harmless.org.uk

• www.papyrus-uk.org

• www.samaritans.org

" I don't want to die, I just want the pain to stop...The only way I can get some relief from this

emotional pain is by hurting myself..."

Thank you for listening

Questions?