Young People and Deliberate Self Harm

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Young People and Deliberate Self Harm

• Contemporary Policy
• and Society

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Definitions
Intentional self-poisoning or injury,
irrespective of the apparent purpose of the act.

• Other terms used to describe self harm -
• Deliberate self harm
• Intentional self harm
• Para suicide
• Attempted suicide
• Non-fatal suicidal behaviour
• Self inflicted violence
• Self poisoning
• Self injury
• Self mutilation NICE 2003

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What is self-harm?

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

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• Some young people self-harm on a regular basis,
  others do it just once or a few times.
• 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.

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How Do People Self Harm?

• 2 broad groups
• Self poisoning - more likely to seek help
• Self injury - cutting by far the most common
  means. Other methods include burning, shooting,
  jumping and insertion
• 80 or people who attend AE having self harmed
  will be due to self poisoning. However, in the
  population self injury is more common

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How common is self-harm?

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

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How common is self-harm?

• There is no standard definition of self-harm used
  in research.
• There are no national statistics on self-harm
  currently available.
• 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.

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How common is self-harm?

• 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?

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How common is self-harm?

• 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 2000.
• Community based studies report higher rates of
  self-harm than hospital based studies.

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How common is self-harm?

• 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 13-15
  said that they had, at some time, tried to harm,
  hurt or kill themselves.
• 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.
• 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.

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Demographics

• Male to Female ratio changing - currently about
  equal. Although in adolescence, girls are 3
  times more likely to self harm
• Mean age 32 years
• Peak ages 15-24 (female), 25-34 (male)
• Divorced, separated, single.
• Inverse relationship with social class.
• Strongly associated with unemployment.
• Greater in inner cities.

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Why do young people harm themselves?

• Difficult or painful experiences or
  relationships. These may include
• Bullying or discrimination.
• Losing someone close to them such as a parent,
  brother, sister or friend.
• Lack of love and affection or neglect by parents
  or carers.

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Why do young people harm themselves?

• Physical or sexual abuse.
• A serious illness that affects the way they feel
  about themselves.
• 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).
• Low self-esteem, linked to poor body image,
  eating disorders, or drug misuse.
• 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.

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Why do young people harm themselves.

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

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Self-harm as a way of coping!

• Punishing themselves relieves feelings of shame
  or guilt.
• 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.

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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.

• Self-harm is something they can control when
  other parts of their life may seem out of
  control.

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Why do people self harm?

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

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Factors Associated with Self Harm

• Socio-economic factors
• Poverty
• Homelessness
• Multiple adverse life events
• Relationship breakdown
• Abuse in adult/childhood
• 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)
• 50 of people diagnosed as having schizophrenia
  will have self harmed at some point.
• Drug/alcohol abuse - 50 of people attending AE
  will have used drugs or alcohol immediately prior
  to, or during the act of self harm.

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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.

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Psychological Characteristics

• 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
• 20 - 50 involves alcohol

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Attitudes to Self Harm

• 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.
• Depression is viewed more favourably than
  manipulation as a cause of self harm.

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Attitudes to Self Harm

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

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Consequences of Negative Attitudes

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

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Why Negative Attitudes?

• Self harm can be a challenge to our
  personal/professional beliefs
• Fear
• Perception of incompetence
• Transference counter transference

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So What Can We Do?

• Risk assessment
• Psychological interventions
• Clinical interventions
• Pharmacological interventions

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Risk of Repetition

• Risk of repetition
• 16 will repeat within a year.
• Repetition occurs early
• 25 within 3 weeks
• 50 within 12 weeks
• 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

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Risk of Suicide

• 1 will commit suicide within the following year
• 3 at 5 years
• 50 of suicides have previous self harmed.
• 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 AE are three
  times more likely to repeat self harm or complete
  suicide.

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Hazards Which May Mislead the Assessment and
Management of Suicide Risk

• Deliberate denial of suicidal ideas
• Variability in degree of distress
• Misleading improvement

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Hazards Which May Mislead the Assessment and
Management of Suicide Risk

• Anger, resentment (national confidential inquiry
  33 of suicides have previous history of
  aggressive behaviour)
• Un-cooperative and difficulty behaviour
• Malignant alienation
• Assuming that the service user is manipulating
  with empty threats

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Risk Management Cycle
Identify Risk
Assess Risk
Review
Risk Management Cycle
Rate Risk
Monitor
Interventions
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Assessment Basic Skills

• 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.
• Need to establish good rapport.
• Progressive focussing down on specific suicidal
  ideas. Useful to begin with more general issues.

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Assessment Basic Skills

• 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.
• Occasionally necessary to use more direct
  questioning.
• Be prepared to ask directly about suicidal intent
  as you are unlikely to implant suicidal ideas in
  individuals.
• Impatient challenging due to frustration may
  provoke high-risk acting out in response.

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Psychological Interventions

• Problem solving therapy
• Cognitive behavioural therapy
• Psycho-dynamic interpersonal therapy
• Dialectical behavioural therapy

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Strategies for Working With Self Harm

• Delaying strategies
• Restoring hope
• Therapeutic activism
• Use of short term no self harm contract

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Strategies for Working With Self Harm

• Alternatives to self harm
• Hospitalisation
• Reduce access to means
• Underpinning all of the above is the importance
  of the therapeutic alliance formed with the
  individual

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Helpful Responses

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