Introduction to self-harm A risk and resilience model Charlotte Levene

Mental health: A definition ‘the strength and capacity of our minds to grow and develop, to be able to overcome difficulties and challenges and to make the most of our abilities and opportunities’

Aims for the session... Understand why some young people might self harm Explore risk factors Explore helpful responses Consider what young people have told us Develop strategies to build resilience in young people

Child Mental Health A capacity to enter into, and sustain, mutually satisfying and sustaining personal relationships Continuing progression of psychological development An ability to play and to learn so that attainments are appropriate for age and intellectual level A developing moral sense of right and wrong A degree of psychological distress and maladaptive behaviour within normal limits for the child’s age and context

Problems & Disorders Mental health problem A disturbance of function in one area of; relationships, mood, behaviour or development, of sufficient severity to require professional intervention. Mental disorder A severe problem (commonly persistent) or the co-occurrence of a number of problems, usually in the presence of several risk factors

A bio-psycho-social model EVENTS (what happens to us) NATURE (what we are born with) NURTURE (what we grow up with)

Defining Self harm When some people feel sad, desperate, angry or confused, they can hurt themselves. This is called ‘self-harm’. People can do this in a number of ways and for different reasons. People who harm themselves on more than one occasion may do so for a different reason each time. They may also harm themselves and not tell anyone about it NICE Guidance on Self Harm (2004)

Truth hurts Young people who self-harm do so because they have no other way of coping with problems and emotional distress in their lives…. It provides only temporary relief and does not deal with the underlying issues.’ Truth Hurts, Mental Health Foundation (2006) http://www.mentalhealth.org.uk/publications/truth-hurts-report1/

Methods of self harm Methods Cutting Scalding burning Hair pulling Excessive risk taking Cutting Scalding burning Hair pulling Breaking bones Banging Ingesting Restrictive eating Whilst cutting arms/back of legs appears to be most common method, there are others…

YoungMinds & Cello Research research 3 in 4 young people don’t know where to turn to talk about self-harm…most seek information online A third of parents would not seek professional help if their child was self-harming Almost half GPs feel that they don’t understand young people who self-harm and their motivations 2 in 3 teachers don’t know what to say to young people who self-harm Talking self harm YoungMinds/Cello (2012) http://www.cellogroup.com/pdfs/talking_self_harm.pdf

How common is it? Approximately 2 children in every classroom will have self-harmed

How common is it? Between 1 in 12 and 1 in 15 young people self-harm (truth hurts 2008) 7% of young people aged 15-16 in England self-harm (Hawton, et al., 2002) 37,000 young people presented to hospital in 2010/11 and many report previous episodes when they did not go to hospital (hospitals admissions statistics 2010) Inpatient admissions of young people under 25 for self harm have increased by 68% in the last 10 years (hospitals admissions statistics 2010)

Increased Vulnerability 318 out of 1000 young people in young offenders institutions report that they have self-harmed (ONS 2010) 18% of children aged 11-16, with a hyperkinetic disorder (similar to severe ADHD) reported that they have self-harmed. This compares to 7% without this disorder. (ONS 2004) 25% of parents, who had a child with an autistic spectrum disorder, reported that their child had self-harmed. (ONS 2004) Looked After Children and care leavers are between 4 and 5 times more likely to self harm in adulthood than those not Looked After (Annual Report of the Chief Medical Officer 2012)

Self Harm Myths What do you think are the main myths that surround self-harming behaviour in young people?

Self harm myths Myths associated with self harm Attention seeking Just about cutting Copying others Associated with specific sub cultures (Emo, goth) Fashionable-didn't happen in my day Is a suicide attempt Its because of the internet Consider: If self-harm is a way of coping with severe emotional distress and usually undertaken privately, why do so many people associate it with the showing of scars and subsequently feel that it is about attention seeking? These seem to be two separate things

Consider what the effect of this stigma is

What is the effect of this stigma? Increase feelings of shame and guilt Encourage likelihood of hiding self-harm Reduce willingness for open discussion/disclosure Increase judgement Add to risk Reduce likelihood of adults identifying young people Increase angry responses Increase in panicked responses Increase in “not taking it seriously” responses Inaccurate and inappropriate referrals

Why do some people self-harm?

What young people have told us… “I don’t really like school and nick off as much as I can. There’s always arguments at home so I go out and hang around with a group of lads and lasses. We all drink a bit; sometimes I cut my arm with a bit of broken glass. It feels good, but then I regret it the next day when I see the scar.” “The thoughts are in my head every day, I can’t take it. Cutting myself is the only way I can deal with him being around “I cut myself when I’m angry, it hurts but it helps my anger.” Cutting takes my mind off things, when I’m unhappy about myself, the way I am.”

Release of unbearable pressure “Cutting for me releases all the built up anger and frustration and pain I feel inside. There are many things that happen to me in my life which cause the pain I feel and how I release it. Mostly the feelings of isolation like being outcast pretty much from relationships altogether. I don’t feel like I am a very stable person and I hate myself a lot of the time. I think body image also has a lot to do with my cutting. School is stressful, home life I can’t handle sometimes.”

Jolt back to reality (when disassociating) “Sometimes when I felt numb and empty, scratching myself helped me to feel emotions again. Brought me back to life in a way” Young person

To physically feel something “Why do kids hurt themselves? Because they can’t feel anything else. Why can’t they feel anything else? Because a previous pain has scarred them, just like scar tissue that you might have now, it doesn’t tan in the sun because it’s dead! If you hurt inside for whatever reason, your inside will die. And then you don’t feel anything. But your brain still works you are still physically alive and the only way to bring those feelings back is to physically feel something”

Escape from the unbearable emotional present For some young people, there are times when the present is just too painful. Something may trigger a past memory or a current situation may be too difficult to bear. Self-harm is a way that the young person can escape from the unbearable emotional present.

It’s a deflection of emotional to physical pain “My emotions can vary rapidly and be very intense. If in an emotionally charged situation, I will either during or shortly after harm myself. I’m not good at dealing with emotions or communicating mine to others.”

Self-punishment Some people carry feelings of self-hatred or self-blame. When such feelings are very powerful, people may use self-harm to punish themselves. This may help reduce their guilt. (HandsonScotland)

“I would just like to mention the adrenalin rush that one experiences with the pain. When I feel numb and like I don’t really exist, I cause myself harm and it brings this rush that brings you back to earth”

Physical release and feeling of calm and well being Self-harm can bring its own physical release. Neurochemicals, such as serotonin, are released when the body is injured in any way and these may bring about feelings of calm and well-being. They produce insensitivity to pain which help the individual survive when faced with danger. Some people say that self-harm gives them this feeling of calm It is likely that the body grows to expect a higher level of these chemicals.

and some people won’t be able to tell you why they self-harm ...and some people won’t be able to tell you why they self-harm.... they might not know or they may not be able to express it in words

Self harm and suicide “Pain works. Pain heals. If I had never cut myself, I probably wouldn’t still be around today. My parents didn’t help me, religion didn’t help me, school didn’t help me but self-harm did. And I’m doing pretty well for myself these days. Don’t get me wrong, not in a heartbeat do I think that self-harm is a good or positive thing, or anything besides a heart-breaking desperate act that saddens me every time I hear about it. But there is a reason why people do it.”

What are risk factors? Conditions, events or circumstances that are known to be associated with emotional or behavioural disorders and may increase the likelihood of such difficulties Risk is cumulative Risk is not causal but can predispose children to mental health problems

Individual Factors Being Bullied Difficulties associated with sexuality Not getting on with parents Problems to do with race, culture and religion Stress about school Divorce Low self esteem Bereavement Feeling rejected Unwanted pregnancy an existing psychological or developmental difficulty low mood/anxiety difficulty communicating Hopelessness poor problem solving skills drug or alcohol abuse Impulsivity Experience of abuse Self-harm can be connected to vulnerability. Many things that can make a person vulnerable could be contributory risk factors to self-harm

Family Factors unreasonable expectations neglect or abuse (physical, sexual or emotional) Religious, ethnicity, cultural identity dilemmas or conflict poor parental relationships and arguments young carers’ role within the family depression, deliberate self harm or suicide in the family domestic violence

Social Factors difficulty in making relationships/ loneliness homophobic attitudes or bullying of children who think they may be gay, lesbian or bisexual persistent bullying or peer rejection easy availability of drugs, medication or other methods of self harm Racism

What can you do to help? Listen non judgementally Acknowledge emotional distress Encourage young person to identify their own support network and encourage them to access other support Recognise your limitations and refer to appropriate service for clinical assessment Explain what is going to happen next Show care and respect Control contagion- talk to any others involved Ensure that you have time and space to reflect-look after yourself too

Assessing Risk Ask the young person to explain in their own words, why they have self-harmed Remember- people self-harm for different reasons at different times.

Don’t…. React with horror or discomfort Ask abrupt or rapid questions Threaten or get angry Engage in power struggles; demanding ‘just stop’ Accuse them of attention seeking Get frustrated Ignore other warning signs Promise to keep things secret

Resilient Children “can resist adversity, cope with uncertainty and recover more successfully from traumatic events or episodes” Newman, T (2002)

Resilience Normal development under difficult circumstances. Relative good result despite experiences with situations that have been shown to carry substantial risk for the development of psychopathology (Rutter) The human capacity to face, overcome and ultimately be strengthened and even transformed by life’s adversities and challenges .. a complex relationship of psychological inner strengths and environmental social supports (Masten)

Sarah’s film...

Harm minimisation Taking control of their lives (helping to reduce risk taking behaviours) Developing more healthy ways of coping Increasing their self esteem Increasing their assertiveness in a positive way

Developing a self harm policy What do you think an effective policy would look like? Who would it target? What would it need to contain? How will you know that its having an effect? Which local services need to be involved in?

So what have we learned..? Defined self harm and explored methods Recognised that the myths and stigma surrounding self-harm lead to numerous adverse affects for those young people who do self-harm Recognised that there are many different reasons why a young person may self harm and they may be different on different occasions Most young people are secretive about self-harm Those who disclose must be listened to, cared for, taken seriously and be assessed by professionals There are many ways you can help a young person reduce risk and build resilience

YoungMinds Parents Helpline: 0808 802 5544 Tel: 020 7089 5050 Website: http://www.youngminds.org.uk Training & Development: matthew.daniel@youngminds.org.uk