5.6 Working with Children who Self-Harm or have the Potential for Suicide
- This is Pan Lancashire multi-agency guidance for those working with children who Self-harm or have the potential for Suicide and their families.
- This guidance seeks to support staff in working with children to reduce the potential damage self-harm can cause to both the child's physical body and to their mental well-being, e.g. self-esteem and provide them with the information required to make confident, informed and consistent decisions and responses when dealing with a child who has self-harmed.
- This care pathway document recognises that young people who self-harm are doing so as a coping mechanism, and that just telling them to stop does not work.
- This guidance advocates a 'harm reduction/minimisation' approach. Both the child and member of staff will be working towards replacing the self-harming behaviours with less risk taking and potentially life threatening coping strategies.
- Children who self-harm mainly do so because they have no other way of coping with problems and emotional distress in their lives. This can be to do with factors ranging from bullying to family breakdown. But self-harm is not a good way of dealing with such problems. It provides only temporary relief and does not deal with the underlying issues.
- It is for all those working in the Children and Young People workforce, primarily for use with:
- Children identified as using self-harm as a coping strategy;
- Children when they require access to specialist mental health services as a result of self-harm, suicide ideation and/or attempted suicide.
This is any child under the age of 18.
Suicide is an intentional, self-inflicted, life-threatening act resulting in death from a number of means.
- Suicidal intent
This is indicated by evidence of premeditation (such as saving up tablets), taking care to avoid discovery, failing to alert potential helpers, carrying out final acts (such as writing a note) and choosing a violent or aggressive means of deliberate self-harm allowing little chance of survival.
- Lancashire's Youth and Community Service conducted some research with young people in 2002 and produced a paper which offers a helpful baseline (Coupe et al, 2002):
"Self-harm might be described as the term used to describe the coping strategy that some people use to deal with stresses in their life:
- It involves a person hurting themselves physically;
- Self-harm often takes the form of a person cutting, burning or banging themselves;
- According to the young people who participated, self-harm is often about "surviving", "coping", "taking control", "release of pressure", "distraction from other stuff - places/people", "complex emotions".
- Self-harm describes a wide range of things that people do to themselves in a deliberate and usually hidden way. In the vast majority of cases self-harm remains a secretive behaviour that can go on for a long time without being discovered.
- Self-harm can involve:
- Cutting, often to the arms using razor blades, or broken glass;
- Burning using cigarettes or caustic agents;
- Punching and Bruising;
- Inserting or swallowing objects;
- Head banging;
- Hair pulling;
- Restrictive or binge eating;
- Problematic substance misuse;
- Frequent and repetitive risk taking behaviour e.g. taking away and driving cars, 'playing chicken'.
(Mental Health Foundation 2006)
The term self-harm is often used as an all encompassing term referring to suicidal ideation and attempted suicide.
- Some young people who self-harm may say that they want to die and a proportion of them may genuinely want to. Nevertheless, self-harm and suicide differ in terms of the intent behind the behaviour - self-harm is motivated by the desire to endure and survive. Understandably, many people assume that when a person injures themselves they are making a suicide attempt. But "self injury is not the same thing as a suicide attempt, in fact it is usually something very different: a desperate attempt to cope and to stay alive in the face of great emotional pain" (Arnold and Magill, 1996).
- Despite these differences, self-harm is associated with an increased risk of suicide, since both actions are based in distress. For example, someone may resort to suicide when self-harm no longer works for them as a coping strategy. Some motivations for self-harming 'overlap' with suicidal motivations: when, for example, a person feels ambiguous about whether the action kills them or not, and given the risks inherent in self-harm, a small proportion of people who self-harm may kill themselves accidentally. As a result, statistics indicate that people who self-harm are more likely to commit suicide (e.g. Hawton 1992) - although the often hidden nature of self-harm means that statistics can be unrepresentative.
- Research indicates that a number of factors may motivate young people to self-harm and the list below is not exhaustive:
- To express emotional distress: "you're showing other people how much you're hurting inside"; (Bywaters and Rolfe 2002)
- Release and relief from pressure: "it's like a release. It feels better after I've taken tablets"; (Spandler 1996)
- Letting bad feelings 'out': "getting all the anger and the hurt out, and the pain"; (Bywaters and Rolfe 2002)
- Distraction from emotional pain: "Taking the pain away from what's in your head and transferring it onto your body"; (Bywaters and Rolfe 2002)
- To gain control over seemingly out-of-control situations and feelings: "You've got to have control over something"; (Spandler 1996)
- To induce a pleasurable state: "my whole body goes kind of calm"; (Bywaters and Rolfe 2002)
- To feel special, to express individuality: "I took a certain pride in being able to take pain. It was like I was good at something"; (Spandler 1996)
- To physically express emotional pain: "it's my way of turning emotion and pain, and things like that into something physical, which is a lot easier to handle in the long-run". (Bywaters and Rolfe 2002)
- According to "Youth and self-harm" (Samaritans 2002), the most common reasons given for self-harm by school-age young people were 'to find relief from a terrible state of mind'. Contrary to popular belief, few were 'trying to frighten someone' or 'get attention'.
Issues that may trigger self-harm
- A number of factors may trigger the self-harm incident:
- Family relationship difficulties (the most common trigger for younger adolescents);
- Difficulties with peer relationships e.g. break up of relationship (the most common trigger for older adolescents);
- Significant trauma, e.g. bereavement, abuse;
- Self-harm behaviour in other students (contagion effect);
- Self-harm portrayed or reported in the media;
- Difficult times of the year (e.g. anniversaries);
- Trouble in school or with the police;
- Feeling under pressure from families, school and peers to conform/achieve;
- Exam pressure;
- Times of change (e.g. parental separation/divorce).
- Previous deliberate self-harm or suicide attempt;
- Intent - does the young person wish to die? What do they understand by death? Do they think that what they have done, or are planning to do, will kill them? N.B. it is the young person's perception of or belief in potential lethality that is important here, not what a professional thinks;
- Evidence of mental illness, especially depression, anxiety, psychosis or eating disorder;
- Poor problem-solving skills - are problems seen as over-whelming? Does the young person see themselves as capable of solving, or coping with, problems? Have they been able to solve problems in the past? May be linked to poor communication skills;
- Impulsivity/planning - Were steps taken to avoid discovery? Were any preparations for death made? A tendency to impulsive behaviour may increase risk of repetition and thus the likelihood of significant harm, but evidence of planning may indicate higher levels of seriousness for any given attempt. But remember that an impulsive act can be just as damaging as a planned one;
- Substance use including alcohol and volatile substances (especially important in impulsive males);
- Hopelessness - is there a future, or any reason to continue living? What plans for the future does the young person have? This has been described as "the missing link" between depression and suicide. It can be especially significant if there has been previous deliberate self-harm or attempts at suicide;
- Anger/hostility/anti-social behaviour - some research suggests conduct disorder may be a higher risk factor than depression. This may be difficult to assess, as information will be needed from sources other than the young person;
- Low self esteem;
- Drug or alcohol abuse.
- Instability (this can mean more than divorce or separation and can include repeated house moves). History of depression, deliberate self-harm, suicide or mental illness in the family, especially in first-degree relatives. History of substance use. Arguments or disputes can be important;
- History of neglect or abuse, whether physical, emotional or sexual, but especially the latter;
- Has the young person experienced prolonged parenting style characterised by "High Criticism and Low Warmth"?
- Experiencing or witnessing domestic abuse;
- Loss or bereavement - this may include such things as loss of status as well as deaths. Anniversaries of losses can be significant;
- Unreasonable expectations;
- Poor parental relationships and arguments.
- Persistent bullying, peer rejection or other victimisation, such as experiencing racial or sexual discrimination, and including homophobic bullying (see next point);
- Issues of gender or sexual orientation - a very high proportion of young people who either are homosexual or think they might be, self-harm or attempt suicide;
- Current stressors or life events;
- Absence of a supportive helping network (could be family, extended family, peers, or professional);
- Absence of a trusted approachable adult;
- Difficulty in making relationships/loneliness;
- Easy availability of drugs, medication or other methods of self-harm.
- Function of deliberate self-harm (other than a clear suicide attempt) - what did the young person hope the act would achieve: a sense of relief or release; punishment; purification; a desire to feel physical rather than emotional pain; a form of communication of distress or other significant matter; something else?
- Method of self-harm - be aware of unintended consequences, such as liver damage from repeated 'Paracetamol' overdoses, stomach ulceration from aspirin overdose, brain damage from oxygen starvation in attempted hanging, drowning or exhaust poisoning, or bone damage resulting from jumping;
- Time of year may be significant, especially when school-related factors are involved, such as bullying or exams. Hence the start of terms or exam periods may see an increase in self-harming behaviour;
- Young people may be highly ambivalent in their views of themselves and any act of self-harm.
- It is ok and appropriate to show concern. Make sure the child / young person is safe; give them something to treat any injuries (e.g. plaster or bandage) and/or seek medical advice and attention as required. Encourage the young person to seek medical attention if they are reluctant and provide the necessary support to facilitate this.
- The young person who has just harmed themselves usually feels upset and vulnerable (although they may hide this). Just because they caused the harm to themselves this does not mean that they will not feel hurt, frightened or shocked by their injuries. Be reassuring rather than questioning them at this stage. They may want to talk, so allow for this.
- People often fear that being sympathetic will somehow 'reinforce' the behaviour as an 'attention-seeking' strategy, thereby perpetuating it and possibly making it worse. In fact, being punitive, hostile or withholding care and support is likely to make the young person feel even worse about themselves, thereby increasing risk. (However, avoid 'amateur' psychology and/or therapy at all costs, unless you are trained and/or qualified to provide either or both!)
- It is usual for people to feel shocked, frightened, anxious and/or upset when they first encounter a child or young person who is self-harming. However, the messages that adults give at this initial point of contact are crucial:
- Calmness - Remain calm and do not openly display the very powerful feelings of shock, anger, distress or panic that you may have;
- Acceptance - Tell the young person that it is okay to talk about self-harm, it is something that you know about and can handle;
- Acknowledgement - Tell the young person how hard it can be to talk about this and acknowledge the courage that it takes to do so;
- Concern - Demonstrate that you are concerned about the distress which lies behind the self-harm;
- Understanding - Make it clear that self-harm is something that can be understood, that there are reasons for it and that other young people do it too - they are not alone;
- Respect and Reassurance - Acknowledge their use of this particular coping strategy and with how frightening it might feel if they think someone is going to take it away;
- Hope - Some people who self-harm think it absolutely impossible to stop; let them know that lots of people who do it are able to stop hurting themselves;
- Information - Provide information about appropriate resources and sources of further help, advice and support but do not rush the young person on to someone else; remember that being available to listen and talk is important in itself and avoids giving messages of being fobbed off or that the problem is simply too big for anyone to deal with);
- Confidentiality - Respect confidentiality whilst ensuring that appropriate procedures are followed. The 'usual' balance needs to be struck here e.g. make it clear why and to whom you may have to pass information on and encourage and support a young person to talk to an appropriate person. (See Information Sharing and Confidentiality Procedure)
|Suicidal thoughts are fleeting and soon dismissed||Ease distress as far as possible. Consider what may be done to resolve difficulties|
|No plan||Link to other sources of support|
|Few or no signs of depression||Make use of line management or supervision to discuss particular cases and concerns|
|No signs of psychosis||Review and reassess at agreed intervals|
|No self-harming behaviour||Consider completing a CAF|
|Current situation felt to be painful but bearable|
|Suicidal thoughts are frequent but still fleeting||Ease distress as far as possible. Consider what may be done to resolve difficulties|
|No specific plan or immediate intent||Consider safety of young person, including possible discussion with parents/carers or other significant figures|
|Evidence of current mental disorder, especially depression or psychosis||Seek specialist advice|
|Significant drug or alcohol use||Possible mental health assessment - discussion with, for example, service's safeguarding champion, primary mental health workers in CAMHS/AMHS|
|Situation felt to be painful, but no immediate crisis||Consider consent issues for the above|
|Previous, especially recent, suicide attempt||Consider increasing levels of support/professional input|
|Current self-harm||Review and reassess at agreed intervals - likely to be quicker than if risk is low|
|Frequent suicidal thoughts, which are not easily dismissed||Ease distress as far as possible. Consider what may be done to resolve difficulties|
|Specific plans with access to potentially lethal means||Safety - discussion with parents/carers or other significant figures more likely|
|Evidence of current mental illness||Request for Specialist CAMHS involvement|
|Significant drug or alcohol use||Consider consent issues|
|Situation felt to be causing unbearable pain or distress||Consider increasing levels of support/professional input in the mean time|
|Increasing self-harm, either frequency, potential lethality or both||Monitor in light of level of Specialist CAMHS involvement|
N.B. at any time during assessment and review, emergency medical treatment may be found to be necessary or child protection concerns may be raised. See Making a Referral to Children's Social Care Procedure.
Direct referral route to Specialist or Emergency Care
- Based on the notion that the level of perceived risk could change at any time, ongoing support systems need to be put in place irrespective of the level of risk.
- Ongoing support may take many forms and may be offered via numerous sources and will be dependent on the child or young person's needs and wishes.
- Make an assessment of risk e.g. emergency medical attention;
- Take suicide gestures seriously;
- Be yourself, listen, be non-judgemental, patient, think about what you say;
- Check associated problems such as bullying, bereavement, relationship difficulties, abuse, and sexuality questions;
- Check how and when parents will be contacted;
- Encourage social connection to friends, family, trusted adults;
- Implement initial care pathway;
- Implement support/contact with young person;
- Seek risk assessment from those in your service who have been trained to provide this level of assessment;
- Make appropriate referrals;
- Using CAF processes set up a meeting to plan the care pathway interventions based upon an understanding of the risks and difficulties;
- Provide opportunities for support, and to strengthen existing support systems.
- Jump to quick solutions;
- Dismiss what the children or young people are saying;
- Believe that a young person who has threatened to harm themselves in the past will not carry it out in the future;
- Disempower the child or young person;
- Ignore or dismiss people who self-harm;
- See it as attention seeking;
- Assume it is used to manipulate the system or individuals;
- Trust appearances.
Appendix 2 - Checklist for Agencies/Establishments - Supporting the Development of Effective Practice