Understanding and responding to young people who self-harm
within youth offending services
Dr Joel Harvey – Clinical Psychologist
Dr Alison Sillence- Clinical Psychologist
Laura Hawksley - YOS Officer
Introductions
Aims
• To survey the risk factors related to self-harm
• To understand why young people self-harm• To examine how and what to ask a young
person about self-harm• To examine how to develop safety plans
about self-harm• To examine how to record and report
information about self harm• To examine ongoing management and
liaison with services
Learning Objectives
• To have a better understanding of self-harming behaviour among young people and how to respond to it
• To have acquired knowledge that you can take back to your local YOS
Exercise 1: What is Self-Harm?
• 10 minutes for group discussion and then we’ll have feedback
• Split into groups:– What is self-harm?– Why do people self-harm?– Is it different from attempting suicide?
What is self-harm?
• Hard to define because it depends on the reasons why people have carried out the behaviour
• Different functions: – coping with intense emotions– communicating distress– re-connecting with self (feel again) and
others– an attempt to end one’s life (i.e. suicide
intent)– a life saving act
Types of self-harm
• Direct– Suicide attempts– Self-injury (without suicidal intention)– Ambiguous
• Indirect– Substance abuse– Easting-disorder– Physical/situational/sexual risk taking
Acts of self-harm
• Cutting• Hitting/Punching• Burning• Overdosing• Interfering with wound healing• Pinching• Biting• Other
Suicide Attempt vs. self-harm
(from Walsh, 2008)Assessment focus
Suicide attempt
Self-injury
Intent To escape pain, end consciousness
Relief from unpleasant emotions
Psychological pain
Unendurable, persistant
Uncomfortable, intermittent
Tunnel vision’ Tunnel vision: one way out
Choices available, temporary solution
Assessment focus
Suicide attempt
Self-injury
Hopelessness and helplessness
central Periods of optimism and some sense of control
Decrease in discomfort?
No immediate improvement
Yes – successful ‘alteration of consciousness’
Chronic/repetitive?
Less often chronic and repetitive
Frequently chronic and high-rate
Self harm or suicide attempt?
• It is important to note that acts of self-harm can have different functions at different times.
• Lethality is not always a reliable guide • Intention is the best way to tell But
- individuals can be ambivalent- may not be able to articulate their reasons- may not know or remember why
- self-harm and attempted suicide not always distinct.
Defining terms
• Today, we will use self-harm to mean deliberate self-injury without suicidal intent. It can also be referred to as non-suicidal self-injury (NSSI).
Self harm in the community
• How common is self harm? Depends on how you define it, but:– 15-20% of adolescents in the community are
estimated to have self-harmed (without suicidal intent) at some time (in Nixon and Heath, 2009).
• Gender difference?– Community studies on NSSI that only ask
about tissue damage don’t show a gender difference.
– Studies that also ask about pill overdosing (without suicide intent) find more females.
Suicide in the community
• Windfur et al. (2009): Rate of around 3 per 100,000 for children aged 10-19 from 1997-2003, increases with age.
• In adolescents aged 15-19 rate was just over 6 per 100,000.
• More common in males: Suicide in young women aged 15-24 under 3 per 100,000. In young men aged 15-24 it was 10 per 100,000 in 2008 (office of national statistics).
Exercise 2: Guess stats for YOS
• Write on a post-it:• Percentage of young people referred
to the Cambridgeshire YOS psychologist who: - had a history of self-harm? - had attempted suicide in the past? - had self-harmed in the past month?
• Of completed SQIFAs how many reported thoughts of harming or killing themselves at least ‘sometimes’ ?
Guess stats for YOS
• Cambridgeshire YOS referrals (Feb-April 2009; N= 39): – 37% had history of self-harming– 21% had history of attempting suicide– 18.4% had self-harmed within the past month
• Of completed SQIFAs over 54% reported thoughts of harming or killing themselves at least ‘sometimes’
Self-harm in the CJS
• Harrington & Bailey (2005): Survey of people in the community (YOS) and in secure settings (STCs and LASCHs) found that 1/3 had mental health needs and 9% had self-harmed in the past month.
Self-harm in prison
• 20% of males aged 16-20 on remand had attempted suicide in their lifetime (Meltzer et al. 1999)
• 38% had thought about suicide.• In 2004, 5425 people self-harmed in
prison; 74 per 1,000 people; young people accounted for 25% of these incidents.
Exercise 3: Risk Factors for Self-harm
• What do you think are the risk factors?
• Problem not located solely within the individual - important to think systemically
Risk factors for self-harm, suicide and offending
behaviourSystemic factors
Self-harm
suicide
offending
Family violence and conflict
yes yes yes
Physical abuseneglect
Yes small link
yes yes
Poor parenting (eg. Discipline, consistency, affection)
Yes yes yes
Risk FactorsSystemic factors
Self-harm
suicide offending
Sexual abuse
Small link Yes Increased in violent offending
Criminal parent
- - Yes
Poverty - - Yes
Risk factorsIndividual factors
Self-harm
suicide offending
impulsivity Yes Yes yes
Mental health problems
BPDAnxiety, depressionetc.
Depression,Anxiety,Etc.
various
Substance abuse
Yes Yes Yes
Risk factors
Individual factors
Self-harm
suicide
Offending behaviour
Lower IQ (hence poorer social skills and problem solving)
- - Yes
Difficulty identifying and expressing emotions, dissociation
Yes - -
Risk factors
• Big risk factors for all of these things is whether someone has done that behaviour before – e.g. previous offending/suicide attempt/self-harm.
• This is an important thing to consider when assessing for risk of self-harm or suicide
Take home message
• Many similar risk factors for suicide, self-harm and offending.
• We work with a vulnerable population• BUT
- Risk factors are not causes, someone can have all the risk factors and still not do the behaviour- Understanding the individual and their circumstances is most important
Coffee Break!
• Drink coffee• Eat biscuits• 15 minutes
Case study: John• 15-year-old boy on a referral order for assaulting peer
on way home from school• Significant peer rejection since assault and his school
attendance is now poor.• Lives with mum and stepdad, older brother recently left
to live with dad.• Girlfriend lives in London. He find the separation hard
and her mum was recently diagnosed with cancer• Finds it hard to talk to parents about how he is feeling• Mum has often suffered from depression.• Self-harming for a number of years. Recently increased
in frequency.• Often self-harms after talking to his girlfriend on the
phone.
Exercise 4: Barriers to working with this client
• what would your worries be about discussing self-harm with this person?
• How do you think these worries could affect the conversation?
Be prepared• Make sure a young person knows about the
limits of confidentiality• Ensure you are aware of your area policy• Never make promises you cannot keep• Young person’s safety is paramount and
takes primacy over confidentiality• Work together towards discussing with
family/carers where appropriate• Have an idea when you go in about the
questions you need to ask and the key information
• Have emergency contact numbers available
Finding an opportunity
• Use assessment as an opportunity to ask about self-harm, suicide attempt and suicidal ideation.
• Can ask at other times e.g. If you notice scars, if young person seems low:
‘sometimes when people feel low, they have thoughts about harming themselves. I’m just wondering if that’s ever the case for you?’
• Its hard to ask, but if you don’t know, you can’t help.
Recent History: Thoughts of Self-harm
• Does the young person ever think about not wanting to be here?
• If yes:- Have you thought about doing anything to end your life?- plans and intent.- why they feel this way- level of hopelessness (scale of 1-10?)- reasons for carrying on? (eg. If they say 9/10 for hopelessness, ask about the 1/10).
Recent History: Thoughts of Self-harm
• Have they told anyone• Access to social support• How do they feel right now?
- current plans/intent - current level of hopelessness
• What would have to change to make them feel more hopeful?
Recent History: Self-harm
• Have they self-harmed recently? IF YES:- What did they do? (eg. Pills? How many, type)- When and where did this happen- What happened immediately before?
(triggers)- How did they feel afterwards? - Had they taken any alcohol/substances?- Anyone else around? Could anyone else have
noticed or found them?- Told anyone? What was their response?- What do they think about the self-harm now?
Recent history: Self-harm
• Has this happened before? IF YES:• How often? If is it not an isolated event:- What generally triggers it?- Any times when they feel this way but do
not self harm (other ways of coping)?- Any times when the self-harm is worse?
(and how bad is it?)- Times when the self-harm is better?
Past Risky behaviours
• If they have not harmed themselves recently:- Have they ever thought about harming
themselves in their lifetime?- Have they ever harmed themselves in their
lifetime? If Yes:- what was the worst time? (what did they do – trying to assess for past suicidality)- ask about triggers, intent, outcome (eg. Hospitalisation).
- How does their life then compare to their life now?
How to ask
• Make sure you have enough time• Try to appear calm, understanding, non-
blaming – they may worry that you will be shocked or horrified or think badly of them.
• Eye contact• Some mirroring of their posture can help (eg.
If they are right back in their seat, also sit back)
• Give them time to talk and encouraging talking: ‘is it ok for you to say a bit more about…?’
• Leave some pauses
How to Ask
• Reflective listening – shows understanding reflecting feelings: ‘so you felt angry and then..’reflecting meaning: ‘it sounds like, to you, this is a way to cope with…’
• Reflecting back often helps people to expand on what they have said.
• Open questions can ‘open’ up the conversation, but they can be intimidating if someone cannot answer.
• Closed questions – yes or no answers. • Good to have a mixture.
How to Ask
• If asking a difficult question it can help to be tentative:
‘I’m just wondering about what was going on for you when…’. ‘Why?’ can sound accusing at times.
How to respond: ending and containing
• If in doubt: reflect!• Help them notice what other coping strategies
they sometimes use: Has there been a time when you really wanted to self-harm but didn’t?
• Help them to think about sources of support• Find out if its ok for you to talk to a parent (if you
think this would be helpful)• Work towards discussing referral to an
appropriate service• Begin a basic safety plan with them, so they know
who they would contact (family member, GP, A&E) if they felt at risk or had harmed themselves seriously.
Role Play!
• 10 minute role play, then:
Get into groups and choose a case example.
LUNCH!
• 12.30 – 13.15
Exercise 5: Role Play
• Get into groups and role play an assessment for the case that you picked.
• How did it feel to ask the questions?• How did it feel to be the young
person?
Formulation: what is it?
• Persons and Davidson (2010) note that ‘the formulation is a hypothesis about the factors that cause and maintain the patient’s problems, and it guides assessment and intervention’
• Friedberg and McClure (2002) formulations as ‘personalized psychological portraits’
• Through taking a formulation approach to clinical work the therapist moves away from a diagnostic model and provides an explanatory account of the presenting difficulties.
Formulation for John: Predisposing Factors
• Mum’s depression – possible attachment problems and difficult regulating emotions
• Witnessing domestic violence• Avoidant family style – difficulties not
discussed• Possible feelings of rejection connected to
relationship with dad, who is closer to brother.
• Any others?
Predisposing: Core Beliefs
• Early experiences could have led to the development of some beliefs about self, world and others:
• I’m worthless• Others leave you, you can’t trust
other people• World is unpredictable
Predisposing: Rules for living
• If you talk about how you really feel, then people might leave
• I need to look after other people, or they’ll leave me
• I should be there for others• I need to control my feelings, or
others will reject me.
Precipitating
• Excluded from school due to assault• Feelings of rejection from peers• Back in school – pressure to manage
behaviour• Girlfriend upset on phone
Perpetuating:
• We’ll draw it out!
Protective
• Mum • Music• Self-reflection
Exercise 6: Group formulation
• Focus on the perpetuating/maintaining cycle
Coffee Break
Who to tell and what to tell – Cambridgeshire YOS
Guidelines• If worker not the responsible officer,
must report immediately to responsible officer, line manager or duty manager (and record this in YOIS within 24 hours)
• Responsible officer must make urgent referral to YOS psychologist
• If a suicide attempt, YOS officer and psychologist agree a ‘Suicide Prevention Plan’.
Who to tell and what to tell – Cambridgeshire YOS
• Responsible officer and line manager and County manager must decide if this meets the ‘Serious Incident’ Notification Criteria, if it does, notification must be completed within 24 hours.
Who to tell and what to tell
• If risk is high (suicide attempt, current intention), YOT worker or health worker can contact:
• GP• If under 17: CAMHS on-call duty worker• If over 17:
- Intake and Treatment duty worker - Home Treatment Team (GP or Intake and Treatment can refer, or can contact directly).
• A&E
Recording – YOISCambridgeshire YOT
guidance• Recorded in YOIS within 24 hours• Link in a ‘case diary’ entry including
the information you have gathered and your initial formulation
• If you have reported it to other team members, record these interactions in YOIS within 24 hours.
• If a ‘suicide prevention’ plan has been done, record this within 24 hours.
Recording – YOISCambridgeshire YOT
guidance• Update ASSET and Vulnerability
Management Plan within 48 hours. If there is a Suicide Prevention Plan, include details.
• Line manager to countersign Vulnerability Management Plan within 72 hours.
• List case at next Vulnerability Planning meeting or Risk Management Panel and note this date as ‘planned intervention’ on YOIS.
• Line manager and County manager must complete a Local Management Report and forward to YJB within 20 days.
How to record
• YOIS• VMP - Smart Goals• Flags• Case diaries• Safety plan• ACCT• Risk and vulnerability registers• Monitoring and review – dynamic!
Talking Again
• Once referral has been made, health worker/CAMHS/other should meet with young person
• Health worker alone or jointly discuss:- who else in the family knows, or can join a session and talk about the self-harm- safety plan: what is it and agreement to develop one- meet to develop comprehensive safety plan
Safety planning
• YOT worker should be aware of the safety plan developed with the young person
• Needs to address the main risks• Needs to be practical – family and young
person have to feel confident they can follow it.
• Developed jointly with young person and family. They are in the best position to know what will help and what is practical.
Referral to CAMHS
• Accepts referrals up to 17th birthday• For self-harm, advises discussing with a
clinician at CAMHS to help determine level of priority before making referral
• Can use Common Assessment Framework (CAF)
• http://www.everychildmatters.gov.uk/deliveringservices/caf/
• Need agreement from child before referral is made
CAMHS Referral – what to include
• Basic information:- name and dob- address- who has parental responsibility- GP details
• Reason for referral- specific difficulties you want them to address- how long has it been a problem and why are they seeking help now?- is the problem general or situation specific?- your understanding of the issues involved
CAMHS referral - continued
• Further helpful information- who else is living at home and details of separated parents if appropriate- Name of school- Who else is or has been professionally involved- Previous contact with service and outcome- Details of known protective factors- any relevant history, i.e. family, life events, developmental factors
Supervision
• What do you want to get from supervision?
• How do you go about getting it?
Ongoing
• Engagement with services• Therapy• Monitoring• Dynamic safety plan• Liaison
What will you be taking away?
• What are the most important points you will take away from this?
• What steps will you take to talk about the training to the rest of your team?
Questions and Feedback
