3 Aims To survey the risk factors related to self-harm To understand why young people self-harmTo examine how and what to ask a young person about self-harmTo examine how to develop safety plans about self-harmTo examine how to record and report information about self harmTo examine ongoing management and liaison with services
4 Learning ObjectivesTo have a better understanding of self-harming behaviour among young people and how to respond to itTo have acquired knowledge that you can take back to your local YOS
5 Exercise 1: What is Self-Harm? 10 minutes for group discussion and then we’ll have feedbackSplit into groups:What is self-harm?Why do people self-harm?Is it different from attempting suicide?
6 What is self-harm?Hard to define because it depends on the reasons why people have carried out the behaviourDifferent functions:coping with intense emotionscommunicating distressre-connecting with self (feel again) and othersan attempt to end one’s life (i.e. suicide intent)a life saving act
7 Types of self-harm Direct Indirect Suicide attempts Self-injury (without suicidal intention)AmbiguousIndirectSubstance abuseEasting-disorderPhysical/situational/sexual risk taking
8 Acts of self-harm Cutting Hitting/Punching Burning Overdosing Interfering with wound healingPinchingBitingOther
9 Suicide Attempt vs. self-harm (from Walsh, 2008) Assessment focusSuicide attemptSelf-injuryIntentTo escape pain, end consciousnessRelief from unpleasant emotionsPsychological painUnendurable, persistantUncomfortable, intermittentTunnel vision’Tunnel vision: one way outChoices available, temporary solution
10 Assessment focusSuicide attemptSelf-injuryHopelessness and helplessnesscentralPeriods of optimism and some sense of controlDecrease in discomfort?No immediate improvementYes – successful ‘alteration of consciousness’Chronic/repetitive?Less often chronic and repetitiveFrequently chronic and high-rate
11 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 guideIntention is the best way to tellBut - 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.
12 Defining termsToday, 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).
13 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.
14 Suicide in the community Windfur et al. (2009): Rate of around 3 per 100,000 for children aged from , increases with age.In adolescents aged rate was just over 6 per 100,000.More common in males: Suicide in young women aged under 3 per 100,000. In young men aged it was 10 per 100,000 in 2008 (office of national statistics).
15 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’ ?
16 Guess stats for YOSCambridgeshire YOS referrals (Feb-April 2009; N= 39):37% had history of self-harming21% had history of attempting suicide18.4% had self-harmed within the past monthOf completed SQIFAs over 54% reported thoughts of harming or killing themselves at least ‘sometimes’
17 Self-harm in the CJSHarrington & 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.
18 Self-harm in prison20% of males aged 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.
19 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
20 Risk factors for self-harm, suicide and offending behaviour Systemic factorsSelf-harmsuicideoffendingFamily violence and conflictyesPhysical abuseneglectYessmall linkPoor parenting (eg. Discipline, consistency, affection)
21 Risk Factors Systemic factors Self-harm suicide offending Sexual abuse Small linkYesIncreased in violent offendingCriminal parent-Poverty
23 Risk factors Individual factors Self-harm suicide Offending behaviour Lower IQ (hence poorer social skills and problem solving)-YesDifficulty identifying and expressing emotions, dissociation
24 Risk factorsBig 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
25 Take home messageMany similar risk factors for suicide, self-harm and offending.We work with a vulnerable populationBUT - 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
27 Case study: John15-year-old boy on a referral order for assaulting peer on way home from schoolSignificant 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 cancerFinds it hard to talk to parents about how he is feelingMum 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.
28 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?
29 Be preparedMake sure a young person knows about the limits of confidentialityEnsure you are aware of your area policyNever make promises you cannot keepYoung person’s safety is paramount and takes primacy over confidentialityWork together towards discussing with family/carers where appropriateHave an idea when you go in about the questions you need to ask and the key informationHave emergency contact numbers available
30 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.
31 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).
32 Recent History: Thoughts of Self-harm Have they told anyoneAccess to social supportHow do they feel right now? - current plans/intent - current level of hopelessnessWhat would have to change to make them feel more hopeful?
33 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 happenWhat 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?
34 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?
35 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?
36 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 contactSome 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
37 How to AskReflective 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.
38 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.
39 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 supportFind 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 serviceBegin 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.
40 Role Play! 10 minute role play, then: Get into groups and choose a case example.
42 Exercise 5: Role PlayGet 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?
43 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.
44 Formulation for John: Predisposing Factors Mum’s depression – possible attachment problems and difficult regulating emotionsWitnessing domestic violenceAvoidant family style – difficulties not discussedPossible feelings of rejection connected to relationship with dad, who is closer to brother.Any others?
45 Predisposing: Core Beliefs Early experiences could have led to the development of some beliefs about self, world and others:I’m worthlessOthers leave you, you can’t trust other peopleWorld is unpredictable
46 Predisposing: Rules for living If you talk about how you really feel, then people might leaveI need to look after other people, or they’ll leave meI should be there for othersI need to control my feelings, or others will reject me.
47 Precipitating Excluded from school due to assault Feelings of rejection from peersBack in school – pressure to manage behaviourGirlfriend upset on phone
52 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 psychologistIf a suicide attempt, YOS officer and psychologist agree a ‘Suicide Prevention Plan’.
53 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.
54 Who to tell and what to tell If risk is high (suicide attempt, current intention), YOT worker or health worker can contact:GPIf under 17: CAMHS on-call duty workerIf over 17: - Intake and Treatment duty worker - Home Treatment Team (GP or Intake and Treatment can refer, or can contact directly).A&E
55 Recording – YOIS Cambridgeshire YOT guidance Recorded in YOIS within 24 hoursLink in a ‘case diary’ entry including the information you have gathered and your initial formulationIf 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.
56 Recording – YOIS Cambridgeshire 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.
57 How to record YOIS VMP - Smart Goals Flags Case diaries Safety plan ACCTRisk and vulnerability registersMonitoring and review – dynamic!
58 Talking AgainOnce referral has been made, health worker/CAMHS/other should meet with young personHealth 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
59 Safety planningYOT worker should be aware of the safety plan developed with the young personNeeds to address the main risksNeeds 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.
60 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 referralCan use Common Assessment Framework (CAF)Need agreement from child before referral is made
61 CAMHS Referral – what to include Basic information: - name and dob - address - who has parental responsibility - GP detailsReason 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
62 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
63 Supervision What do you want to get from supervision? How do you go about getting it?
64 Ongoing Engagement with services Therapy Monitoring Dynamic safety planLiaison
65 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?