1. 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

2. Introductions

3. 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

4. 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

5. 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?

6. 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

7. Types of self-harm Direct Indirect Suicide attempts
Self-injury (without suicidal intention)
Ambiguous
Indirect
Substance abuse
Easting-disorder
Physical/situational/sexual risk taking

8. Acts of self-harm Cutting Hitting/Punching Burning Overdosing
Interfering with wound healing
Pinching
Biting
Other

9. 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

10. 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

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 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.

12. 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).

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 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’

17. 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.

18. Self-harm in prison
20% 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 factors
Self-harm
suicide
offending
Family violence and conflict
yes
Physical abuse
neglect
Yes
small link
Poor parenting (eg. Discipline, consistency, affection)

21. Risk Factors Systemic factors Self-harm suicide offending Sexual abuse
Small link
Yes
Increased in violent offending
Criminal parent -
Poverty

22. Risk factors Individual factors Self-harm suicide offending
impulsivity
Yes
yes
Mental health problems
BPD
Anxiety, depressionetc.
Depression,
Anxiety,
Etc.
various
Substance abuse

23. 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

24. 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

25. 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

26. Coffee Break!
Drink coffee
Eat biscuits
15 minutes

27. 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.

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 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

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 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?

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 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?

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 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

37. 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.

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 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.

40. Role Play! 10 minute role play, then:
Get into groups and choose a case example.

41. LUNCH!
12.30 – 13.15

42. 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?

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 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?

45. 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

46. 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.

47. Precipitating Excluded from school due to assault
Feelings of rejection from peers
Back in school – pressure to manage behaviour
Girlfriend upset on phone

48. Perpetuating:
We’ll draw it out!

49. Protective
Mum
Music
Self-reflection

50. Exercise 6: Group formulation
Focus on the perpetuating/maintaining cycle

51. Coffee Break

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 psychologist
If 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: 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

55. Recording – YOIS Cambridgeshire 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.

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
ACCT
Risk and vulnerability registers
Monitoring and review – dynamic!

58. 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

59. 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.

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 referral
Can 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 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

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 plan
Liaison

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?

66. Questions and Feedback