Young people and self-harm. The 5 essential questions answered.

1. What should I know?
2. How can I help?
3. What works?
4. Where to go next?
5. What do young people say?

1. What should I know?

“I want to ask you a question: what do you think when you see the cuts on my arms: attention seeker? Deliberate self-harmer? Depression? High risk? Or a young person like any other with hopes and dreams, friends and family who just happens to have a mental illness.”

Said by a young mental health activist talking to an audience of professionals. Why do they do it? This is perhaps the most common question asked about young people who self-harm. Each young person is unique and no one answer will explain the whole story for everyone. But there are some common facts about self-harm and it will help you to help a young person if you have accurate information.

  • Self-harm is common among younger people. A survey of young people aged 15–16 years estimated that more than 10% of girls and more than 3% of boys had self-harmed in the previous year.Both boys and girls self-harm across a very broad age range. Rarely, although it is known, children as young as six self-harm and it can continue through someone’s teens and into adult life.
  • Self-harm is not only about cutting and may not be to the wrist or forearms. It can involve burning, bruising, taking an overdose, pulling hair or picking skin. There are emotional ways of self-harming too, such as closing oneself off from loved ones in a very determined way.
  • The seriousness of the underlying problem cannot be measured by how bad the injury is. People who hurt themselves a bit can feel just as bad as those who hurt themselves a lot.
  • Self-harming can be hidden and many hurt themselves secretly for a long time before others find out.

Why young people self-harm

There are many possible reasons behind self-harming and these include:

-       Having a lot of pressures at home or at school
–       Experiencing difficulties with family and friends
–       Being bullied or pressured by peers to fit in
–       Suffering abuse
–       Worrying about personal identity, sexuality, race, culture or religion
–       Struggling with practical things about money, education, employment or housing.

Many young people experience the issues listed above but not all of them self-harm. Young people react to and deal with emotional stress and trauma in many different ways. Those who self-harm often say they do it because it releases an unbearable tension and that the pain they inflict while self-harming takes away the bigger emotional pain, for a while.

Why young people want to stop self-harming

Young people often reach the point at which they want to stop self-harming; the main reasons given are they:

  • Begin to see that they are “growing out” of it – it begins to feel like an ineffective way to deal with life problems
  • Start to find other, more positive, ways of coping and want to improve their overall mental health
  • Want to take care of their physical health
  • Feel the shame, embarrassment or secrecy becomes too overwhelming and uncomfortable
  • Need to escape pressure and reactions from others
  • Dislike the physical scars it leaves behind
  • Recognise the pain it causes to their friends and families
  • Realise it is no longer working or helping them to cope.

Why you should take it seriously Young people who self-harm often feel embarrassed and guilty; depressed and afraid; helpless, isolated and out of control. While many young people who self-harm do it as a way of dealing with the problems in their lives, a small number have different motives and may be considering suicide. There is often no obvious way that we can tell the difference between the two, so it is even more important that we do everything we can to understand and support every young person we suspect to be self-harming.

In this section we used these sources of information and evidence:

Fox, C., & Hawton, K., (2004) Deliberate Self-harm in Adolescence. London: Jessica Kingsley Publishers http://www.selfharm.co.uk/get/facts/what_is_self-harm

National Institute for Health and Clinical Excellence (NICE) Self-harm – CG16 http://www.nice.org.uk/cg16

YoungMinds booklet Worried about self-harm?  http://www.youngminds.org.uk/assets/0000/7354/Self-Harm__Single_page_.pdf 2.

How can I help?

What have I done? What could I have done? Why didn’t I know? Why didn’t you tell me sooner? Self-harming is shocking and hard to understand. As family, friends and workers, we can feel baffled and at sea. We may struggle with feelings of guilt and blame. Try to keep unhelpful thoughts out of your mind and focus instead on what you can do. It helps if you start by:

  • Being observant
  • Recognising some possible signs, such as a young person wearing long sleeves all the time, even in hot weather, constantly picking at scabs or often wearing bandages and plasters, including on the wrists.
  • Acknowledging that there are things in the young person’s life causing self-harming, which you may know not know about. This may partly be their way of coping. It might bring some release and relief.
  • Getting underneath the self-harm itself and being open to understanding why the young person is doing it.
  • Looking out for signs of peer pressure.
  • Taking care not to address the issue in public, but finding a moment where you can have a private conversation.

Here are some broad questions that may be helpful in supporting a young person:

-        What was going on that first caused you to think about self-harming?
–        What seems to trigger that feeling now?
–        Are there any patterns about where you are or who you are with?
–        Are there things deeply worrying you that you feel you can’t share with someone else?
–        What helps you cope when you feel upset?
–        Is there a special person to talk to, place to go where you feel safe or something to do that helps you?
–        Who else knows of what is happening to you and who would it be best to let know? Do you need support to do that? Have you been to the GP? If so, how did that go? If not, should we see about making an appointment?

  • Check out some websites that explain distraction techniques and be familiar with them. Distraction has been shown to help some people by easing the urge to self-harm, but be aware that not all techniques work for all people.
  • Make sure the young person knows who to contact when they’re on their own, such as ChildLine or the Samaritans, but also local supports and services.
  • You may need to let the young person know that if you are really concerned about the risk to them or to others, you can’t keep this to yourself. Be clear about who you need to tell and why, what may be written down and what might happen next.
  • Weigh up the risk of significant harm and let others know if you are worried for the young person’s safety, doing everything you can to get the young person’s knowledge and agreement.
  • If you are working with young people in a paid job or as a volunteer, your workplace will have policies and guidelines about safeguarding and there will be a named safeguarding lead you can talk to.

In this section we used these sources of information and evidence:

McDougall, T, Armstrong, M and Trainor, G (2010)Helping Children and Young People Who Self-harm. An introduction to self-harming and suicidal behaviours for health professionals. Routledge

National Self Harm Network  http://www.nshn.co.uk/downloads/Distractions.pdf

3. What works? You can help a young person access further support and services, and may be able to prevent them from reaching a crisis. Dealing with a young person’s disclosure does not require any special skills or extra training. You need to be aware of your own feelings in aiming to treat the young person with respect, unconditional regard and warmth.  Then you can use your core skills and be a good listener, making sure the young person gets the help they need – and want.

  • Listening and taking the young person seriously works.

One really helpful skill is the ability to signpost to services that provide what the young person wants. Research carried out by the Mental Health Foundation in 2006 and relevant now and gives us a clear picture of the sorts of support young people want. 85 percent of young people wanted individual support and counselling, while 71 percent wanted drop-in services with group support. A large proportion of young people (61 percent) asked for self help groups with some adult support, while a further 20 percent were keen on self help with no adult help. All young people wanted (and still want) access to accurate information in a choice of formats – including online, print based and helplines. Sometimes people are so distressed they don’t know what they want and it could be helpful to use some of these ideas as suggestions

  • Work with the young person to find the right support for them

In environments in which children and young people are not supervised, all medicines and potentially harmful substances should be locked away. Knives, razors and other potential cutting instruments should be removed.

  • Reduce the opportunity for the young person to self harm

If you are able to help a young person early on, when the self-harm has only just begun, you could be helping to prevent it becoming more serious. Stepping in to support at this stage is called “early intervention” and the evidence shows the earlier, the better.

  • Don’t delay addressing the issue

In this section we used these sources of information and evidence:

Mental Health Foundation (2006) Truth Hurts Report. The final report of the National Inquiry into self-harm among young people. http://www.mentalhealth.org.uk/publications/?entryid5=38712&q=684278%c2%actruth+hurts%c2%ac

National Institute for Health and Clinical Excellence (NICE) Self-harm – CG16 http://www.nice.org.uk/cg16

4. Where to go next? There are many resources, groups and organisations that can help you. Here are a few:

Sometimes you will meet young people whose self-harming is frequent and/or severe and extremely worrying. They could have other issues, like substance misuse or mental health difficulties. You must help those young people get specialist help, for example through their GP or A&E service. If you find a young person who has self-harmed causing a wound that is bleeding profusely, or if you suspect the young person has swallowed any form of toxic substance, including overdosing on medication and/or alcohol, you must get the young person to A&E straight away. The most helpful actions you can take are:

  • Recognise a potential emergency and contact emergency services on 999 immediately.
  • Assist the emergency services by giving clear directions about the location of the young person, their name, your name and your relationship to the young person.
  • Reassure the young person and gently but persistently ask neutral questions to establish what has happened.
  • Accompany the young person to the A&E department and wait with them until other arrangements are made.
  • Tell A&E staff all the facts you have gathered.
  • Stay until you are sure the young person is happy for you to leave and is receiving appropriate treatment.

You must not attempt to give first aid unless you have been trained and it is up to date. If you work or volunteer with young people you should know about the first aid procedures in your organisation and you will have a named first aider. If you are not a trained first aider the best “first aid” you can provide is a calm, empathic presence, being non-judgmental and supportive, encouraging the young person to talk and trying to establish some facts so you can help the first aider and/or other services when they arrive.

In this section we used these sources of information and evidence: Anderson, Y., and Nixon, B., (2011) Self harm in children and young people Handbook http://www.cernis.co.uk/pdf/handbook.pdf National Institute for Health and Clinical Excellence (NICE) Self-harm – CG16 http://www.nice.org.uk/cg16

5. What do young people say? Young people’s stories are an important part of helping us understand and know what to do and what not to do. The story below is one young man’s journey.

Self-harm started for me when I was 14. The last time I self harmed was 6 months ago.It initially began when I was in school and struggling with sexuality. I came out as gay, I indulged in sexual promiscuity and the combination of a poor home life, bullying in school and coming to grips with my feelings for other men built up. I found solace in an older gentleman. This older man to me was a friend, but looking back I was groomed and abused by this man. A diagnosis of HIV soon followed after repeatedly having flu like symptoms.At this point in my life everything seemed messy. I was struggling in school. Struggling at home. Struggling still to understand what my sexuality meant to me. I was scared. I was struggling to understand what HIV was. I was in the care of the police, sexual health services, social services and mental health services. There was a feel of chaos and little stability in my life.I initially self harmed with the belief it will end my life. I remember going into the bathroom around tea time, locking the door and turning on the shower. I picked up some scissors and I cut my wrists. At that moment I wanted to die. I felt disgusting. I didn’t want to be here. This led to me being admitted into a psychiatric unit. The coming year or two I was in and out of this hospital. Until I reached 19 I was In no talk health services receiving care. I received a wrongful mental health diagnosis and was wrongly treated as was said by the GMC. The bulk of my self-harm began when I was 15. I felt like the physical pain I was inflicting into myself was detaching away from the greater more intense emotional pain I was suffering. It was a way if me controlling my pain. For 18 months I felt like I was in control by self-harming, only now looking back I realise just how little control I actually had. There was a gap between me being 16 and 18 where no self-harm happened. I managed to find other ways of distracting myself. At first I had urges whenever a bad mood struck me, but then I began to realise it’s just a bad mood. All my previous feelings about myself have gone. I want to be here. Since I self-harmed at 16 I have had one major relapse, and this time the cutting made me feel worse. I felt like all my work I had come through had been wasted. I felt like I had lost control once more. I am not going to say I will never hurt myself again. And I am never going to say I will hurt myself again, I feel the most important thing for me to recognise is that I have got through self harming and the feelings I had after I most recently self harmed proved to me that I no longer found self harming an activity that enabled me to vent out my feelings.it no longer gave me that doped up coke like state of being zoned out. It made me feel worthless. Today. Marks aren’t visible. I have a few in places people can easily see. But I’ve moved on to a point where I am able to just look at my body and see it as my body rather than a body with scars and burns all over.  Family are still a little shy of it as when I am around company we don’t know so well, they prefer I make sure I am covered up to avoid questions. But mostly if people see me as being fine and getting on with things, then questions usually aren’t asked. I have moved away from centering my attention on mental health. I feel healthier and happier being a normal 19 year old who faces life’s challenges.

………more thoughts………..

I’m scared I’m doing the wrong thing – or I’m going to do more harm than good.

It is really common for people who don’t have any training in mental health to be worried about causing harm in their attempts to help. We have a few ideas about this:

Do what you already know how to do well. Have empathy – try to put yourself in that young person’s shoes and see the world as they see it. Don’t judge – it is never helpful to tell someone that they are causing problems for others, or to make them feel shame. That will just add another burden to that young person, who already feels they can’t cope. Show concern – it is genuine and sincere. Listen hard and pay attention to what is said – and not said. Offer practical advice – places to go, people to see.

Don’t try to do what you are not qualified for If you are not a counsellor or therapist there are limits to how much support you can offer to someone with significant or severe problems. Your skill will be in helping to find the counsellor or therapist and supporting the young person to engage with them.

Know how to access a specialist service If a young person you know has a real problem with self-harm and probably with mental health issues as well, you can help them get a specialist service.  For those aged 18 and under this will be a referral to child and adolescent mental health services (CAMHS). Often it needs to go through a GP, but more and more CAMHS are now taking self-referral. Young people aged 19 and over definitely need to see their GP as specialist adult mental health services have strict criteria. Many GP surgeries now have counsellors or psychologists on site.

Always share your concerns An old saying goes: A problem shared is a problem halved. It is easy to get things out of perspective – we all do it. Sharing your worries and concerns with a trusted friend can help you sort out in your own mind what you are going to do for the best. If you are a professional or volunteer, be careful not to identify the young person as that would be breaking confidentiality.

How do I deal with my own emotions when hearing about or discovering a young person’s self-harming?

Reactions could include:

Feeling: sorrow, alarm, panic, anxiety, shock.

Being:  scared, distressed, upset, taken aback, fazed, freaked out, repulsed, bewildered, frustrated, mystified.

It is perfectly normal and acceptable to have a range of feelings and reactions to self-harm. What we need to do is think about our responses and manage our feelings so that we don’t let them paralyse us, or prevent us from being helpful and calm. Be honest with yourself – if your feelings are strong and you cannot hide them, then talk with a friend or colleague about it and find someone else to work with the young person. It is very hard for anyone to understand why a young person is self-harming. You may feel guilty and wonder what you have done wrong. You might feel angry at the young person, thinking Why are you doing this? But remember it is no ones fault. If you can get past these feelings and manage to use the helping skills of having empathy, being non-judgmental, listening and paying attention, then you can still support the young person. But – examine yourself closely – there is nothing wrong with finding someone else to help. If you feel the need to express your emotions, make sure you do it with someone you trust – but don’t add your stress to the young person.  

What do I do if the young person won’t accept help?

One of our team worked with a young person who refused help from anyone except her. She was not trained in counselling and at the time didn’t know much about mental health. In discussion with her supervisor they agreed that the worker would make a list of helpful websites and other self help resources and give it to the young person, encouraging him to use it. She then informed him that if they continued to work together around his self-harming she would be discussing it with her supervisor on a regular basis and she asked for his consent to share information. The worker felt that the young person needed to know that by choosing to confide only in her, he was placing her under pressure and creating risk that she needed to manage. If a young person won’t accept help at all you can only keep trying in as many different ways as you can, and be open about your concerns with others – there may be things you haven’t tried, or people who could help better.

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