3.9 Self-Harm: Guidance

These guidelines provide information for professionals working with children and young people on how to support people up to the age of 18 who harm themselves, and how to access appropriate services where needed.

This document can be read alongside the following additional guidelines:

• Self-Injurious Behaviour: Guidelines and resources to help support children and young people with special educational needs and disabilities who show self-injurious behaviours.
• Guidelines and resources for schools to help support children and young people who self-harm

Self-harm is any behaviour, initiated by the individual, which directly results in physical harm to that individual. Physical harm will be considered to include bruising, laceration, bleeding, bone fractures and breakages and other tissue damage (Murphy and Wilson, 1985).

The Mental Health Foundation (2003) define the difference between deliberate self-harm and suicide:

• deliberate self-harm is self-harm without suicidal intent, resulting in non-fatal injury
• attempted suicide is self-harm with intent to take life, resulting in non-fatal injury
• suicide is self-harm, resulting in death.

Some people who self-harm have a strong desire to kill themselves. However, there are other factors which motivate people to self-harm, including a desire to escape an unbearable situation or intolerable emotional pain; to reduce tension; to express hostility; to induce guilt or to increase caring from others. Even if the intent to die is not high, self-harming behaviour may express a powerful sense of despair and needs to be taken seriously. Moreover, some people who do not intend to kill themselves may do so, because they do not realise the seriousness of the method they have chosen to self-harm or because they do not get help in time.

Over the last 40 years there has been a large increase in the number of young people who deliberately harm themselves. It is thought that around 13% of young people may try to hurt themselves on purpose at some point between the ages of 11 and 16, but the actual figure could be much higher. In 2014, figures were published suggesting a 70% increase in 10–14 year olds attending Accident and Emergency (A&E) for self-harm related reasons over the preceding two years.

In the vast majority of cases, self-harm remains a secretive behaviour that can go on for a long time without being discovered. Many children and young people may struggle to express their feelings and will need a supportive response to assist them to explore their feelings and behaviour and the possible outcomes for them.

Any assessment of self-harm behaviours should begin with a consideration of the possible triggers of such behaviour. The causes/triggers of self-harm behaviours can relate to internal factors and/or external factors. When considering triggers it is important to not only look at the immediate triggers, but recognise that past triggers or an accumulation of many triggers over time may well result in the young person showing self-harming behaviour.

The following risk factors, particularly in combination, may make a young person vulnerable to self-harm:

Individual factors

• depression/anxiety
• poor communication skills
• low self esteem
• poor problem-solving skills
• hopelessness
• impulsivity
• drug or alcohol abuse

Family factors

• unreasonable expectations
• abuse (physical, sexual, emotional) or neglect
• poor parental relationships and arguments
• depression, deliberate self-harm, suicide or other mental health difficulties in the family
• drug/alcohol misuse in the family
• domestic violence

Social factors

• difficulty in making relationships/loneliness
• persistent bullying or peer rejection
• easy availability of drugs, medication or other methods of self-harm

People of any age, gender, ethnicity or background may find themselves using self-harm as a coping mechanism for many different reasons. However, professionals should be aware that for some children and young people protected characteristics (for example disability, being lesbian, gay, bisexual or transgender or coming from a black or minority ethnic background) may be a factor in self-harm. The increased bullying, hate crime and isolation experienced by children and young people in these groups is likely to play a part. For example, research by Stonewall suggests that two in five (41%) of LGB school pupils have attempted or thought about taking their own life directly because of bullying and the same number say that they deliberately self-harm directly because of bullying. According to the same report, 59% of trans youth said they had deliberately hurt themselves, compared with 8.9% of all 16- to 24-year-olds.

The pressures for some groups of young people and in some specific settings may increase the risk of self-harm, for example:

• young people in residential settings (e.g. inpatient units, prison, sheltered housing or hostels, or boarding schools)
• young people with mental health difficulties.

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 a relationship (the most common trigger for older adolescents)
• bullying
• significant trauma, e.g. bereavement, abuse
• self-harm behaviour in other students
• identification with a peer group which promotes self-harm
• 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).

A more detailed list of potential cases and triggers of self-harm for children and young people with special education needs and disabilities can be found in the document Self-Injurious Behaviour: Guidelines and resources to help support children and young people with special educational needs and disabilities who show self-injurious behaviours.

There may be changes in the behaviour of the young person which are associated with self-harm or other serious emotional difficulties, for example:

• changes in eating/sleeping habits
• increased isolation from friends/family
• changes in activity and mood, e.g. more aggressive than usual
• lowering of academic grades
• talking about self-harm or suicide
• abusing drugs or alcohol
• becoming socially withdrawn
• expressing feelings of failure, uselessness or loss of hope
• giving away possessions.

Some young people get caught up in mild repetitive self-harm such as scratching, which is often done in a peer group. In this case it may be helpful to take a low-key approach, avoiding escalation, although at the same time being vigilant for signs of more serious self-harm.

Examples of self-harming behaviour include:

• cutting
• taking an overdose of tablets
• swallowing hazardous materials or substances
• burning – either physically or chemically
• over/under-medicating, e.g. misuse of insulin
• punching/hitting/bruising
• hair pulling/skin picking/head banging
• episodes of alcohol/drug/substance misuse or over/under-eating can at times be acts of deliberate self-harm.

Self-harm can be a transient behaviour in young people that is triggered by particular stresses and resolves fairly quickly, or it may be part of a longer-term pattern of behaviour that is associated with more serious emotional/psychiatric difficulty. Where there are a number of underlying risk factors, the risk of further self-harm is greater.

Once self-harm (particularly cutting) is established, it can be difficult to stop. Self-harm can have a number of functions for the young person and it becomes a way of coping, including:

• reduction in tension (safety valve)
• distraction from problems
• form of escape
• outlet for anger and rage
• opportunity to feel
• way of punishing self or others
• way of taking control
• care-eliciting behaviour
• a means of gaining identity with a peer group
• non-verbal communication (e.g. of abusive situation)
• a suicidal act.

When a person inflicts pain upon himself or herself, the body responds by producing endorphins, a natural pain reliever that gives temporary relief or a feeling of peace. The addictive nature of this feeling can make self-harm difficult to stop.

Young people who self-harm still feel pain, but some say the physical pain is easier to stand than the emotional/mental pain that led to the self-harm initially.

The cycle of self-harm / cutting

Using support networks

It is helpful to identify supportive individuals and networks in a young person’s life and how to get in touch with them. Examples are friends, family, school teacher, counsellor. Knowing how to access a crisis line is also important.

Distraction activities

Replacing the cutting or other self-harm with other safer activities can be a positive way of coping with the tension. What works depends on the reasons behind the self-harm. Activities that involve the emotions intensely can be helpful. Examples of distraction activities include:

• contacting a friend or family member
• going for a walk/run or other forms of physical exercise
• getting out of the house and going to a public place, e.g. a cinema
• reading a book
• keeping a diary
• looking after an animal
• watching TV
• listening to music.

Coping with distress using self-soothing

Self-soothing techniques include:

• using stress-management techniques such as relaxation
• having a bubble bath
• stroking a cat or other animal
• going to the park and looking at the things that are around (birds, flowers, trees)
• listening to the sounds while walking
• listening to soothing music.

Discharging unpleasant emotions in other ways

Sometimes it can be helpful to find other ways of discharging emotion which is less harmful than self-harm, including:

• clenching ice cubes in the hand until they melt writing, drawing and talking about feelings
• writing a letter expressing feelings, which need not be sent
• going into a field and screaming
• hitting a pillow/soft object
• listening to loud music
• physical exercise.

In the longer term, a young person may need to develop ways of understanding and dealing with the underlying emotions and beliefs. Regular counselling/therapy may be helpful. Support from family members or carers is likely to be an important part of this. It may also help if the young person joins a group activity such as a youth club, a keep fit class or a school-based club that will provide opportunities for them to develop friendships and feel better about themselves. Learning stress-management techniques, ways to keep safe and how to relax may also be useful.

For some young people, self-harm may express the strong desire to escape from a conflict or unhappiness at home, and to live elsewhere. Injuring oneself can achieve a temporary respite if it entails a hospital admission or a short break at the home of a friend or relative. The young person may request admission to foster care or a residential home and parents may doubt their ability to cope at this stage. Entering care often carries with it many long-term disadvantages and increased vulnerability for the young person. It is acknowledged that for some young people, being looked after is the best way forward but in most cases it is preferable to try to support the young person and family members in finding a resolution to their difficulties rather than to separate them further.

For those who are already in care, self-harm may still be an expression of a desire to escape from their situation, for example, leaving the home. As before, it is important to support the young person, understand the nature of their difficulties and help them to find a way of resolving them.

If you believe that a young person would be at serious risk of abuse in returning home or in remaining in their residential setting, consult their social worker for advice.

If a child or young person goes missing from home or from a residential setting then the BSCP procedures on missing children should be initiated.

The following steps (also see Appendix A - Helping Young People Who Self Harm: Flowchart) should be taken in the first instance when an incident of self-harm in a young person is identified. Reference should also be made to other relevant BSCP policy/guidelines as appropriate, in particular see What to do if you have a concern about a child in Buckinghamshire.

• When a young person has self-harmed, keep calm, give reassurance and follow first aid guidelines.
• When you recognise signs of distress, try to talk with the young person about how they are feeling.
• In the case of an overdose of tablets, a child should be medically assessed by their GP or A&E Department.
• If the young person is in a serious condition, an ambulance must be called.
• Record and share your concerns with a senior member of staff.
• Discuss the importance of letting parents know and address any concerns they have about this. For children in care, the discussion should include notifying their social worker (depending on the legal status of the young person).
• Contact the parents to discuss concerns, unless there are particular reasons why they should not be contacted. In these cases, consult with designated safeguarding lead. Give the parents a factsheet on self-harm if appropriate.
• Suggest to the parents and/or social worker a referral to CAMHS, or an appointment with their GP if there are serious medical issues. If the young person is known to CAMHS, contact the lead professional/care coordinator or Single Point of Access (telephone: 01865 901 951)
• Ask for feedback from other agencies to support work with the young person.
• Follow up with the parents with a letter indicating your concern (see sample letter in Appendix C).
• Have crisis telephone numbers available and easily accessible to young people.
• Follow agreed policy with regard to informing senior management of your concerns.
• Record any incident (see sample incident form in Appendix D).
• Record any meetings with the young person. Include an agreed action plan, including dates, times and any concerns you have. Document who else has been given any information.
• Seek support for yourself if necessary
• Advice can be obtained from the CAMHS Single Point of Access team (telephone: 01865 901 951).

The child should be included in discussions where possible based on an assessment of their age, capacity and condition at time.

If you are concerned that an episode of self-harm was a serious attempt by the young person to end their life, contact your local CAMHS Single Point of Access team (telephone: 01865 901 951).

Further strategies for schools and residential settings to help a young person who self-harms include:

• arrange a mutually convenient time and place to meet
• at the start of the meeting set a time limit
• make sure the young person understands the limits of your confidentiality
• encourage them to talk about what has led them to self-harm
• remember that listening is a vital part of this process
• support the young person in beginning to take steps to keep himself/herself safe and reduce the self-injury (if they wish to), for example:
  • washing implements used to cut
  • avoiding alcohol if they feel they are likely to self-injure
  • taking better care of injuries (the school health nurse or first aider may be helpful here).
• help them to learn how to express their feelings in other ways, e.g. talking, writing, drawing or using safer alternatives
• help them to build up self-esteem
• help them to find their own way of managing their problems, for example:
  • if they say they dislike themselves, begin working on what they say they do like.
  • if life at home is impossible, begin working on how to talk to parents/carers.
• help them identify their own support network
• offer information about support agencies; remember some internet sites may contain inappropriate information.

Schools should refer to the document 'Guidelines and resources for schools to help support children and young people who self-harm' for further information.

It is important to understand the reasons behind the self-harm and support the young person in keeping safe.

Key workers/staff should work with the young person to build up self-esteem, develop problem-solving skills, and encourage strategies to cope with difficult feelings.

If the young person is involved with CAMHS they should be supported to attend appointments and be encouraged to make use of the support offered.

It may be helpful to explore with the young person what led to the self-harm – the feelings, thoughts and behaviour involved. This can help the young person make sense of the self-harm and develop alternative ways of coping.

An important part of prevention of self-harm is having a supportive environment in the school or residential setting which is focused on building self esteem and encouraging healthy peer relationships. An effective anti-bullying policy and a means of identifying and supporting young people with emotional difficulties is an important aspect of this.

A checklist of procedures and practices that can help schools manage and prevent self-harm can be found in Appendix B.

Confidentiality is a key concern for young people and they need to know that it may not be possible for professionals to offer complete confidentiality.

If you consider that a young person is at serious risk of harming himself/herself or others, confidentiality cannot be kept. It is important not to make promises of confidentiality that you cannot keep, even though the young person may put pressure on you to do so. If this is explained at the outset of any meeting the young person can make an informed decision as to how much information they wish to divulge.

When a young person is self-harming it is important to be vigilant in case close contacts of the individual are also self-harming.

Occasionally schools or residential settings may discover that a number of students in the same peer group are harming themselves. Self-harm can become an acceptable way of dealing with stress within a peer group and may increase peer identity. This can cause considerable anxiety in school staff, parents and carers, as well as in other young people.

It can happen that two or more young people may self-harm simultaneously. It is important that each case is looked at individually in terms of levels of risk and need in the first instance. It is of course important at a later stage to consider what it was within the group dynamic that led to this situation and how best it could be managed in the future.

Each individual may have different reasons for self-harming and should be given the opportunity for one-to-one support. However, it may also be helpful to discuss the matter openly with the group of young people involved. In general it is not advisable to offer regular group support for young people who self-harm.

Where there appears to be linked behaviour or a local pattern emerging, a multi-agency strategy meeting should be convened.

It is important to encourage young people to let you know if one of their group is in trouble, upset or shows signs of harming. Friends can worry about betraying confidence, so they need to know self-harm can be dangerous, and by seeking help and advice for their friend they are taking a responsible action.

The peer group of a young person who self-harms may value the opportunity to talk to an adult, either individually or in a small group.

People working with young people may experience a range of feelings in response to self-harm in a young person (e.g. anger, sadness, shock, disbelief, guilt, helplessness, disgust or rejection). It is important for all work colleagues to have an opportunity to seek support for their own needs and discuss the impact that self-harm has on them personally. The type and nature of the forums where these issues are discussed may vary between settings.

For those who are supporting young people who self-harm, it is important to be clear with each individual how often and for how long you are going to see them (i.e. the boundaries need to be clear). It can be easy to get caught up into providing too much, because of one’s own anxiety. However, the young person needs to learn to take responsibility for their self-harm.

If you find the self-harm upsets you, it may be helpful to be honest with the young person. You need to be clear that you can deal with your own feelings and try to avoid the young person feeling blamed. They probably already feel low in mood and have a poor self-image; your anger/upset may add to their negative feelings. However, your feelings matter too. You will need the support of your colleagues and management, if you are to listen effectively to young peoples’ difficulties.

In schools, young people may present with injuries to first aid or reception staff. It is important that these frontline staff are aware that an injury may be self-inflicted, and that they pass on any concerns.

In residential settings, young people may present to a range of staff, including key workers, domestic staff, admin staff or cooks.

Staff taking this role should take the opportunity to attend training days on self-harm or obtain relevant literature. Liaison with the local CAMHS may be helpful.