North Bristol NHS Trust

Self Harm Information and suggestions for school staff

Exceptional healthcare, personally delivered

Contents Page What is self harm and how common is it? Risk factors for self harm...........................2

Bibliography.............................................19 ........

Acknowledgement In compiling these guidelines, information has Triggers for self harm been drawn from “Self Harm: Guidelines for Warning signs.............................................3. school staff (2004) Oxfordshire Adolescent Self Harm Forum” Examples of self harming behaviour Reasons young people self harm What keeps self harm going?....................4 The cycle of self harm / cutting.................5 ... What can schools do to prevent self harm? Confidentiality Support for staff.........................................6 .... How to help What to avoid.............................................7. Primary school aged children....................8 Helping young people who self harm (flow diagram)............................................9 ... Appendix A: My Safety Net.....................10 ...... Appendix B: Examples of coping strategies..................................................11 Appendix C: Sample of an incident form..........................................................12 .... Appendix D: Fact sheet for parents / carers.........................................................13 .... Appendix E: Sample of letter to parents / carers.........................................14 Appendix F: Helpful resources for young people............................................15. Appendix G: Useful addresses, numbers and websites ............................18 ... Self Harm information

1

Self harm – information and suggestions for school staff The information and suggestions in this booklet are intended to give school staff ideas to support young people who harm themselves.

What is self harm and how common is it?  Self harm is any behaviour such as self-cutting, swallowing objects, taking an overdose or running in front of cars etc., where the intent is to deliberately cause self harm.  A small proportion of young people who self harm have a strong desire to kill themselves. However, there are other factors that motivate people to self harm (see below). Even if the intent is not to die, self harming behaviour may indicate serious difficulties and needs to be taken seriously.  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/mental health difficulty. Where there are a number of underlying risk factors present the risks of further self harm is greater.  Over the last forty years there has been a large increase in the number of young people who deliberately harm themselves. A large community study in the UK found that in 15- 16 year olds, approximately 6.9% of young people (3.2% males and 11.2% females) had self harmed in the last year. (Hawton et al. 2002)  Fortunately completed suicide is very rare. Statistically in a city the size of Bristol it would be expected that there is one male suicide every 2 ½ years and one female suicide every 6 years. Though rare this does not mean that any self harm behaviour should be dismissed. All attempts of suicide or deliberate self-harm should be noticed, taken seriously and the young person listened to carefully. (www.statistics.gov.uk/downloads/theme_population/PT92book_V3.pdf [Last Accessed February 2011]).

Risk factors for self harm behaviour Any of the following risk factors may make a young person vulnerable to self harm: Individual Factors  low mood/anxiety  an existing psychological or developmental difficulty e.g. aspergers syndrome, learning difficulty  difficulty communicating  low self esteem  poor problem solving skills  hopelessness  impulsivity  drug or alcohol abuse  confusion about sexuality or feeling different / unaccepted (eg if gay, lesbian or bisexual) 2

Self Harm information

Family factors  unreasonable expectations  religious/ethnicity/cultural identity dilemmas or conflict  young carers’ role within the family  domestic violence  neglect or abuse (physical, sexual or emotional)  poor parental relationships and arguments  depression, deliberate self harm or suicide in the family Social factors  difficulty in making relationships/ loneliness  persistent bullying or peer rejection  racism  homophobic attitudes or bullying of children who think they may be gay, lesbian or bisexual  easy availability of drugs, medication or other methods of self harm

Triggers for self harm behaviour 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 relationship (the most common trigger for older adolescents)  bullying  significant trauma e.g. bereavement, abuse  self harm behaviour in other students or in the media (contagion effect)  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)

Warning signs There may be a change in behaviour of the young person which is associated with self harm or other serious emotional difficulties:  changes in eating/sleeping habits  increased isolation from friends/family  changes in activity and mood e.g. more, or less irritable or aggressive than usual  lowering of academic grades  talking about self-harming or suicide Self Harm information

3

 abusing drugs or alcohol  becoming socially withdrawn  expressing feelings of failure, uselessness or loss of hope  giving away possessions

Examples of self harming behaviour  cutting  taking an overdose of tablets  swallowing hazardous materials or substances  burning – either physically or chemically  over/under medicating e.g. misuse of paracetamol, insulin or thyroxine  punching/hitting/bruising  hair pulling/skin picking/head banging  high risk behaviour, such as running in front of cars  episodes of alcohol/drug abuse or over/under eating can at times be acts of deliberate self harm

Young people report they self harm to:  Relieve tension  Feel alive inside  Gain control  Numb themselves  Comfort themselves  Vent anger  Relieve emotional distress or overwhelming feelings  Stop bad thoughts  Feel the warm blood  See ‘red’  Punish themselves  To replace emotional pain with physical pain

What keeps self harm going? Once self harm (particularly cutting) is established it may be difficult to stop. Self harm can form a number of functions for the student and can become a way of coping. Examples of functions include  Reduction in tension (safety valve)  Distraction from problems  Form of escape  Outlet for anger and rage 4

Self Harm information

 Way of punishing self  Perceived way of taking control  Care-eliciting behaviour  A means of getting identity with a peer group  Non-verbal communication It can also have suicidal intent.

The cycle of self harm/cutting 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 that 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.

Negative emotions (Sadness, anger, despair) Tension (Inability to control emotions, maybe using disassociation to cope with tension) Self harm act (Cutting, burning etc.) Positive effects (Endorphins released, tension and negative feelings dispelled for a short period) Negative effects (Shame and guilt over self-harm act)

Self Harm information

5

What can schools do to prevent self harm? An important part of prevention of self harm is having a supportive environment in the school which is focused on building self esteem and encouraging healthy peer relationships. In effective policy on bullying and a means of identifying and supporting young people with emotional difficulties is an important aspect of this.  Devise a school policy, including a clear confidentiality policy.  Educate school staff  Develop a safety plan  Educate students to be ‘good friends’ by reporting peers distress  Address emotional well-being, promoting coping strategies and self-harm as part of the PHSE curriculum (secondary schools)  Have crisis telephone numbers available and easily accessible to young people. (Appendix F)  Control contagion (when self harm becomes a common occurrence amongst a group of young people)

Confidentiality Confidentiality is a key concern for young people and they need to know that it may not be possible for staff to offer complete confidentiality. If you consider that a young person is at serious risk of harming him/her self or others then 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.

Support / training for staff School staff may experience a range of feelings in response to self harm in a young person (e.g. anger, sadness, shock, disbelief, guilt, helplessness, feeling deskilled or rejected). This is particularly the case when the child is young. However, teachers are very good at coping with a lot of behaviour that shows a child or young person’s distress. Self-harming behaviour is one such behaviour. It is important for staff to have an opportunity to discuss the impact that self harm has on them personally. Support from colleagues and management is important if teachers are to listen effectively to young people’s difficulties. The type and nature of the forums where these issues are discussed will vary between schools. Staff should take the opportunity to attend training days on self harm or obtain relevant literature. Liaison with the local specialist child and adolescent mental health team (CAMHS) may be helpful.

6

Self Harm information

How to help a young person who has self-harmed  If there are safeguarding concerns at any point in this process contact the local Children and Young eople’s Services according to the school child protection policy, being sure to follow the agreed South West child protection procedures. See www.swcpp.org.uk/  Make sure the young person understands the limits of your confidentiality. 

It is important that all attempts of suicide or deliberate self-harm are taken seriously. Assess for suicidal risk by asking them what they hoped would happen as a result of their self- harm and how they feel now. If you are concerned about immediate or imminent suicidal risk the child or young person should be taken to A&E for an emergency psychiatric assessment.



What appears to be important for many young people is having someone to talk to, who listens properly and does not judge. This person may be a mentor, counsellor, youth worker, school health nurse, connexions personal adviser, special educational needs co-ordinator, emotional and behaviour outreach teacher, educational psychologist or other.



Take a non-judgemental attitude towards the young person. Try to reassure them that you understand the self-harm is helping them to cope at the moment and you want to help them, and explain that you need to tell someone. Try to work out together who the best person is to tell (see paragraph on confidentiality).

 Help them identify their own support network (Sample: Appendix A) and alternative coping strategies (Examples: Appendix B).  Offer information about support agencies. Remember some internet sites may contain inappropriate information. (Appendix F) 

Control contagion - Be vigilant in case close contacts of this individual are also self harming. Each individual may have different reasons for self harming and should be given the opportunity for one to one support. It may also be helpful to discuss the matter openly with the group of young people involved.

 Support peers - The peer group of a young person who self harms may value the opportunity to talk to an adult, either alone or in a small group.  Follow flow chart suggestions (see page 9).

Be careful to avoid:  Reacting with horror or discomfort to the disclosure  Asking abrupt and rapid questions  Threatening or getting angry  Engaging in power struggles and demanding they ‘just stop’  Accusing them of attention seeking  Getting frustrated if behaviour continues after support has been provided  Ignoring other warning signs  Promising to keep the events secret Self Harm information

7

Primary School Aged Children It is unusual for children of primary school age to engage in self-harming behaviours, but it is not unknown. Self harm can be easily missed or misdiagnosed in this age group. If a primary school child is found to be self harming this is often a sign that there are difficulties in the child’s environment A common assessment (CAF) should be completed. This process will help the school to work alongside the family and other professionals to support and protect the child. CAMHS (Child and Adolescent Mental Health Service) Primary Mental Health Specialists are available for advice and support if there are concerns about a child’s emotional/mental health. See appendix G for contact details. Behaviours may include:  Small shallow cuts  Hair pulling  Head banging against hard objects  Deliberate self-grazing or scratching Primary school teachers are particularly familiar with supporting children who are showing distress and a child that is self harming should be supported with the same positive behaviour strategies they would use with a child showing other distress (e.g. crying).  Do not focus on the self harm or trying to get the child to talk.  Boost the child’s self esteem and sense of belonging in the class by focussing on things they are good at.  Remember school can be a safe haven for children to get away from their problems. Maintain routines, boundaries and positive behaviour management strategies whilst being aware that the child is having a difficult time.  Establish and promote peer relationships e.g. using Circle of Friends.  Provide positive encouragement if they show safer ways of expressing feelings.  Consider any stresses in the school environment that can be changed, for example, more support around learning difficulties/bullying.

8

Self Harm information

Helping young people who self harm The process below is intended to supplement existing schools arrangements. NB: If there are safeguarding concerns at any point in this process, contact the local Children and Young People’s Services according to the School Child Protection Policy, being clear to follow the South West child protection guidelines - www.swcpp.org.uk Member of staff informed/discovers young person who is self harming Stay calm. Give re-assurance. Listen. Follow first aid guidelines as necessary. Ensure young person understands limits of confidentiality. In an emergency or case of overdose (however small) school staff consult GP or A&E. Inform Senior Management Team (SMT) Discuss with SMT and agree with them and the young person whether to inform parents / carers (Consider age, severity, risk, home circumstance) Complete relevant incident report and paperwork. Consultation with Primary Mental Health Specialist (PMHS) at your local Child and Adolescent Mental Health Service (CAMHS) may be helpful. See appendix G for contact details. Consider initiating a Common Assessment. (CAF) See appendix G for local contact details Arrange meeting with parents and young person if appropriate. Seek consent for other relevant professionals’ involvement. At meeting continue assessing needs. Plan & co-ordinate support services identified. Implement plan. Record & set review date. Continue to monitor & review regularly with young person and others as agreed. Seek consultation if required.

Self Harm information

9

Appendix A My Safety Net There are different types of people in our lives; try to identify some people in each of the groups below that you would feel comfortable talking to. 1 Family and close friends 2 Friends and people you see every day 3 Help lines and professional people you could go to for help Also, write into the safety net the things that you can do yourself to cope with difficult feelings and keep yourself safe

3

2

1

Me

10

Self Harm information

Appendix B Examples of Coping strategies Replacing self harm behaviours with other safer activities can be a positive way of coping with tensions. What works depends on the individual and the possible reasons behind the self harm. Examples of ways of coping:  Writing, drawing and talking about feelings  The rainbow journal: www.selfinjurysupport.org.uk/self-injury-self-help-ideas  Contacting a friend, family member, crisis line  Going to a quiet place and screaming.  Screaming silently  Hitting a pillow/soft object  Listening to loud music. (Be aware of music that will lower mood).  Going for a walk/run or other forms of physical exercise  Reading a book  Keeping a diary  Having a bath  Looking after an animal  Drawing red lines on the skin with a washable pen  Clenching ice cubes in the hand until they melt – this can relieve tension  Using ice cubes with a red dye may be even more effective  Elastic band around the wrist and snapping it to cause pain. (Although this can be used as a way of self-harming)

Self Harm information

11

Appendix C Sample of an incident form to be used when a young person self harms School /College:



Date of report:

Staff member:



Position:

Young person’s name: Age:



Gender:



Year:



Incident: Date and time of occurrence: Action taken by school personnel:



Recommendations:



Follow up:



12

Self Harm information

Appendix D Fact sheet for parents /carers on self harm It can be difficult to find out that someone you care about is harming him or her self. As a parent / carer you may feel angry, shocked, guilty and upset. These reactions are normal, but what the person you care about really needs is support from you. They need you to stay calm and to listen to them. The reason someone self harms is to help them cope with very difficult feelings that build up and which they cannot express. They need to find a less harmful way of coping. What is self harm? Self harm is any behaviour such as self-cutting, swallowing objects, taking an overdose, hanging or running in front of cars etc. where the intent is to deliberately cause harm to self. How common is self harm? Over the last forty years there has been a large increase in the number of young people who harm themselves. A recent large community study found that in 15-16 year olds, approximately 6.9% of young people had self harmed in the previous year. Is it just attention seeking? Some people who self harm have a desire to kill themselves. However, there are many other factors which lead people to self harm, including a desire to escape, to reduce tension, to express hostility, to make someone feel guilty or to increase caring from others. Even if the young person does not intend to kill themselves, self harming behaviour may express a strong sense of despair and needs to be taken seriously. It is not just attention seeking behaviour. Why do young people harm themselves? All sorts of upsetting events can trigger self harm. Examples are: arguments with family members, break up of a relationship, failure of exams or bullying at school. Sometimes several stresses occur over a short period of time and one more incident can be the final straw. Young people who have emotional or behavioural problems or low self-esteem can be particularly at risk from self harm. Suffering a bereavement or serious rejection can also increase the risk. Sometimes young people try to escape their problems by taking drugs or alcohol. This only makes the situation worse. For some people self harm is a desperate attempt to show people that something is wrong in their lives. What can you do to help? Try to:  Keep an open mind  Make the time to listen  Help them find different ways of coping  Go with them to get the right kind of help as quickly as possible Some people you can contact for help, advice and support are:  Your family doctor  Young Minds Parents Information Service. Tel: 08000 182138 Self Harm information

13

 The Samaritans. Tel: 08457 90 90 90  MIND Infoline. Tel: 020 8522 1728 (Self help books also available)  Youth Access. Tel: 0208 772 9900  School Health Nurse  Health Visitor Reasonably priced booklets can be found at: www.basementproject.co.uk or www.selfinjurysupport.org.uk/

14

Self Harm information

Appendix E Sample of letter to parents Dear (Parent/Carer) Thank you for coming to school to discuss………………………………………….. After our recent meeting I am writing to express concern about ……………..’s own safety and welfare. The recent incident of self harm (or threat to self harm) by ……………………. suggests that he/she may need professional help. I recommend that you visit your local doctor for advice and help. We will continue to provide support within the school community but would appreciate any information that you feel would help us to do this as effectively as possible. If there is anything else we can do to help ……………………… please contact me.

Yours sincerely,

Title

Self Harm information

15

Appendix F Helpful Resources for Young People On this leaflet is a list of useful telephone numbers and websites for groups that can support you when you feel you need it.

Samaritans Samaritans believe that offering people the opportunity to be listened to in confidence, and accepted without prejudice, can alleviate despair and suicidal feelings. You can contact us in complete confidence in the following ways:

Youth2Youth helpline For all young people 11-19 years old You can contact us in 3 ways: Email: send your problem/concern to us via www.youth2youth.co.uk Online Chat: Enter our chat room and “talk” to one of our trained helpers live. Monday and Thursday evenings between 6:30pm and 9:30pm www.youth2youth.co.uk Telephone: Call us and talk about your problem - we can even call you back. Helpline times: Monday and Thursday evenings between 6:30pm and 9:30pm on 020 8896 3675 Please note: Youth2Youth does not offer an emergency service. If you consider your problem to be life threatening or if it is extremely serious we ask you to contact the emergency services or other appropriate agencies.

16

Self Harm information

By Telephone: on our local number 0117 983 1000 or on the national number 08457 909090 (charged at local rate) By email: We recognise that some people may find it easier or may need time and space to find a way through emotional distress by communicating by email. The address is [email protected]

Off The Record Bristol What we do Off The Record (OTR) provides free, confidential, easy to access counselling for everyone aged 11-25 living in Bristol. You can talk about whatever you need to with your counsellor and they won’t judge you or tell you what to do. Your counsellor will listen to you and support you to find your own ways to move forward and get the most out of life. We offer counselling from several locations around Bristol including the City Centre, Barton Hill, Lawrence Weston, Lockleaze and Withywood. Get in Touch! Off The Record 2 Horfield Road, St Michaels Hill, Bristol BS2 8EA Phone: 0808 808 9120 Text: 0789 688 0011 E-mail: [email protected] Web: www.otrbristol.org.uk Join us on Facebook Follow us on Flickr & Vimeo Registered Charity No. 1085351 Registered Company No. 4150044 For support and information talk to a Youth Support Worker (YSW) YSWs are trained members of the OTR team who can support you around a range of different issues. Occasionally, people come to meet a Youth Support Worker when they feel they need immediate support because they are in crisis and they can’t wait for a counselling session. Other support and services include:C-Card and Sexual Health: We offer the C-card service and Chlamydia testing kits at Off The Record. You can find out more about this by looking at our website. Groups and Workshops: Throughout the year we run groups, workshops and training at Off The Record on a variety of different themes and issues. have a loook at on the website for more details Need to talk?

Get Connected

Call ChildLine 0800 1111

Telephone and email support for under 25’s.

Calls are free and confidential

0808 808 4994

Childline online chat via www.childline.org.uk

(1pm - 11pm 7 days a week) www.getconnected.org.uk

Chat to a Childline counsellor online in a 1-2-1 session any time you want. Self Harm information

17

Appendix G Local Contact details Queries regarding CAF Bristol www.bristolpartnership.org/the-partnership/children-and-young-peoples-trust-board/sharedresponsibilities-and-processes/multi-agency-working-arrangements/109-common-assessmentframework South Gloucestershire Integrated Working Team (01454) 865 734 www.southglos.gov.uk/NR/exeres/9f6b109a-cfff-4521-b0b6-b3f318e3191e Primary Mental Health Specialists Bristol North CAMHS (0117) 323 5800 Bristol South CAMHS (0117) 340 8121 Bristol East CAMHS (0117) 342 5466 Bristol Central CAMHS (0117) 342 5466 South Gloucestershire CAMHS (0117) 947 4800 Useful addresses and telephone helplines Young MINDS 0800 018 2138 102 – 108 Clerkenwell Road Mon. and Fri. 10am – 1pm London EClM 5SA tel. (020) 7336 8445 Tues., Weds., Thurs. 1pm – 4pm E-mail: [email protected] Young MINDS Parents Information Service Off The Record Helpline times: Drop-in times:

0800 018 2138

0808 808 9120 9.30-20.00 Mon / Tues / Wed 11.30-17.00 Mon / Tues / Wed

Bristol Crisis Service for Women National helpline (0117) 925 1119 PO BOX 654 Fri. and Sat. 9pm– 2.30am Bristol Sun. 6pm-9pm Avon BS99 lXH www.selfinjurysupport.org.uk/self-injury-self-help-ideas Samaritans



Childline CALM (Campaign Against Living Miserably) Helpline for males 15 – 24

08457 90 90 90 0800 1111

24 hour helpline 24 hr helpline

0800 58 58 58 7 days a week 5pm –3am

Indigo Project supports young people aged 13-24 in Bristol and South Gloucestershire www.indigoproject.co.uk HOPELineUK www.papyrus-uk.org 18

Self Harm information

0870 170 4000

www.selfharmuk.org TESS Text/email support for 11-25 year old women who self-injure. Text number 0780 047 2908 accessed through www.selfinjury.org.uk Web sites Reasonably priced information booklets for young people who self harm, their family and friends. www.basementproject.co.uk National Self-Harm Network PO BOX 16190 London NW1 3WW www.nshn.co.uk www.teachers.gov.uk/teachingandlearning/library/self-harm/ Bibliography www.selfharm.org.uk www.selfharm.org.uk/article.aspa?PageId=531&NodeId=246 www.scie.org.uk/publications/briefings/briefing16/index.asp#contents www.cde.state.co.us/ssw/download/pdf/SSWConf2005_Finger_Jennifer_Self-Injury_CSSWA_ Handout.pdf Adolescent Self Harm Forum Oxfordshire (2004). Self Harm: Guidelines for School Staff Hawton et al. (2002) Deliberate self harm in adolescents: self report survey in schools in England. BMJ, 325, 1297-1211. Oxfordshire Adolescent Self Harm Forum (2004). Self Harm: Guidelines for assessment and treatment.

Self Harm information

19

Notes

20

Self Harm information

How to contact us:

www.nbt.nhs.uk

Details correct at time of going to press – February 2011 Produced by Bristol and South Gloucestershire (Child and Adolescent Mental Health Service (CAMHS) Image on front cover © Barnardo’s  North Bristol NHS Trust