Definitions by jizhen1947


									 Young People and
Deliberate Self Harm

  Contemporary Policy
      and Society
  “Intentional self-poisoning or
    injury, irrespective of the
  apparent purpose of the act.”

Other terms used to describe self harm -
 Deliberate self harm

 Intentional self harm

 Para suicide

 Attempted suicide

 Non-fatal suicidal behaviour

 Self inflicted violence

 Self poisoning

 Self injury

 Self mutilation
                           NICE 2003
What is self-harm?

   cutting or burning - the most
    common forms of self-harm
   taking overdoses of tablets or
   punching themselves
   throwing their bodies against
   pulling out their hair or eyelashes
   scratching, picking or tearing at
    their skin causing sores and
   inhaling or sniffing harmful
   swallowing things that are not
   inserting objects into their bodies
   Some young people self-
    harm on a regular basis,
    others do it just once or a
    few times.

   For some it is part of coping
    with a specific problem and
    they stop once the problem
    is resolved. Other people
    self-harm for years
    whenever certain kinds of
    pressures or feelings arise.
How Do People Self
2 broad groups
 Self poisoning - more likely to
  seek help
 Self injury - cutting by far the
  most common means. Other
  methods include burning,
  shooting, jumping and insertion

  80% or people who attend A&E
  having self harmed will be due
  to self poisoning. However, in
  the population self injury is
  more common
How common is self-
   Self-harm is more common
    than people realise. It's
    impossible to say exactly
    how many young people self-
    harm because:
   Many young people hurt
    themselves secretly before
    finding the courage to tell
   Many of them never ask for
    counselling or medical help.
How common is self-
   There is no standard definition of self-
    harm used in research.

   There are no national statistics on self-
    harm currently available.

   Self-harm is most common in children
    over the age of 11 and increases in
    frequency with age. It is uncommon in
    very young children although there is
    evidence of children as young as five
    trying to harm themselves.
How common is self-
 Self-harm is more
 common amongst girls
 and young women than
 amongst boys and
 young men. Studies
 indicate that, amongst
 young people over 13
 years of age,
 approximately three
 times as many females
 as males harm
 themselves. Why?
How common is self-
   A study in Oxford found that
    approximately 300 per
    100,000 males aged
    between 15 and 24 years,
    and 700 per 100,000 females
    of the same age, were
    admitted to hospital following
    an episode of self-harm
    during the year 2000.
   Community based studies
    report higher rates of self-
    harm than hospital based
How common is self-
   A national survey of children and
    adolescents carried out in the
    community found that 5 per cent of
    boys and 8 per cent of girls aged 13-15
    said that they had, at some time, tried
    to harm, hurt or kill themselves.
   In the same national survey, rates of
    self-harm reported by parents were
    much lower than the rates of self-harm
    reported by children. This suggests
    that many parents are unaware that
    their children are self-harming.
   A study carried out in schools in 2002
    found that 11 per cent of girls and 3
    per cent of boys aged 15 and 16 said
    they had harmed themselves in the
    previous year.

Male to Female ratio changing
- currently about equal.
Although in adolescence, girls
are 3 times more likely to self
Mean age 32 years

Peak ages 15-24 (female), 25-

34 (male)
Divorced, separated, single.

Inverse relationship with

social class.
Strongly associated with

Greater in inner cities.
Why do young people
harm themselves?
   Difficult or painful
    experiences or relationships.
    These may include:

   Bullying or discrimination.

   Losing someone close to
    them such as a parent,
    brother, sister or friend.

   Lack of love and affection or
    neglect by parents or carers.
    Why do young people harm
   Physical or sexual abuse.

   A serious illness that affects the way
    they feel about themselves.

   Problems and pressures of everyday
    life. From family, school and peer
    groups to conform or to perform well
    (e.g. in getting good exam results).

   Low self-esteem, linked to poor body
    image, eating disorders, or drug

   Peer pressures - young people may
    find themselves among friends or other
    groups who self-harm and may be
    encouraged or pressurised to do the
Why do young people harm themselves….

   When the level of
    emotional pressure
    becomes too high it acts
    as a safety valve - a way
    of relieving the tension.
 Cutting   makes the
    blood take away the
    bad feelings.
 Pain   makes them feel
    more alive when they
    feel numb or dead
Self-harm as a way of coping!

 Punishing  themselves
  relieves feelings of
  shame or guilt.
 When it's too difficult to
  talk to anyone, it's a
  form of communication
  about their
  unhappiness - a way of
  saying they need help.
Self-harm as a way of coping Extreme
feelings of fear, anger, guilt, shame,
helplessness, self-hatred, unhappiness,
depression or despair can build up over time.
When these feelings become unbearable, self-
harm can be a way of dealing with them.

   Self-harm is something they can
    control when other parts of their life
    may seem out of control.
    Why do people self harm?

To communicate distress
To obtain temporary respite from

intolerable issues
To effect change in the

behaviour of others
As a way of expressing emotion

      e.g. anger
Self punishment

To gain control

To commit suicide

To prevent suicide
    Factors Associated with Self
   Socio-economic factors
     – Poverty
     – Homelessness
     – Multiple adverse life events
     – Relationship breakdown

   Abuse in adult/childhood

   Mental disorder - around 70% of those
    attending A & E would meet the criteria for
    mental disorder. (For most this will be
    reactive and short lived depressive

   50% of people diagnosed as having
    schizophrenia will have self harmed at
    some point.

   Drug/alcohol abuse - 50% of people
    attending A&E will have used drugs or
    alcohol immediately prior to, or during the
    act of self harm.
Vulnerability Factors
Long Term - Early Loss or
Separation From Parents. Difficult
Relationships With Parental
Figures. Abuse.

Short Term - Relationship
Problems, Social Isolation,
Drug/alcohol Misuse.

Precipitating Factors - Relationship
Problems, Financial Worries, Loss.
Likely to Have Occurred in the Prior
Few Days.
       Psychological Characteristics

   Difficulty with engagement
   Hostility
   Internalised Anger
   Anxiety/irritability
   Poor coping strategies
   Poor problem solving capability
   Dichotomous thinking
Autobiographical      memory defecits
   Poor impulse control
   Hypersensitivity to rejection
   Poor self image
   Ambivalence
   20 - 50% involves alcohol
Attitudes to Self Harm

   Attitudes of health and social
    care professionals towards self
    harm tend to be more positive if
    the individual is seen as being
    seriously mentally or physically

   Depression is viewed more
    favourably than ‘manipulation as
    a cause of self harm.
Attitudes to Self Harm
   Individuals who self harm without
    the intention of dying viewed less
    favourably than those who were
    attempting to commit suicide

   Repeated acts of self harm lead
    to particularly negative attitudes

   Workers often talk in stereotypes
    such as - ‘genuinely suicidal,’
    ‘mad’, ‘silly girls’, ‘personality
    disorder’, manipulative’
    Consequences of
    Negative Attitudes
   Feelings of anger/frustration can
    lead to avoidance or withdrawal
    of treatment
   Detachment
   Some staff over compensate
    becoming overly proactive
   Inconsistency can lead to
    confusion and uncertainty. Can
    mirror inconsistency and abusive
    responses they experienced in
    dysfunctional relationships
       Why Negative

   Self harm can be a challenge
    to our personal/professional

   Fear

   Perception of incompetence
   Transference counter
So What Can We Do?

   Risk assessment

   Psychological interventions

   Clinical interventions

   Pharmacological
    Risk of Repetition
Risk of repetition

     16% will repeat within a year.

Repetition occurs early

    25% within 3 weeks
    50% within 12 weeks

Factors associated with repetition:

  Previous history of self-harm
  Psychiatric history
  Lower social class
  Alcohol or drug problems
  Antisocial personality
  Lack of co-operation with
  High suicidal intent
         Risk of Suicide

1% will commit suicide within the
following year
3% at 5 years

50% of suicides have previous self


Factors associated with suicide:

Older age
Previous history of self harm
Psychiatric history
Poor physical health
Social isolation

Individuals who self discharge from A&E
are three times more likely to repeat self
harm or complete suicide.
  Hazards Which May
Mislead the Assessment
  and Management of
      Suicide Risk
   Deliberate denial of suicidal
   Variability in degree of
   Misleading improvement
  Hazards Which May
Mislead the Assessment
  and Management of
      Suicide Risk
   Anger, resentment (national
    confidential inquiry: 33% of
    suicides have previous
    history of aggressive
   Un-cooperative and difficulty
   Malignant alienation
   Assuming that the service
    user is manipulating with
    empty threats
Risk Management
          Identify Risk

Review                    Assess Risk


Monitor                   Rate Risk

    Assessment: Basic Skills
   Due to lack of effectiveness of risk
    factors we have to conclude that face
    to face skills are of primary and
    paramount importance in our approach
    to suicide risk.

   Need to establish good rapport.

   Progressive focussing down on
    specific suicidal ideas. Useful to begin
    with more general issues.
    Assessment: Basic Skills

   Acknowledgement of suicidal ideation often
    associated with emotional catharses.Process
    should not be an interrogation. Use open
    ended questions at a speed individual is
    comfortable with.

   Occasionally necessary to use more direct

   Be prepared to ask directly about suicidal
    intent as you are unlikely to implant suicidal
    ideas in individuals.

   Impatient challenging due to frustration may
    provoke high-risk acting out in response.
   Problem solving therapy

   Cognitive behavioural

   Psycho-dynamic
    interpersonal therapy

   Dialectical behavioural
Strategies for Working
    With Self Harm
   Delaying strategies

   Restoring hope

   Therapeutic activism

   Use of short term no self
    harm contract
Strategies for Working
    With Self Harm
   Alternatives to self harm

   Hospitalisation

   Reduce access to means

    Underpinning all of the
    above is the importance of
    the therapeutic alliance
    formed with the individual
        Helpful Responses

   Show you are concerned

Don’t see stopping self harm as the

most important goal

Make it clear that it’s ok to talk about
the injury

Convey respect for the persons
efforts to survive

Encourage new ways of expressing

   Help develop support networks

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