Self-Harm and Suicidal Ideation
Conference
2nd October 2014
Emma Grinham
Young Person Chair of the Mental Health
Anti Stigma Programme
David Loyd-Hearn
Commissioning Manager Children and Young people
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Introduction
Self Awareness of Self Harm
Key Note - Self Harm = Symptoms – The Spectrum
What happens when a young person goes into
hospital?
Break – Coffee and Market stalls
Northamptonshire toolkit
What will you do next? Action planning
What do you know now? Evaluation
Getting to know the key facts….
Self-Harm = Symptoms
Self-harm across the spectrum
Why is Emotional Well Being and Mental Health
for Children important?
Emotional wellbeing underpins being successful at
school, making and keeping friendships and
making the most of life.
Approximately 50% of lifetime mental illness
starts before the age of 14 and it is estimated that
potentially half these problems are preventable.
Self Harm can sometimes be a coping mechanism
or fashion, but it can also lead to significant harm
and occasionally suicide. It is not the act that
matters, but the intent.
Around 1 in 10 children and young people may
have a
mental health
problem at any one time.
Self-harming admissions are higher in
Northamptonshire than the national average.
Research suggests self-harming behaviours are
average.
In adulthood half of all women, and a quarter of
men will be affected by depression at some stage
in their life.
Recent Northamptonshire Public Health
assessment suggests local wider costs £1347
million due to mental illness
When it comes to children and young people, 1 in
10 children self-harm, with suicide accounting for
20% of deaths in young people between the ages
of 15-24.
Key Findings from CYP Survey
(775 Responses)
Unmet needs continue to feature which
do not fit in defined Specialist CAMHS
criteria e.g. challenging behaviour, self
harm as a coping mechanism. We are
working together to resolve.
73% of a significant sample of young
people have body image concerns, this
increases to 90% of the sample of
CAMHS users. Young people suggest this
is sometimes a cause for self-harm.
Behaviour Issues account for 52% of
paediatric referrals and a significant
number of CAMHS referrals. If untreated,
sometimes these cases may lead to selfharm.
Anxiety and Depression is the number 1
reason for referral (and can lead to
eating
issues or self harm as a coping
mechanism). Young People increasingly
find self harm is an acceptable coping
Mechanism.
We are a national outlier for self harm
due to the adherence of NICE guidance,
though we are about average in
There is a significant lack of knowledge
of services, what is available and how to
access. If in doubt, visit
What is self-harm?
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Self-mutilation
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Self-destructive behaviours (compulsively pursued acts that causes self-harm)
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Self-harm without suicidal intent
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Attempted suicide
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Minority who self-harm attend A&E departments or specialist services
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Most are supported in the community
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Most young people who self-harm do not continue with this into their 20’s
How many young people self-harm?
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Rarer in pre-teens
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10% of adolescents in the UK self-harm
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At 14yrs; 25% F & 14% M experience suicidal ideation
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Only 2-3% present to medical services
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Huge number remain unknown
National and Local Statistics
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72% of people who seek help for depression are female
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75% of people who take their own lives are men.
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National rates of self-reported self-harm are 7% for 11-16 year olds but several times higher
in those with:
• emotional disorder (28%)
• conduct disorder (21%)
• ADHD (18%).
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Applying national rates to Northamptonshire would mean that 2940 11-16 year olds would
report self-harm. Our actual figure is lower, though in schools anecdotal evidence suggests
the rates could be as many as 50%.
Northamptonshire A&E Admission Rates
for Self Harm
Locality
Inpatient
Inpatient
Inpatient
Inpatient
Admissions Admissions Admissions Admissions
of 0-19's in of 0-19's in of 0-19's in of 0-19's in
2009-10
2010-11
2011-12
2012-13
Western Northampton
51
60
64
55
Kettering
35
51
40
49
East/Southern Northampton
30
48
55
40
Central Northampton
44
43
55
28
East Northants
15
19
20
26
Daventry North
28
30
23
23
Corby
29
28
24
25
Wellingborough
15
21
14
20
Daventry South
14
17
18
17
Oundle & Wansford
1
0
1
4
Not coded
19
15
23
12
Total
281
332
337
299
200
180
160
140
120
100
80
60
40
20
0
Years 0-4
Years 5-11
Years 12-16
Years 17-18
All
All
All
All
Inpatient Inpatient Inpatient Inpatient
Admissions Admissions Admissions Admissions
in 2009-10 in 2010-11 in 2011-12 in 2012-13
Hospital Admissions (Approx)
East Midlands 2010
• Under 10 yrs Low figures
• 10-14 yrs 350
• 15-19 yrs 1500
• 30-34 yrs 800
• 20-24 yrs 1300
• 30-39 yrs 1100
• 25-29 yrs 1000
• 40-44 yrs 1200
• 50-54 yrs 550
• 45-49 yrs 700
• 55-59 yrs 300
• 60-64 yrs 170
• 65-85+ yrs figures reduce
Under 18’s Hospital Admissions by PCT
East Midlands 2010
• Derbyshire
210
12.4
• Derby City
104
17.4
• Nottinghamshire
164
9.2
• Nottingham City
118
17.3
• Northamptonshire
220
12.8
• Leicestershire
199
12.2
• Leicester City
91
11.2
• Lincolnshire
155
9.8
• East Midlands Total 1261
12.0
Per 10,000 area population
What are we doing about self-harm? Short
Term
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The conference marks the launch of the new self- harm toolkits for Northamptonshire on
www.asknormen.co.uk
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Web resources for young people by young people available on http://www.talkoutloud.info/how-do-youfeel/self-harm.aspx
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We have redefined the acute self harm and suicidal ideation pathway
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We are actively working with Northampton and Kettering Locality Forums to embed action plans.
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Auditing Urgent Care Admissions
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Developing questionnaires for acute self-harmers
What are we doing about self-harm? Long
Term
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The 2014-17 Children and Young People Emotional Wellbeing and Mental Health Strategy looks at
improving emotional resilience
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The Partnership are working to improve outcomes relating to challenging sexualised behaviours, drug and
alcohol misuse, parental mental health and interpersonal violence
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Initiatives to improve family relationships, resilience and coping strategies
o Five to Thrive
o Targeted Mental Health in Schools (TaMHS)
o Talk Out Loud Anti Stigma Programme
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Support of adults with mental health concerns or harmful behaviours
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Developing the Children’s Community Health Services
Priorities for the 2013-17 Emotional Wellbeing
and Mental Health Strategy
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The promotion of positive emotional wellbeing and early intervention
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Improved integration in targeted and specialist services including a single point of access
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Better support for children and young people who are chronically or acutely unwell
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Strengthened thresholds and pathways for behavioural and neurological developmental issues
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Focus on key groups of vulnerable children and young people to prevent poor emotional wellbeing
outcomes and ensure there are appropriate interventions when they require additional support
Children and Young People Community Health
Transformation Programme
Key drivers…
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National and local drivers
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Two local providers
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Growing gaps between the service models
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Opportunity to improve cohesion with NCC/ Police and Communities
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A lot of good practice and people to build on
Future Model for County Wide Children and
Young People Services
Key Features of the Whole System
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Single Point of Access - straddles specialist and targeted services
 Robust Triage decision
 Specialist role within 10 Early Help areas
 Targeted Support
 M/D & M/A Specialist Assessment and Intervention
Services delivered in local community locations wherever possible
Key professional identified where there is multiple need
‘Step up’ and ‘Step down’ in place across all levels of the pathway
Specialist services developing the skills, knowledge and competencies across the
pathway
Clinical oversight/responsibility in place where appropriate
Proposed Generic Pathway
Highly Specialist Services
Specialist Residential
Home care package of
support
Acute Hospital
MH Inpatient
Crisis and Short Term Home Intervention Service
Continuing care
assessment
Specialist Services
Needs remain complex intense enduring and
unpredictable – require bespoke package of
care
M/D assessment Diagnosis i.e.:
ASD/ADHD/Aspergers, no ongoing input from specialist
services required – ‘step down’
to targeted, early help services
monitor as required
Targeted Services
Early Help
Needs require urgent, short term
intense home support
M/D assessment and range of
interventions required.
Co-ordinated Health Plan Key health
Professional
Long Term – monitor and review
Individual Specialist
assessment Individual
intervention
Short term- discharge – step
down
Referral Management
Centre
CAF completed
Acutely Ill child
Universal Services
Emerging needs identified non-specific
multiple needs
Emerging Needs identified specific/single
need
Websites and Links
Northampton Young Healthy Minds Gateway- www.asknormen.co.uk
CAMHS- http://www.nhft.nhs.uk/main.cfm?type=CONTENTCAMHS
Northampton Youth Forumhttp://www.northampton.gov.uk/info/200124/forums/329/northampton_youth_forum
Northamptonshire Parent Forum Group-www.northantspfg.co.uk
Out There- http://www.thelowdownevents.info/new-youth-group-out-there/
Shooting Stars- http://www.northantspfg.co.uk/shooting-stars/
Talk Out Loud – www.talkoutloud.info
Young Minds- http://www.youngminds.org.uk/
Youth Space - www.youthspace.me
Websites and Links – Youth Counselling
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Youth Counselling across the county - http://www.servicesix.co.uk/
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Northampton - http://thelowdown.info/
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Daventry - http://www.time2talk.org.uk/
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Kettering and Corby - http://kyi.org.uk/
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Oundle - http://www.oundle.gov.uk/oundle-town-council-properties/courthouse/chat/
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Wellingborough - http://www.servicesix.co.uk/
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ADHD Support http://www.autismconcern.net/index.php?option=com_content&view=article&id=195:newadhd-a-as-dual-diagnosis-provision-in-northamptonshire
Self-Harm – the acute story
Julie Quincey
Named Nurse Safeguarding Children
Northampton General Hospital
Young person up to 18 years presents at A&E following Deliberate Self-harm act
Triaged in A&E, and if no medical treatment is
required, transfer to ward (Child or Adult
setting) with child self-harm pathway
documentation started by A&E staff
Clerked on the ward and medically assessed
Ward ring Child and Adolescent Mental
Services (CAMHS) to request risk assessment
• Prior to 12.00 midday Mon – Fri 9 – 5 call
CAMHS Newland House, 01605 656060
• Between 17.00-22.00 the CAMHS CRISIS
team can be contacted for consultation
via Berrywood hospital reception on
01604 682682
If patient admitted out of hours, they should
be kept in overnight and CAMHS informed
next working day
CAMHS undertake mental health risk
assessment. If safeguarding concerns request
ward contacts social care for joint assessment
and inform Hospital Safeguarding team
Once assessment is completed, and medical
review taken place, the patient can be
discharged home. If there are safeguarding
concerns then a joint discharge planning
meeting with children’s social services should
ensure safe discharge.
Patient refuses treatment and absconds
from Hospital
Inform police (999) and ask for welfare
check clearly record the incident number
in the patient record
Police return with patient - continue with
pathway
Patient refuses to return, inform GP and
refer to children’s social services and ask
them to consider referral to CAMHS
Ensure Paediatric Liaison Form is completed and copied to school
nurse and GP, or if Interagency referral to social services has been
completed, a copy of this will be sent to GP and School Nurse. Ensure
Safeguarding team is copied in. DOCUMENT EVERYTHING IN THE
PATHWAY, COMPLETE SAFEGUARDING CHRONOLOGY.
Why do we assess the next working day
• As per NICE guidelines we do the following
• First they need to be medically stable
• Secondly they need time out to sleep, to
reflect and to rest
• Then CAMHS will come and assess
Catherine’s Story
Catherine’s story
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Catherine was admitted to NGH having taken an overdose of 24 paracetamol, 8 ibruprofen, 3
nytal and her father’s anti-depressants 15 tablets were missing
I was present when Catherine was admitted she had come via ambulance
She was in secondary school, looked very thin, nicely dressed and otherwise looked well
looked after
She came with her older brother, her father and her step-mother
Her father and step mother were distressed and were struggling to come to terms with
Catherine’s actions, her brother seemed detached
The treatment
• Catherine’s paracetamol levels were high and therefore she required a
parvolex drip and stayed in over night
• We weighed her and checked her eating pattern though thin she had a
normal BMI and we observed her eating well on the ward
• The next morning she was pronounced medically fit for discharge
• CAMHS attended and did their assessment they felt she was not mentally
ill but would follow her up in the community
Catherine and her family tell their story
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I told Catherine she could go home but she refused she said her brother was
hitting her and she was not going to go home anymore, she had not shared this
with the CAMHS worker
As the safeguarding nurse I needed to understand more
It took the next three hours to unpick the story. Catherine had originally lived with
her birth mother who struggled with mental health problems both children
suffered emotional abuse and after a case conference were placed with their
father
Catherine’s step mother was very calm and understanding but had found
Catherine emotionally shut down and non-communicative
Catherine and her family tell their story
• Catherine shared that her brother Toby was really hard to live with as he
had behavioural problems
• I had observed Toby for a number of hours and he struck me as being on
the autistic spectrum, I discussed this with his father and step-mother
and they agreed to a referral to CAMHS to have him assessed, I later found
out he had been diagnosed with high functioning autism
• Catherine agreed to go home once she knew Toby would get help
Catherine
• With the parents agreement we referred Catherine as a child in need to
social services, the family were assessed and were eventually signed
posted to a life story worker who worked with Catherine
• Though Catherine was not mentally ill she was struggling to make sense of
her world as was her brother
• The family had been through a lot of trauma they needed time and help to
make sense of the many changes
• To my knowledge Catherine did not self-harm again
Jack’s story
How Jack came to hospital
• Jack was seen by the police he was standing outside his
girlfriends house at 3 am in the morning it was snowing
heavily, his head and shoulders were covered in snow
• Jack was not making sense when the police spoke to him his
words were slurred and his eyes looked dilated, he eventually
admitted to the police he had taken an overdose
• The police brought him to A&E and he was admitted to the
children’s ward, he was 17 years old effectively homeless and
sofa surfing he originally was from out of county
The treatment
• Jack also required a parvolex drip
• He had also self harmed through cutting and required steristrips to his arms and the cuts to his legs were cleaned up
• He appeared to have a chest infection and bloods were taken
• During the night Jack slept deeply
• The next morning he was ready to see CAMHS
Jack takes his leave
• I was rung by the ward, Jack was refusing to stay as he was worried about
his girlfriend
• We managed to calm Jack whilst we waiting for CAMHS Jack started to tell
me that he had stood every night for the past week outside his girlfriends
house, she and her mother didn’t know. He felt it was the only way he
could keep her safe and he felt compelled to do it
• Jack appeared to be highly distractible and appeared to be listening to
something, I shared my concerns with the CAMHS worker I was beginning
to wonder if Jack was manic or indeed psychotic
CAMHS assessed
• CAMHS agreed that Jack was showing pressure of speech, had distorted
thinking he believed his mobile was sending him messages but his mobile
was completely dead and had been for a number of days
• He was also stating if he left the hospital he would jump from a building
• The CAMHS worker explained to Jack he was ill and said he needed to be
admitted to psychiatric hospital
Jack ran
Jack
• Jack was returned to the ward by the police
• Eventually Jack was transferred to psychiatric hospital by the
police and the AMHP worker under section 3 of the mental
health act
• I do not know the outcome of Jack’s story
Kelsie’s story
Kelsie’s story
• Kelsie had over 20 admissions to NGH in a three month period in her late
teens
• She allegedly took overdoses however the tox screen never showed toxic
levels in her blood
• She frequently self-harmed by cutting, burning and using ligatures
• Kelsie during this time became looked after by social services
• As her story slowly unfolded it was discovered she had been sexually
exploited
• Kelsie has learning difficulties
Kelsie to date
• Kelsie has been very hard to help
• Though she is not mentally ill she does use self-harming
behaviour to express her feelings
• She frequently disappears from her foster carers
• She will return to her mother’s and then go missing again
• She is potentially at risk when she does not engage
• Kelsie is now a young adult and continues to be admitted to
NGH with self-harm
What can we learn
• These cases are pretty typical
• Catherine’s was due to the effect of coping with emotional
abuse
• Jack had developed bi-polar
• Kelsie has a troubled background, learning disability and is at
risk of sexual exploitation
Catherine
• Catherine had had many changes, her new school was aware
of the troubles she had experienced with her birth family, but
as Catherine was quiet and a good student it was assumed
both by school and her parents that she was coping
• Catherine’s history is a high risk for vulnerability to self harm
• Parental mental illness
• Child protection proceedings
• Brother with emerging developmental disorder
• Mentoring at school may have helped
Jack
• Jack was homeless and only became known to services after
admission
• Though his girlfriends mother knew Jack was troubled he had
hid the homelessness from her and his girlfriend agreed to
keep quiet
• The police responded really well, Jack has got an early
diagnosis and if he follows his medical regime he should have
better outcomes
Kelsie
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Kelsie had been permanently excluded on more than one occasion
She was well known to social services
Her learning difficulty had never been formally diagnosed
Her mother rarely reported her missing
Kelsie’s vulnerabilities made her ideal for men to sexually exploit
All workers should be familiar with the CSE toolkit to spot the risk factors
and take action sooner
The Community & Schools Pathway
and Toolkit
Emma Tucker
Specialist Primary Mental Health
Practitioner, CAMHS
Dr Emma Rowley
Senior Educational Psychologist, NCC
What is Self-harm?
• Self-harm in the literature is used to cover deliberate acts of
injury which may or may not involve a wish to die.
• One example is that of physical mutilation e.g. cutting the
skin, repeatedly banging a part of the body etc.
• Most people who injure themselves in what they call selfharm do not intend to intentionally risk their lives
Why do young people Self Harm ?
• Act of self-harm or self injury can be symptoms of distress
• The importance of the act is meaningful to the individual who
carries it out
• It is important not to generalise about young people who selfharm
• It can be a way of coping with many different emotions
Explanation from people who Self-harm
To be able to feel
anything
For the physical
pain to overtake the
emotional pain
To break numbness
A sense
of control
To let the anger
out
A way of
punishing myself
The pain proves
your human
It is like an
addiction
I like watching
the blood run
Cycle of self-harm
Negative emotions
Sadness, anger and despair
Tension
Inability to control emotions, maybe
using dissociation 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
Definition
‘Self-poisoning or self-injury, irrespective of the apparent
purpose of the act’
NICE, 2004
The Two Pathways
• The Community & School pathway and acute
pathway
Community
& School
Pathway
If
necessary,
Acute
Pathway
The Community & School Pathway
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Improved communication home, school and other agencies
Self- harm team
CaMHS consultation through liaison line
Checking with safeguarding protocols
Consideration of informing parent/carer
Risk assessments and forms
The Toolkit
• Toolkit has been developed by Northamptonshire Multi-agency pathway
development team and also includes guidance from other national and regional
organisations
• Guidance for schools to support children, young people and families at an
individual and systemic level
• Bringing a national perspective into the local framework including example
policies for schools
• Tools can be used in either a preventative or supportive capacity
• Toolkit contains both practical and theoretical evidence based approaches to
helping and supporting young people
Using the Toolkit and Pathway
Scenario....
You are approached by a young person who attends your organisation e.g school/
community group who has indicated that they have self-harmed by cutting them
self. They have shown you the cut on their forearm.
For five minutes on your tables, discuss how you would use the
pathway and toolkit to help you to support this young person
and decide on a plan of support...
Key aspects to consider
• Working as a self- harm team, consider peer support/supervision and
confidentiality issues.
• Informing parents and use of scripts for telephone conversation/ letter to parents
to arrange meeting
• Any necessary further referral e.g. Safeguarding, CaMHS, Educational Psychologist,
Community Support?
• Tools that may be useful e.g. proactive support plan, script for talking to a young
person, coping strategies and distractions, risk assessment, protective behaviours
• Documenting the support- appropriately evidencing a plan of support in school
and ensuring paperwork is clear and relevant should an ongoing referral need to
be made
• Consistent documentation to be handed over when relevant between the two
pathways in order that all agencies recognise plans of support.
Look after you-supervision and team support
are paramount!
A closing thought...
Remember you could be the one person who
makes a difference... But you don’t have to help
alone!
What will you do next?
• Action planning
Remember self-harm is only part of people’s
stories...it does not define them as a person.
For more information please see:
www.asknormen.co.uk