Understanding and responding to
young people who self-harm within
youth offending services
Dr Joel Harvey – Clinical Psychologist
Dr Alison Sillence- Clinical Psychologist
Laura Hawksley - YOS Officer
Introductions
Aims
• To survey the risk factors related to self-harm
• To understand why young people self-harm
• To examine how and what to ask a young person about
self-harm
• To examine how to develop safety plans about selfharm
• To examine how to record and report information
about self harm
• To examine ongoing management and liaison with
services
Learning Objectives
• To have a better understanding of self-harming
behaviour among young people and how to
respond to it
• To have acquired knowledge that you can take
back to your local YOS
Exercise 1: What is Self-Harm?
• 10 minutes for group discussion and then we’ll
have feedback
• Split into groups:
– What is self-harm?
– Why do people self-harm?
– Is it different from attempting suicide?
What is self-harm?
• Hard to define because it depends on the
reasons why people have carried out the
behaviour
• Different functions:
–
–
–
–
–
coping with intense emotions
communicating distress
re-connecting with self (feel again) and others
an attempt to end one’s life (i.e. suicide intent)
a life saving act
Types of self-harm
• Direct
– Suicide attempts
– Self-injury (without suicidal intention)
– Ambiguous
• Indirect
– Substance abuse
– Easting-disorder
– Physical/situational/sexual risk taking
Acts of self-harm
•
•
•
•
•
•
•
•
Cutting
Hitting/Punching
Burning
Overdosing
Interfering with wound healing
Pinching
Biting
Other
Suicide Attempt vs. self-harm
(from Walsh, 2008)
Assessment
focus
Intent
Suicide attempt
Self-injury
To escape pain,
Relief from
end consciousness unpleasant
emotions
Psychological pain Unendurable,
Uncomfortable,
persistant
intermittent
Tunnel vision’
Tunnel vision: one Choices available,
way out
temporary
solution
Assessment
focus
Suicide attempt
Hopelessness and central
helplessness
Decrease in
discomfort?
Chronic/
repetitive?
Self-injury
Periods of
optimism and
some sense of
control
No immediate
Yes – successful
improvement
‘alteration of
consciousness’
Less often chronic Frequently
and repetitive
chronic and highrate
Self harm or suicide attempt?
• It is important to note that acts of self-harm can have
different functions at different times.
• Lethality is not always a reliable guide
• Intention is the best way to tell
But
- individuals can be ambivalent
- may not be able to articulate their reasons
- may not know or remember why
- self-harm and attempted suicide not always distinct.
Defining terms
• Today, we will use self-harm to mean deliberate
self-injury without suicidal intent. It can also be
referred to as non-suicidal self-injury (NSSI).
Self harm in the community
• How common is self harm? Depends on how
you define it, but:
– 15-20% of adolescents in the community are
estimated to have self-harmed (without suicidal
intent) at some time (in Nixon and Heath, 2009).
• Gender difference?
– Community studies on NSSI that only ask about
tissue damage don’t show a gender difference.
– Studies that also ask about pill overdosing (without
suicide intent) find more females.
Suicide in the community
• Windfur et al. (2009): Rate of around 3 per
100,000 for children aged 10-19 from 19972003, increases with age.
• In adolescents aged 15-19 rate was just over 6
per 100,000.
• More common in males: Suicide in young
women aged 15-24 under 3 per 100,000. In
young men aged 15-24 it was 10 per 100,000 in
2008 (office of national statistics).
Exercise 2: Guess stats for YOS
• Write on a post-it:
• Percentage of young people referred to the
Cambridgeshire YOS psychologist who:
- had a history of self-harm?
- had attempted suicide in the past?
- had self-harmed in the past month?
• Of completed SQIFAs how many reported
thoughts of harming or killing themselves at
least ‘sometimes’ ?
Guess stats for YOS
• Cambridgeshire YOS referrals (Feb-April 2009; N= 39):
– 37% had history of self-harming
– 21% had history of attempting suicide
– 18.4% had self-harmed within the past month
• Of completed SQIFAs over 54% reported thoughts of harming
or killing themselves at least ‘sometimes’
Self-harm in the CJS
• Harrington & Bailey (2005): Survey of people in
the community (YOS) and in secure settings
(STCs and LASCHs) found that 1/3 had mental
health needs and 9% had self-harmed in the past
month.
Self-harm in prison
• 20% of males aged 16-20 on remand had
attempted suicide in their lifetime (Meltzer et al.
1999)
• 38% had thought about suicide.
• In 2004, 5425 people self-harmed in prison; 74
per 1,000 people; young people accounted for
25% of these incidents.
Exercise 3: Risk Factors for Selfharm
• What do you think are the risk factors?
• Problem not located solely within the individual
- important to think systemically
Risk factors for self-harm, suicide
and offending behaviour
Systemic factors
Self-harm suicide
offending
Family violence and
conflict
yes
yes
yes
Physical abuse
neglect
Yes
small link
yes
yes
yes
yes
Poor parenting (eg.
Yes
Discipline,
consistency, affection)
Risk Factors
Systemic
Self-harm
factors
Sexual abuse Small link
suicide
offending
Yes
Criminal
parent
-
-
Increased in
violent
offending
Yes
Poverty
-
-
Yes
Risk factors
Individual
factors
Self-harm
suicide
offending
impulsivity
Yes
Yes
yes
Mental health
problems
BPD
Anxiety,
depressionet
c.
Yes
Depression,
Anxiety,
Etc.
various
Yes
Yes
Substance abuse
Risk factors
Individual factors
Selfharm
-
Lower IQ (hence
poorer social skills and
problem solving)
Difficulty identifying Yes
and expressing
emotions, dissociation
suicide Offending
behaviour
Yes
-
-
Risk factors
• Big risk factors for all of these things is whether
someone has done that behaviour before – e.g.
previous offending/suicide attempt/self-harm.
• This is an important thing to consider when
assessing for risk of self-harm or suicide
Take home message
• Many similar risk factors for suicide, self-harm
and offending.
• We work with a vulnerable population
• BUT
- Risk factors are not causes, someone can have
all the risk factors and still not do the behaviour
- Understanding the individual and their
circumstances is most important
Coffee Break!
• Drink coffee
• Eat biscuits
• 15 minutes
Case study: John
• 15-year-old boy on a referral order for assaulting peer on way
home from school
• Significant peer rejection since assault and his school attendance
is now poor.
• Lives with mum and stepdad, older brother recently left to live
with dad.
• Girlfriend lives in London. He find the separation hard and her
mum was recently diagnosed with cancer
• Finds it hard to talk to parents about how he is feeling
• Mum has often suffered from depression.
• Self-harming for a number of years. Recently increased in
frequency.
• Often self-harms after talking to his girlfriend on the phone.
Exercise 4: Barriers to working
with this client
• what would your worries be about discussing
self-harm with this person?
• How do you think these worries could affect
the conversation?
Be prepared
• Make sure a young person knows about the limits of
confidentiality
• Ensure you are aware of your area policy
• Never make promises you cannot keep
• Young person’s safety is paramount and takes primacy
over confidentiality
• Work together towards discussing with family/carers
where appropriate
• Have an idea when you go in about the questions you
need to ask and the key information
• Have emergency contact numbers available
Finding an opportunity
• Use assessment as an opportunity to ask about
self-harm, suicide attempt and suicidal ideation.
• Can ask at other times e.g. If you notice scars, if
young person seems low:
‘sometimes when people feel low, they have
thoughts about harming themselves. I’m just
wondering if that’s ever the case for you?’
• Its hard to ask, but if you don’t know, you can’t
help.
Recent History:
Thoughts of Self-harm
• Does the young person ever think about not wanting to
be here?
• If yes:
- Have you thought about doing anything to end your
life?
- plans and intent.
- why they feel this way
- level of hopelessness (scale of 1-10?)
- reasons for carrying on? (eg. If they say 9/10 for
hopelessness, ask about the 1/10).
Recent History:
Thoughts of Self-harm
• Have they told anyone
• Access to social support
• How do they feel right now?
- current plans/intent
- current level of hopelessness
• What would have to change to make them feel
more hopeful?
Recent History:
Self-harm
• Have they self-harmed recently? IF YES:
- What did they do? (eg. Pills? How many, type)
- When and where did this happen
- What happened immediately before? (triggers)
- How did they feel afterwards?
- Had they taken any alcohol/substances?
- Anyone else around? Could anyone else have noticed or
found them?
- Told anyone? What was their response?
- What do they think about the self-harm now?
Recent history:
Self-harm
• Has this happened before?
IF YES:
• How often? If is it not an isolated event:
- What generally triggers it?
- Any times when they feel this way but do not self harm
(other ways of coping)?
- Any times when the self-harm is worse? (and how bad is
it?)
- Times when the self-harm is better?
Past Risky behaviours
• If they have not harmed themselves recently:
- Have they ever thought about harming themselves in
their lifetime?
- Have they ever harmed themselves in their lifetime? If
Yes:
- what was the worst time? (what did they do – trying to
assess for past suicidality)
- ask about triggers, intent, outcome (eg.
Hospitalisation).
- How does their life then compare to their life now?
How to ask
• Make sure you have enough time
• Try to appear calm, understanding, non-blaming – they
may worry that you will be shocked or horrified or
think badly of them.
• Eye contact
• Some mirroring of their posture can help (eg. If they
are right back in their seat, also sit back)
• Give them time to talk and encouraging talking: ‘is it ok
for you to say a bit more about…?’
• Leave some pauses
How to Ask
• Reflective listening – shows understanding reflecting
feelings: ‘so you felt angry and then..’
reflecting meaning: ‘it sounds like, to you, this is a way
to cope with…’
• Reflecting back often helps people to expand on what
they have said.
• Open questions can ‘open’ up the conversation, but
they can be intimidating if someone cannot answer.
• Closed questions – yes or no answers.
• Good to have a mixture.
How to Ask
• If asking a difficult question it can help to be
tentative:
‘I’m just wondering about what was going on for
you when…’. ‘Why?’ can sound accusing at
times.
How to respond: ending and
containing
• If in doubt: reflect!
• Help them notice what other coping strategies they sometimes
use: Has there been a time when you really wanted to self-harm
but didn’t?
• Help them to think about sources of support
• Find out if its ok for you to talk to a parent (if you think this
would be helpful)
• Work towards discussing referral to an appropriate service
• Begin a basic safety plan with them, so they know who they
would contact (family member, GP, A&E) if they felt at risk or
had harmed themselves seriously.
Role Play!
• 10 minute role play, then:
Get into groups and choose a case example.
LUNCH!
• 12.30 – 13.15
Exercise 5: Role Play
• Get into groups and role play an assessment for
the case that you picked.
• How did it feel to ask the questions?
• How did it feel to be the young person?
Formulation: what is it?
• Persons and Davidson (2010) note that ‘the formulation is a
hypothesis about the factors that cause and maintain the
patient’s problems, and it guides assessment and
intervention’
• Friedberg and McClure (2002) formulations as ‘personalized
psychological portraits’
• Through taking a formulation approach to clinical work the
therapist moves away from a diagnostic model and provides
an explanatory account of the presenting difficulties.
Formulation for John: Predisposing
Factors
• Mum’s depression – possible attachment
problems and difficult regulating emotions
• Witnessing domestic violence
• Avoidant family style – difficulties not discussed
• Possible feelings of rejection connected to
relationship with dad, who is closer to brother.
• Any others?
Predisposing: Core Beliefs
• Early experiences could have led to the
development of some beliefs about self, world
and others:
• I’m worthless
• Others leave you, you can’t trust other people
• World is unpredictable
Predisposing: Rules for living
• If you talk about how you really feel, then
people might leave
• I need to look after other people, or they’ll leave
me
• I should be there for others
• I need to control my feelings, or others will
reject me.
Precipitating
•
•
•
•
Excluded from school due to assault
Feelings of rejection from peers
Back in school – pressure to manage behaviour
Girlfriend upset on phone
Perpetuating:
• We’ll draw it out!
Protective
• Mum
• Music
• Self-reflection
Exercise 6: Group formulation
• Focus on the perpetuating/maintaining cycle
Coffee Break
Who to tell and what to tell –
Cambridgeshire YOS Guidelines
• If worker not the responsible officer, must
report immediately to responsible officer, line
manager or duty manager (and record this in
YOIS within 24 hours)
• Responsible officer must make urgent referral to
YOS psychologist
• If a suicide attempt, YOS officer and
psychologist agree a ‘Suicide Prevention Plan’.
Who to tell and what to tell –
Cambridgeshire YOS
• Responsible officer and line manager and
County manager must decide if this meets the
‘Serious Incident’ Notification Criteria, if it does,
notification must be completed within 24 hours.
Who to tell and what to tell
• If risk is high (suicide attempt, current intention), YOT
worker or health worker can contact:
• GP
• If under 17: CAMHS on-call duty worker
• If over 17:
- Intake and Treatment duty worker
- Home Treatment Team (GP or Intake and Treatment
can refer, or can contact directly).
• A&E
Recording – YOIS
Cambridgeshire YOT guidance
• Recorded in YOIS within 24 hours
• Link in a ‘case diary’ entry including the
information you have gathered and your initial
formulation
• If you have reported it to other team members,
record these interactions in YOIS within 24
hours.
• If a ‘suicide prevention’ plan has been done,
record this within 24 hours.
Recording – YOIS
Cambridgeshire YOT guidance
• Update ASSET and Vulnerability Management Plan
within 48 hours. If there is a Suicide Prevention Plan,
include details.
• Line manager to countersign Vulnerability Management
Plan within 72 hours.
• List case at next Vulnerability Planning meeting or Risk
Management Panel and note this date as ‘planned
intervention’ on YOIS.
• Line manager and County manager must complete a
Local Management Report and forward to YJB within
20 days.
How to record
•
•
•
•
•
•
•
•
YOIS
VMP - Smart Goals
Flags
Case diaries
Safety plan
ACCT
Risk and vulnerability registers
Monitoring and review – dynamic!
Talking Again
• Once referral has been made, health
worker/CAMHS/other should meet with young
person
• Health worker alone or jointly discuss:
- who else in the family knows, or can join a
session and talk about the self-harm
- safety plan: what is it and agreement to
develop one
- meet to develop comprehensive safety plan
Safety planning
• YOT worker should be aware of the safety plan
developed with the young person
• Needs to address the main risks
• Needs to be practical – family and young person
have to feel confident they can follow it.
• Developed jointly with young person and family.
They are in the best position to know what will
help and what is practical.
Referral to CAMHS
• Accepts referrals up to 17th birthday
• For self-harm, advises discussing with a clinician at
CAMHS to help determine level of priority before
making referral
• Can use Common Assessment Framework (CAF)
• http://www.everychildmatters.gov.uk/deliveringservice
s/caf/
• Need agreement from child before referral is made
CAMHS Referral – what to include
• Basic information:
- name and dob
- address
- who has parental responsibility
- GP details
• Reason for referral
- specific difficulties you want them to address
- how long has it been a problem and why are they
seeking help now?
- is the problem general or situation specific?
- your understanding of the issues involved
CAMHS referral - continued
• Further helpful information
- who else is living at home and details of
separated parents if appropriate
- Name of school
- Who else is or has been professionally involved
- Previous contact with service and outcome
- Details of known protective factors
- any relevant history, i.e. family, life events,
developmental factors
Supervision
• What do you want to get from supervision?
• How do you go about getting it?
Ongoing
•
•
•
•
•
Engagement with services
Therapy
Monitoring
Dynamic safety plan
Liaison
What will you be taking away?
• What are the most important points you will
take away from this?
• What steps will you take to talk about the
training to the rest of your team?
Questions and Feedback