Understanding and responding to young people who self-harm within youth offending services

1. 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

2. Introductions

3. 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 self-harm • To examine how to record and report information about self harm • To examine ongoing management and liaison with services

4. 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

5. 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?

6. 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

7. Types of self-harm • Direct • Suicide attempts • Self-injury (without suicidal intention) • Ambiguous • Indirect • Substance abuse • Easting-disorder • Physical/situational/sexual risk taking

8. Acts of self-harm • Cutting • Hitting/Punching • Burning • Overdosing • Interfering with wound healing • Pinching • Biting • Other

9. Suicide Attempt vs. self-harm(from Walsh, 2008)

11. 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.

12. 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).

13. 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.

14. Suicide in the community • Windfur et al. (2009): Rate of around 3 per 100,000 for children aged 10-19 from 1997-2003, 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).

15. 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’ ?

16. 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’

17. 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.

18. 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.

19. Exercise 3: Risk Factors for Self-harm • What do you think are the risk factors? • Problem not located solely within the individual - important to think systemically

20. Risk factors for self-harm, suicide and offending behaviour

21. Risk Factors

22. Risk factors

23. Risk factors

24. 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

25. 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

26. Coffee Break! • Drink coffee • Eat biscuits • 15 minutes

27. 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.

28. 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?

29. 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

30. 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.

31. 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).

32. 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?

33. 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?

34. 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?

35. 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?

36. 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

37. 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.

38. 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.

39. 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.

40. Role Play! • 10 minute role play, then: Get into groups and choose a case example.

41. LUNCH! • 12.30 – 13.15

42. 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?

43. 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.

44. 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?

45. 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

46. 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.

47. Precipitating • Excluded from school due to assault • Feelings of rejection from peers • Back in school – pressure to manage behaviour • Girlfriend upset on phone

48. Perpetuating: • We’ll draw it out!

49. Protective • Mum • Music • Self-reflection

50. Exercise 6: Group formulation • Focus on the perpetuating/maintaining cycle