Supporting young people who repeatedly self-harm

Barriers and facilitators to training delivery and subsequent implementation of a localised child and adolescent mental health initiative: a qualitative content analysis

BACKGROUND

Ensuring that children and young people (CYP) can obtain mental health support from a broad variety of sources is of upmost importance. This is especially true given the increasing prevalence of mental health difficulties in this population, and the associated challenges with receiving support from specialised healthcare services. Equipping professionals, from a wide range of sectors, with the skills needed to provide this support is a vital starting point. This study explored the experiences of professionals who had participated in CYP mental health training modules that related directly to the local implementation of the THRIVE Framework for System Change in Greater Manchester, UK (GM i-THRIVE) to establish the perceived barriers and facilitators behind the implementation of this training programme.

METHODS

Directed qualitative content analysis of semi-structured interview data from nine CYP-facing professionals was conducted. Both the interview schedule and initial deductive coding strategy were developed using the findings of a systematic literature review by the authors, that was conducted to explore wider CYP mental health training experiences. This methodology was used to establish the presence or absence of these findings within GM i-THRIVE, before generating tailored recommendations for their training programme.

RESULTS

When the interview data were coded and analysed, a strong level of thematic similarity with the authors' review was found. However, we deduced that the emergence of additional themes might reflect the contextual uniqueness of GM i-THRIVE, that is likely to be further compounded by the COVID-19 pandemic. Six recommendations were made for further improvement. These included the facilitation of unstructured peer interaction during training, and ensuring that jargon and key words are fully clarified.

CONCLUSIONS

Methodological limitations, guidance for usage, and potential applications of the study's findings are explored. Whilst the findings were largely akin to those of the review, subtle yet important differences were found. These are likely to reflect the nuances of the training programme discussed, however, we tentatively suggest that our findings are transferable to similar training interventions. This study provides a valuable example of how qualitative evidence syntheses can be used to aid study design and analysis: an underused approach.

The barriers and facilitators to the reporting and recording of self-harm in young people aged 18 and under: a systematic review

BACKGROUND AND AIMS

This systematic review sought to identify, explain and interpret the prominent or recurring themes relating to the barriers and facilitators of reporting and recording of self-harm in young people across different settings, such as the healthcare setting, schools and the criminal justice setting.

METHODS

A search strategy was developed to ensure all relevant literature around the reporting and recording of self-harm in young people was obtained. Literature searches were conducted in six databases and a grey literature search of policy documents and relevant material was also conducted. Due to the range of available literature, both quantitative and qualitative methodologies were considered for inclusion.

RESULTS

Following the completion of the literature searches and sifting, nineteen papers were eligible for inclusion. Facilitators to reporting self-harm across the different settings were found to be recognising self-harm behaviours, using passive screening, training and experience, positive communication, and safe, private information sharing. Barriers to reporting self-harm included confidentiality concerns, negative perceptions of young people, communication difficulties, stigma, staff lacking knowledge around self-harm, and a lack of time, money and resources. Facilitators to recording self-harm across the different settings included being open to discussing what is recorded, services working together and co-ordinated help. Barriers to recording self-harm were mainly around stigma, the information being recorded and the ability of staff being able to do so, and their length of professional experience.

CONCLUSION

Following the review of the current evidence, it was apparent that there was still progress to be made to improve the reporting and recording of self-harm in young people, across the different settings. Future work should concentrate on better understanding the facilitators, whilst aiming to ameliorate the barriers.

Negative stance towards treatment in psychosocial assessments: The role of personalised recommendations in promoting acceptance

People presenting to the emergency department with self-harm or thoughts of suicide undergo a psychosocial assessment involving recommendations for e.g. contact with other practitioners, charity helplines or coping strategies. In these assessments, patients frequently adopt a negative stance towards potential recommendations. Analysing 35 video-recorded liaison psychiatry psychosocial assessments from an emergency department in England (2018-2019), we ask how these practitioners transform this negative stance into acceptance. We show that practitioners use three steps to anticipate and address negative stance (1) asking questions about the patient's experience/understanding that help the patient to articulate a negative stance (e.g., "what do you think about that"); (2) accepting or validating the reasons underlying the negative stance (e.g., "that's a very real fear and thought to have"); and (3) showing the patient that their reasons were incorporated in the recommendation (e.g., "it's telephone support if you're a bit more uncomfortable with face to face"). These steps personalise the recommendation based on the patient's specific experiences and understanding. When practitioners followed all three of these steps, the patient moved from a negative stance to acceptance in 84% of cases. When practitioners made a recommendation but did not follow all three steps, the patient moved from a negative stance to acceptance in only 14% of cases. It is not the case that each communication practice works on its own to promote patient acceptance, rather Steps 1 and 2 build on each other sequentially to develop and demonstrate shared understanding of the patient's negative stance. In this way, acceptance and validation play an indispensable role in addressing a patient's concerns about treatment.

Stigma towards non-suicidal self-harm: evaluating a brief educational intervention

BACKGROUND:

health professionals' attitudes towards self-harming behaviour are predominantly negative. Research examining educational interventions to change negative attitudes is limited.

AIMS:

this study aimed to provide an educational intervention for student nurses to change negative attitudes around self-harm.

METHODS:

attitudes around self-harm and mental health in general were assessed through the Self-Harm Antipathy Scale and the Mental Health Attitude Scale. Fifty-five adult nursing students took part in the 45-minute intervention. This included facts and figures, celebrity stories and personal stories regarding self-harm, all intended to increase understanding.

FINDINGS:

after the intervention, attitudes measured by the Self-Harm Antipathy Scale had improved significantly.

CONCLUSION:

patients who self-harm will without doubt continue to experience negative attitudes from health professionals. This study shows an educational intervention can change attitudes towards those who self-harm.

An interpretative phenomenological analysis of young people's self-harm in the context of interpersonal stressors and supports: Parents, peers, and clinical services

RATIONALE

Self-harm in young people is of significant clinical concern. Multiple psychological, social and clinical factors contribute to self-harm, but it remains a poorly understood phenomenon with limited effective treatment options.

OBJECTIVE

To explore young women's experience of self-harm in the context of interpersonal stressors and supports.

METHOD

Fourteen adolescent females (13-18 years) who had self-harmed in the last six months completed semi-structured interviews about self-harm and supports. Interpretative phenomenological analysis was undertaken.

RESULTS

Themes identified were: 1) Arguments and worries about family breakdown; 2) Unhelpful parental response when self-harm discovered and impact on seeking support; 3) Ongoing parental support; 4) Long-term peer victimization/bullying as a backdrop to self-harm; 5) Mutual support and reactive support from friends (and instances of a lack of support); 6) Emotions shaped by others (shame, regret and feeling 'stupid to self-harm'); and 7) 'Empty promises' - feeling personally let down by clinical services. These themes were organised under two broad meta-themes (psychosocial stressors, psychosocial supports). Two additional interconnected meta-themes were identified: Difficulties talking about self-harm and distress; and Impact on help-seeking.

CONCLUSION

Parents and peers play a key role in both precipitating self-harm and in supporting young people who self-harm. The identified themes, and the apparent inter-relationships between them, illustrate the complexity of self-harm experienced in the context of interpersonal difficulties, supports, and emotions. These results have implications for improving support from both informal and clinical sources.

Residential staff responses to adolescent self-harm: The helpful and unhelpful

Adolescent self-harm is prevalent in residential and secure care and is the cause of distress to those harming themselves, to the staff caring for them and for other young people living with them. This article sought service user views on what staff supports were effective and what were counter-productive in order to improve the care offered to young people. Seven young people living in residential or secure care were interviewed. Thematic analysis was used to elicit key themes. Global themes of safety and care were elicited. The young people understood and accepted that the role of staff was to provide these. Within these themes, they noted numerous responses that had both helpful and unhelpful effects, including increased observation, removal of means and extra collaborative support. Service users made numerous recommendations to increase the helpful effects of staff support. Young people provided informed and helpful guidance on how best to care for them. Their views can help mental health professionals and care staff increase their helpful responses making them more effective and less counter-productive. This study is a rare representation of the views of young people in residential and secure care and how to respond to their self-harm behaviour.

A sequence analysis of patterns in self-harm in young people with and without experience of being looked after in care

OBJECTIVES

Young people in the public care system ('looked-after' young people) have high levels of self-harm.

DESIGN

This paper reports the first detailed study of factors leading to self-harm over time in looked-after young people in England, using sequence analyses of the Card Sort Task for Self-harm (CaTS).

METHODS

Young people in care (looked-after group: n = 24; 14-21 years) and young people who had never been in care (contrast group: n = 21; 13-21 years) completed the CaTS, describing sequences of factors leading to their first and most recent episodes of self-harm. Lag sequential analysis determined patterns of significant transitions between factors (thoughts, feelings, behaviours, events) leading to self-harm across 6 months.

RESULTS

Young people in care reported feeling better immediately following their first episode of self-harm. However, fearlessness of death, impulsivity, and access to means were reported most proximal to recent self-harm. Although difficult negative emotions were salient to self-harm sequences in both groups, young people with no experience of being in care reported a greater range of negative emotions and transitions between them. For the contrast group, feelings of depression and sadness were a significant starting point of the self-harm sequence 6 months prior to most recent self-harm.

CONCLUSIONS

Sequences of factors leading to self-harm can change and evolve over time, so regular monitoring and assessment of each self-harm episode are needed. Support around easing and dealing with emotional distress is required. Restricting access to means to carry out potentially fatal self-harm attempts, particularly for the young persons with experience of being in care, is recommended.

PRACTITIONER POINTS

Self-harm (and factors associated with self-harm) can change and evolve over time; assessments need to reflect this. Looked-after young people reported feeling better after first self-harm; fearlessness of death, access to means, and impulsivity were reported as key in recent self-harm. Underlying emotional distress, particularly depression and self-hatred were important in both first and most recent self-harm. Looked-after young people should undergo regular monitoring and assessment of each self-harm episode and access to potentially fatal means should be restricted. The CaTS would have clinical utility as an assessment tool Recruiting participants can be a significant challenge in studies with looked-after children and young people. Future research with larger clinical samples would be valuable.

Response Inhibition, Peer Preference and Victimization, and Self-Harm: Longitudinal Associations in Young Adult Women with and without ADHD

Self-harm (suicidal ideation and attempts; non-suicidal self-injuries behavior) peaks in adolescence and early-adulthood, with rates higher for women than men. Young women with childhood psychiatric diagnoses appear to be at particular risk, yet more remains to be learned about the key predictors or mediators of self-harm outcomes. Our aims were to examine, with respect to self-harm-related outcomes in early adulthood, the predictive validity of childhood response inhibition, a cardinal trait of attention-deficit hyperactivity disorder (ADHD), as well as the potential mediating effects of social preference and peer victimization, ascertained in early adolescence. Participants were an ethnically and socioeconomically diverse sample of 228 girls with and without ADHD, an enriched sample for deficits in response inhibition. Childhood response inhibition (RI) predicted young-adult suicide ideation (SI), suicide attempts (SA), and non-suicidal self-injury (NSSI), over and above full-scale IQ, mother's education, household income, and age. Importantly, teacher-rated social preference in adolescence was a partial mediator of the RI-SI/SA linkages; self-reported peer victimization in adolescence emerged as a significant partial mediator of the RI-NSSI linkage. We discuss implications for conceptual models of self-harm and for needed clinical services designed to detect and reduce self-harm.

Hearing the voices of young people who self-harm: implications for service providers

The incidence of adolescent self-harm and suicidal behaviour has increased globally, with many adolescents repeating the behaviour. While studies indicate that large numbers of adolescents who self-harm do not seek professional help, research focusing on barriers to help seeking from an adolescent perspective is limited. Locally, a rise in reported and unreported rates of self-harm and a number of suspected child suicides prompted the commissioning of a research project to ascertain young people's experiences of help and support for self-harm and how their future needs could be best met. Qualitative research, adopting an interpretive phenomenological analysis, was used to elicit narratives of adolescents engaging in self-harm. Data were collected via 1:1 interviews with seven participants and analysed in two stages: an analysis of each individual narrative, and thematic analysis across the group. Three themes were identified: (i) cutting out the stress; (ii) stepping onto the path of help; and (iii) cutting to the chase. In conclusion, mental health nurses have a vital role in providing knowledge and support to those likely to have initial contact with this vulnerable group and to the wider population, ensuring we more effectively address the increasing use of this risky behaviour among young people.

Young people's views of UK mental health services

AIMS AND METHOD

Adolescence is the period of highest risk for the development of mental illness, but also the age group least likely to seek help from mental health services. We undertook a systematic review of the published literature on the views of young people of mental health services in the UK and a thematic analysis of the findings to explore the reasons behind this to guide those developing services for young people.

RESULTS

Thirty-one studies were identified, which captured the views of 13 605 young people including 625 young people who had experience of mental health services. Positive views to emerge were of qualities of mental health workers and encouraging self-reliance. Negative views were of stigma, lack of information, medicalization of their problems and a lack of continuity of care.

CONCLUSIONS

Young people have consistent views of the positive and negative aspects of mental health services, which could be helpfully incorporated in the design of services. The views of some groups of young people have not been well represented, however, and the views of minority ethnic groups and those who have disengaged from services in particular need to be actively sought.

'Listen to them': Adolescents' views on helping young people who self-injure

Non-suicidal self-injury (NSSI) among adolescents is a significant problem, yet the majority do not seek professional help. Parents and teachers are arguably most in contact with young people, and are critical in identifying and referring adolescent self-injurers. This study explored what adolescents believe parents and teachers can do to help young people who self-injure. A school-based sample of 2637 students (aged 12-18 years) completed a self-report questionnaire. Adolescents believe having non-judgemental parents and teachers to talk to, improved parent-child relationships, referral to professionals, reduced school pressures, and student education, are pivotal to helping young self-injurers. However, many adolescents, particularly those exposed to NSSI, were unsure about whether parents and teachers could do anything to help. These finding have important implications for educational programs that prepare parents and teachers to address adolescent NSSI.

An investigation of the motivations driving the online representation of self-injury: a thematic analysis

The objetive of the study was to identify a) the motivations for communicating about non-suicidal self-injury (NSSI) in a publicly accessible online forum, b) The significance (if any) of the "publicness" of the behavior. Using a Thematic Analysis of 423 text-based posts from an online NSSI forum, 5 motivations for using the site were identified: confessional, marking a turning point, acting as a deterrent, dispelling myths and offering or seeking support. Motivations for using the site differ markedly from motivations for engaging in NSSI and tend to be more outwardly focused. The publicness of the site therefore seems to be significant in terms of bearing witness, providing the opportunity to confront negative stereotypes, and the ability to seek and offer support to like-minded individuals.

Differential profiles of risk of self-harm among clinically referred primary school aged children

Risk of self-harm among clinic referred children aged 6- to 12-years-old was investigated using the recently developed Self-Harm Risk Assessment for Children (SHRAC) instrument which comprises six factors: Affect traits; verbalizing of self-harm; socialization; dissociation; self-directing; and self-appraisal. The SHRAC was completed by the mothers of 125 primary school aged children referred to a University based clinic for psychological assessment. These children were subsequently assigned to one of four groups (non clinical, externalizers, internalizers, and combined internalizers/externalizers). Multivariate analysis of variance with univariate F and Scheffé follow-ups revealed differences in risk of self-harm between the four groups. Overall, individuals with both internalizing (anxiety/withdrawn, anxiety/depressed and somatic complaints) and externalizing (rule-breaking behavior and aggressive behavior) characteristics were more at risk of self-harm. These individuals scored highest across each of the six domains. The findings demonstrate the SHRAC to be a reliable instrument for educational psychologists to use with children they suspect of being at risk of self-harm.

Psychological characteristics, stressful life events and deliberate self-harm: findings from the Child & Adolescent Self-harm in Europe (CASE) Study

There is evidence to suggest that both psychological characteristics and stressful life events are contributory factors in deliberate self-harm among young people. These links, and the possibility of a dose-response relationship between self-harm and both psychological health and life events, were investigated in the context of a seven-country school-based study. Over 30,000, mainly 15 and 16 year olds, completed anonymous questionnaires at secondary schools in Belgium, England, Hungary, Ireland, the Netherlands, Norway and Australia. Pupils were asked to report on thoughts and episodes of self-harm, complete scales on depression and anxiety symptoms, impulsivity and self-esteem and indicate stressful events in their lives. Level and frequency of self-harm was judged according to whether they had thought about harming themselves or reported single or multiple self-harm episodes. Multinomial logistic regression assessed the extent to which psychological characteristics and stressful life events distinguished between adolescents with different self-harm histories. Increased severity of self-harm history was associated with greater depression, anxiety and impulsivity and lower self-esteem and an increased prevalence of all ten life event categories. Female gender, higher impulsivity and experiencing the suicide or self-harm of others, physical or sexual abuse and worries about sexual orientation independently differentiated single-episode self-harmers from adolescents with self-harm thoughts only. Female gender, higher depression, lower self-esteem, experiencing the suicide or self-harm of others, and trouble with the police independently distinguished multiple- from single-episode self-harmers. The findings reinforce the importance of psychological characteristics and stressful life events in adolescent self-harm but nonetheless suggest that some factors are more likely than others to be implicated.

The girl who swallows knives: uncontrollable deliberate self-harm in a teenage girl with borderline personality disorder

The authors describe the case of a now 19-year-old girl who after a traumatic childhood, began to deliberately self-harm at the age of 13, often by cutting her forearms. More recently, however, swallowing inanimate objects has been her method of choice. At the time of writing, she has had over 150 accident and emergency department (A&E) attendances, over 10 gastroscopies and a laparotomy. Knives, razors and six-inch sewing pins have all been removed from her gastrointestinal tract. So far, psychiatrists have been unable to stop her and her risk of accidental death rises every time she deliberately self-harms. The authors include the patient's personal views on her illness and discuss borderline personality disorder as a condition.

Public stigma in health and non-healthcare students: attributions, emotions and willingness to help with adolescent self-harm

BACKGROUND

For people who self-harm, there is growing evidence to suggest that services and treatment outcomes can be adversely affected by healthcare staffs' stigmatising attitudes and behaviours. To date, the empirical literature has tended to focus on the attitudes of experienced healthcare professionals working with adults who self-harm. Additionally, there has been few theory or model-driven studies to help identify what healthcare students think and feel about young people who self-harm.

OBJECTIVES

The aim of the present study was to explore the way healthcare and non-healthcare students think and feel about adolescent self-harm behaviour using Corrigan et al.'s [Corrigan, P.W., Markowitz, F.E., Watson, A., Rowan, D., Kubiak, M.A., 2003. An attribution model of public discrimination towards people with mental illness. Journal of Health and Social Behaviour 44, 162-179] attribution model of public discrimination towards people with mental illness.

DESIGN

The study was a questionnaire-based, cross-sectional, survey that consisted of two hypothetical vignettes.

SETTINGS

Two universities in England, United Kingdom.

PARTICIPANTS

One hundred and eighty-four final-year students, covering health (medicine, nursing, clinical psychology) and non-health care (physics) professions.

METHODS

Students were presented with vignettes describing a young female who self-harms. Attributions of controllability were experimentally manipulated across the vignette conditions and students were asked to complete self-report questionnaires measuring attitudes towards self-harm, familiarity with self-harm and social desirability.

RESULTS

Consistent with the public discrimination model, students who believed that a young person was responsible for their self-harm reported higher feelings of anger towards them. Anger, in turn, was associated with a belief in the manipulatory nature of the self-harm and with less willingness to help. Perceived risk was found to be associated with higher levels of anxiety and increased support for the use of coercive and segregatory strategies to manage self-harming behaviour. Gender and student type were important influences on public stigma, with both men and medical students reporting more negative attitudes towards self-harm.

CONCLUSIONS

This study provides evidence that a number of factors may adversely affect the care and treatment received by young people who self-harm, namely: students' causal attributions, the gender and profession of healthcare students, and familiarity with self-harm behaviour. To improve the effectiveness of service provision and treatment outcomes for people who self-harm, it is important that health care service providers and teaching institutions consider the implications of these factors when developing staff and services, and base interventions on theoretical models of stigma and discrimination.

Help-seeking before and after episodes of self-harm: a descriptive study in school pupils in England

Background

Deliberate self-harm in young people is a cause for concern in many countries. The vast majority of episodes of self-harm do not result in presentation to hospital and relatively little is known about to whom or where adolescents who harm themselves go for help.

Methods

This school-based survey of 5,293 15–16 year olds in the United Kingdom investigated sources of help and barriers to help seeking before and after an episode of self-harm.

Results

Friends (40%) and family (11%) were the main sources of support. Far fewer adolescents had sought help from formal services or health professionals. Barriers to help seeking include perceptions of self-harm as something done on the spur of the moment and therefore not serious or important or to be dwelt upon. Many adolescents felt they should be able to, or could cope on their own and feared that seeking help would create more problems for them and hurt people they cared about or lead to them being labelled as an 'attention seeker'. The decision to seek help was in some cases hampered by not knowing whom to ask for help. Gender and exposure to self-harm in the peer group influenced perceived barriers to help-seeking.

Conclusion

There are both push and pull factors' acting on young people in their understanding of what leads them to want to harm themselves and potential mechanisms for seeking help. The implications for community based prevention programmes are discussed.

Barriers and Facilitators to Children's and Young People's Views Affecting CAMHS Planning and Delivery

The views of children and young people about the mental health services they receive are central to the tenets of recent government health services policymaking. But do changes to service delivery result from research or projects eliciting children's and young people's views? This article presents evidence that changes may well not result and then discusses what prevents or facilitates CAMHS acting on recommendations gained from user views.

Eliciting Children's and Young People's Views of Child and Adolescent Mental Health Services: A Systematic Review of Best Practice

BACKGROUND

  A systematic review of children's and young people's views of Child and Adolescent Mental Health Services (CAMHS) was undertaken to identify the methods used, the 'best practice' methods, and the methods most effective in leading to service changes.

METHOD

  Electronic databases and grey literature were systematically searched. Both authors independently quality-appraised studies using a standard framework. Of 381 studies identified, only 13 were both relevant and of sufficient quality to be included in the review. Interviews, focus groups, brainstorming exercises, and questionnaires were the methods used.

RESULTS

  No study reported a change of practice as a result of hearing children's and young people's views.

Adolescents' views on preventing self-harm. A large community study

BACKGROUND

Deliberate self-harm (DSH) is a major problem in young people in the United Kingdom. The majority of young people who harm themselves do not seek help and therefore community based prevention strategies are important. However little is known about young peoples' views on the prevention of DSH. The aims of this study were to identify what adolescents believe can be done to prevent them from feeling like they want to harm themselves, and to investigate differences in the views held according to gender, ethnic group and previous experiences of self-harm.

METHOD

Pupils in a representative sample of 41 secondary schools in England completed an anonymous, self-report questionnaire including the question "what do you think could be done to help prevent young people from feeling that they want to harm themselves?" Thematic analytic methods were used to categorise responses, which were then also analysed by gender, ethnicity, lifetime history of DSH and lifetime exposure to DSH among friends.

RESULTS

The written responses of 2,954 students aged 15-16 years were analysed. Eleven broad categories of responses were identified covering causes and possible ways of preventing suicidal behaviour in young people, including; the primacy of informal social networks over professional organisations, the importance of confiding stable relationships, the need for structured group activities, and the key role that schools play in young peoples lives. Mental illness was mentioned by only 3% of respondents, although concerns about stigma acted as a barrier to seeking help for some young people. Bullying and serious problems at home were highlighted as psychosocial stressors that need to be addressed.

CONCLUSIONS

The adolescents in this study considered family, friends and school as the main sources of support in preventing suicidal behaviour, and more pertinent than external helping agencies. Enhancing the provision of school-based mental heath programmes and increased youth-orientation in helping services are indicated.