How can we support children and young people who self-harm?
What is meant by self-harm, what are the signs and risk factors associated with it, and how can we respond to and support children, young people and their families?
The World Health Organisation has predicted that mental illness is set to become the biggest public health challenge of the 21st century. The latest government mental health strategy document referring to the treatment and support for young people who self-harm acknowledges the seriousness of the problem in the UK. While not every young person who self-harms has a mental illness nevertheless, it is a risk factor.
How serious is the problem?
A recent UK study that used reliable national databases to look at trends in reports of self-harm among young people aged 10 to 19 since 2001 found annual rates of self-harm of 37 per 10,000 girls and 12.3 per 10,000 boys. There were several other notable findings, including a 68% rise in rates of self-harm among girls aged 13 to 16 since 2011, something that wasn't seen in boys or any other age group in girls. Many cases involved drugs or alcohol, and the study also highlighted a social divide – finding higher rates in more deprived areas.
How do you know if someone you know self-harms?
It may seem an odd question to some, but a few people aren't sure if what they do is ‘really’ self-injury. At the right time try asking these questions or at least think about them yourself as the professional concerned:
- Do they deliberately cause physical harm to themselves to the extent of causing tissue damage (breaking the skin, bruising, leaving marks that last for more than an hour)?
- Do they cause this harm to themselves as a way of dealing with unpleasant or overwhelming emotions, thoughts, or situations (including dissociation)?
- If the self-harm is not compulsive, do they often think about self-harm even when they are relatively calm and not doing it at the moment?
If they answer yes to one and two, they are a self-harmer. If they answer yes to three, they are most likely a repetitive self-harmer. The way they choose to hurt themselves could be cutting, hitting, burning, scratching, skin-picking, banging their head, breaking bones, not letting wounds heal, among others. They might do several of these. How they injure themselves isn't as important as recognising that they do and what it means in their life.
Why do young people self-harm?
Fundamentally, self-harm is a sign that a young person is experiencing overwhelming emotional distress. So self-harm is in fact a symptom rather than the core problem. Self-harming may help the young person to feel in control or help them to manage their feelings, but equally the young person may not understand why they self-harm.
If a young person causes physical harm to their body in order to deal with overwhelming feelings, they have nothing to be ashamed of. It's important as a professional to acknowledge that this is their way of keeping themselves alive and maintaining psychological integrity with the only tool they have right now. It's a crude and ultimately self-destructive tool, but it works; they get relief from the overwhelming pain/fear/anxiety in their life. The prospect of giving it up may be unthinkable, which makes sense; because they may not realise that self-harm isn't the only or even best coping method around.
What can be done?
Practitioners who initially come into contact with a young person who has self-harmed are crucial not just in terms of immediate physical aid but in setting the scene for how well the young person copes and moves on. Unfortunately myths and misconceptions about self-harm abound, and these can contribute to poor care and negative attitudes from family, practitioners and other people a young person may turn to for support. Recent paired publications from Research in Practice on this topic – Understanding self-harm among children and adolescents: Frontline Briefing and Responding to self-harm among children and adolescents: Suggestions for practice – offer practical guidance and create the basis for informed, reflective, confident practice which will make a difference to children, young people and their families. This guidance emphasises that listening attentively to a young person who is disclosing their self-harming and responding calmly with respect, compassion and sensitivity is the first step in providing the right support. This kind of response can also make all the difference to whether or not a young person goes on to seek and access support.
Trying to understand why a young person has harmed themselves is vital – so for example exploring the stressors in the young person’s life that may ‘trigger’ their self-harm and focusing on dealing with these underlying problems is a good place to start. Self-harming can indicate that somewhere along the line, a young person didn't learn good ways of coping with overwhelming feelings. Keep all your options open in terms of developing hypotheses and assessment processes. Professionals need to work very hard to assure a young person that they are not worthless, bad or sick; rather try to suggest to them that they just never learned positive ways to deal with their feelings.
With the right support, for many people who self-harm there comes a moment when they realise that change is possible, that they can escape, that things can be different. They begin to believe that other tools do exist and begin figuring out which of these non-self-destructive ways of coping work for them. It is worth remembering that often this ‘right support’ begins with what Sellen-Cole has referred to as a practitioner’s ‘most crucial tool’ – that is, their relationship with the young person.
About the author
Steven Walker has worked for 30 years in social work and child and adolescent mental health, ending his career as Head of Child and Adolescent Mental Health Services (CAMHS) at Anglia Ruskin University. He qualified as a Psychotherapist in 1991 with extensive experience of working directly with families and young people. Steven has published 14 books, 50 scholarly publications and presented his research at ten international conferences. He volunteers with a Youth Charity and is a Sessional Lecturer at the University of Essex.
He is also the author of a book – Responding to Self Harm in Children and Adolescents: A Professionals Guide to Identification, Intervention and Support – which aims to provide a resource for professionals who may encounter situations where concerns are expressed about the behaviour, emotional state, or mental health of a child or young person. This could be in child protection, young offenders, hospital and primary health, family support, long term planning, fostering and adoption, juvenile justice, education, social care, probation, and of course child and adolescent mental health services.
Related Research in Practice resources
Recommended further reading
- A Bright Red Scream: Self-Mutilation and the Language of Pain by Marilee Strong: Penguin USA.
- The Scarred Soul: Understanding and Ending Self-inflicted Violence by Tracy Alderman: New Harbinger Publications.
- Healing the Hurt Within: understand self-injury and self-harm, and heal the emotional wounds by Jan Sutton: How To Books Ltd.
- The Self-harm Help Book by Lois Arnold and Anne Magill: The Basement Project.
- Self-harm: perspectives from personal experience by Louise Roxanne Pembroke: Chipmunkapublishing.
WHO (2009) World Health Day.Geneva, World Health Organisation
Department of Health and Social Care (2011) No Health without Mental Health- a cross governmental outcomes strategy for people of all ages. London, Department of Health
Incidence, clinical management, and mortality risk following self harm among children and adolescents: cohort study in primary care BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j4351 (Published 18 October 2017) Cite this as: BMJ 2017;359:j435
Sellen-Cole, J. (2015). Youth self-harm and suicide awareness: A reflective guide for staff working with children and young people. Hove: Pavilion.
Walker, S. (2012). Responding to Self Harm in Children and Adolescents: A Professionals Guide to Identification, Intervention and Support. London, Jessica Kingsley.
NICE (2004) Self-harm: short-term treatment and management. London, National Institute for Health and Clinical Excellence: https://www.nice.org.uk/guidance/cg16/resources/selfharm-shortterm-treatment-and-management-189900253