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Helping young people who self-harm

Paul Watson
Team Leader for School Nursing
West and Breckland

Self-harm is most common among 15-19 year olds but can affect children as young as 11. How should school nurses best approach caring for young people who self-harm?

The National Institute for Health and Clinical Excellence (NICE) describes self-harm as "Self-poisoning or injury, irrespective of the apparent purpose of the act".1

This subject is often the school nurse's 'bread and butter' work, wrapped up in other issues that present at the door.
Self-harm is not usually an attempt at committing suicide, but a way of expressing deep emotional feelings, such as low self-esteem. It can also be a way to cope with traumatic events, or situations, such as the death of a loved one, or an abusive relationship and it must be remembered that self-harming is not an illness, but rather an expression of personal distress.1

School nurses are one of the few groups of professionals who can influence the population's health before habits become ingrained and are generally in a unique and often isolated position when it comes to dealing with the needs of children and young people.2 As such, where the school nurse is able to deliver a drop-in at a secondary school they might be a 'lone voice'; or, if lucky, they might be included as part of a pastoral team, made up of school staff and other multidisciplinary team members.

Whatever the case, the school nurse holds an important position within the school community, offering confidential (where appropriate) support and advice to pupils.3 Therefore, it is important that they know what to do with this information or young person once they have disclosed their concerns.

Young people who visit the school nurse may experience competing voices. One says, "Why am I so boring, so ordinary? What did I do to deserve this? Why can't I be more popular, talented, attractive, intelligent? What did other people do to deserve all their luck, their happy families? Why can't I have those things?" With this voice nagging away inside, there are young people who long to be different in some way, in any way.4

Dealing with these issues and concerns may take the form of containing them and preventing them progressing into self-harm. Unfortunately, with burning, scratching and cutting becoming a seemingly acceptable behaviour and in fact, almost a cultural norm for many adolescents, self-harm appears to be more prevalent now than ever before, especially for those working with children and adolescents.5

The true irony of self-harm is that when young people present to the school nurse, or are referred as 'self-harming' the problem is generally symptomatic of another issue that they are struggling to deal with. As self-harming has been described as a 'physical expression of emotional distress' young people often feel overwhelmed with unhappy emotions, and they may find that the physical act of hurting themselves makes them feel better.1

This work can be the most rewarding if you are able to establish what the problem is that is causing this to be a symptom, and the results can be a dramatic improvement in the behaviour and the wellbeing of the young person.
Too often, however, it is the young person who visits the drop-in for a seemingly routine or mundane appointment who discloses, once they start to trust you, that they are self-harming (often after the third or fourth visit). These young people will usually try to keep the behaviour a secret from their friends and family. They may injure themselves in places that can be easily hidden by clothing, and will be very careful to hide the damage and scars.1 Many times it will be these visitors who are hiding their situation from friends, family and school, changing their behaviour to be able to mask and disguise their new personal and private behaviours.

Activities like eating disorders, drug misuse or binge drinking to induce illness could be included in their harmful behaviour, as could failed suicide attempts. But, significantly, much self-injury takes place in private in a young person's own room, never coming to the attention of health and social services and frequently kept from parents or carers.6 Often this change in behaviour is simply put down to typical teenage attitudes, allowing the self-harming behaviour to go unnoticed and the young person to start to feel neglected and misunderstood, resulting in a continued and increased negative behaviour pattern.

Self-harm is much more common among girls and teenagers, with research showing that the most common age group is 15-19 year olds; although some children may start to self-harm as young as 11.1 Sadler (2002) reported that cutting with razors, knives and broken glass was often the main method of injury, although burning, hitting walls and jumping from a height were also mentioned.6

As a school nurse seeing these young people it is important to be aware not only of your own skills and abilities, but also of the position in which you are employed. School nursing staff may say such things as "I've been seeing this young person for five years now, what will they do if I'm not there?" or "If I don't see them every week how will they cope?"

It is very important that all staff are aware of their own abilities and obligations, being aware that continuing to see young people without moving them on emotionally, or referring to a more appropriate service, such as the Child and Adolescent Mental Health Service (CAMHS), can do more harm than good. The physical effects of self-harm can usually be treated with dressings or stitches, but the emotional causes may need a psychological (mental health) assessment and counselling (talking therapy) to deal with the underlying issues.1

Unless the school nurse has specific training in such issues as self-harm, and is employed in a specific role to do further mental health work, they should only be completing the tier one work, referring on to specialist services where necessary.
The young person who is self-harming may feel deep shame and guilt, often confused or worried by their own behaviour. If the school nurse or other professional finds out that a young person is self-harming, they should approach them with care and understanding.1 When this referral process fails and the school nurse 'hangs on' to young people, a dependency may be formed between both parties. The young person may use the sessions as an emotional crutch while at school, and the staff members use the sessions as reinforcement that they are good at their jobs and able to mend all ills, arguing that only they can manage such a heavy caseload and that these young people will only come and talk to them.

It could be argued that the observation and care of children's and young people's mental health is every one's duty. However, it is more important to remember that staff should only engage with the young person to complete the appropriate level of work for the job that they are employed, ensuring that, if necessary, they are referred on to a more appropriate service as soon as possible.

It should not be necessary to continue seeing the young person in conjunction with the specialist, but rather step back and let the specialist and the young person work through the issues.

If the specialist service feels that there is a need for joint working then they will make contact, and this can be organised between the school nurse, the specialist service and the young person.

Your comments (terms and conditions apply):

"The number of young people self-harming is alarming and those are the ones I know about in my school community. Referring them on to CAMHS should be the appropriate action to take but they then, if accepted, have to wait up to a year for an assessment. The school nurse in the interim is the only health professional left to support them" - Susan Lindsay, Glasgow