Mid and south Essex (MSE) Self-harm and Suicide prevention Programme

December 2021 (Edition 1)

Disclaimer

This document has been developed for clinicians, professionals, and allied health professionals.

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1. Aim of the toolkit.

2. What is self-harm?

3. Why do people self-harm and who is likely to be at risk?

4. Spotting the signs of self-harm .

Things to look out for

5. Self-help and helping

5a. Self-help.

5b Pathway of recommended actions for responding to self-harm.

5c. How can I support someone who has self-harmed?

5d. Assessing risk.

5f. Talking to someone who is self-harming – some conversation prompts .

5g. Dos and don’ts of talking to someone about Self-harm.

6. Talking to someone who is self-harming – some possible distraction/coping strategies.

7. Other factors to consider.

8. Advice and referrals for support.

9. Useful information and contacts.

9a Other useful resources/references.

1. Aim of the toolkit

Following the successful roll-out of the existing children’s self-harm management toolkit for educational settings across Southend, Essex, and Thurrock, a workstream in the Wave 3 Suicide Prevention Plan (NHSE MSE) focusing on Self-Harm prevention, felt it important to develop a toolkit to be used for adults. Two focus groups were held to gain insights from key stakeholders, provider partners and experts by experience and development, took place through a content review group tasked with developing this information.

The focus of this toolkit is on spotting the signs of self-harm and how to respond to it, as well as raising awareness of self-harm and where to find support. This toolkit is aimed at any adult community (age 17 years upwards) with a neurotypical presentation. It has not been possible to include the specialism needed for self-harm management within the neurodiverse community, this would need to be scoped by the wider suicide agenda.

Although this toolkit includes information around responding to self-harm, in the event of a medical emergency, please call 999, or 111 (option 2) if you feel mental health support is needed

2. What is self-harm?

The term “self-harm” or “self-injury” is used to describe a wide range of behaviours. Self-harm is often understood to be a physical response to an emotional pain. It can be seen as an intentional act of damaging or injuring one’s body, irrespective of apparent motivation though is usually a way of expressing or coping with overwhelming emotional distress. Some more well-known forms of self-harm include cutting, burning or pinching, but there are many forms of self-harm, including drug and alcohol abuse, putting oneself at risk of harm or struggling with eating difficulties. Not all forms of self-harm can be seen as this can sometimes be hidden. Though some people who have self-harmed are at higher risk of suicide, many of those who self-harm do not want to end their lives.²

3. Why do people self-harm and who is likely to be at risk?

There are a range of different reasons and functions why people self-harm. Some common reasons include:

To deal with distressing experiences and difficult emotions.

Self-harm can occur at times when a person feels overwhelmed, exposed, anxious, stressed, angry, unable to cope and/or unable to express themselves. Self-harm can lead to feelings of relief, calmness and of being in control. Some people self-harm to deal with feeling unreal, numb, isolated, or disconnected. Self-harm in these circumstances may lead to feelings of being more real and able to cope in the short term. Some self-harm because physical pain seems more real and therefore easier to deal with than emotional pain.

To enlist help or concern

For some self-harm is a way of expressing distress non-verbally. Self-harm should not be assumed to be “attention seeking behaviour”, however superficial it appears. It’s almost always a sign that something is wrong and needs to be taken seriously. Avoid making judgements or assumptions about why someone has self-harmed.

A response to the distress caused by some intrusive thoughts

The reasons can also change over time and will not be the same for everybody.

There are many possible causes of emotional distress. It’s often a build-up of many smaller things that leads people to think about self-harm.

Some examples include:

being bullied
pressure at school/college/university or work
family arguments or relationship problems
money worries
low self-esteem
struggling with stress, anxiety or depression
personal concerns related to gender, sexuality or identify, for example about being treated differently, being accepted, or understood
grief after bereavement or loss
physical or sexual abuse
being in contact with the criminal justice system
experiencing complex mental health difficulties that sometimes cause impulsive behaviour or difficulty controlling emotions, often due to past trauma

Although there is evidence of a link between suicide, suicidal thoughts and people who have previously self-harmed, not everyone who self-harms wants to end their life. Some people describe their self-harm as a way of staying alive by responding to or coping with severe emotional distress; the self-harm stops them from becoming so overwhelmed that they make an attempt on their life.

It’s important to find the right support or treatment to help deal with the underlying cause in a less harmful way.

Content adapted from:

https://www.nhs.uk/mental-health/feelings-symptoms-behaviours/behaviours/self-harm/why-people-self-harm/

Brown B, Nutt L, Beavis J, Bird K, Moore V. Understanding and responding to children and young people who self-harm A guide for practitioners Cambridgeshire and Peterborough NHS foundation trust (Feb 2009)

Who self-harms?

We have the potential to self-harm in some way or form throughout our lifetimes, and this can look like many different things, such as punching a wall when we are angry or misusing alcohol.

Below are some risk factors which may mean people are more at risk of self-harm or self-injury, particularly if they have a number of risk factors. Those with some of the protective factors listed may be less at risk of self-harm. However, someone who self-harms may not have any of these risk factors and may self-harm despite having protective factors.

Personal characteristics

Risk factors

Low self esteem
Poor coping, communication or problem-solving skills
Mental distress, difficulty or illness, e.g., anxiety/depression
Alcohol/substance misuse
Impulsivity
Stress or worries about school, work or peers
History of similar behaviour in the past
Past or current experience of abuse
Feeling isolated
Recent bereavement or loss
Worries about being accepted for who they’re (e.g., sexuality/gender identity)
Chronic illness/disability
Racial discrimination and/or abuse

Protective factors

Healthy self-esteem
Higher ability/attainment
Good coping skills
Positive work-life balance
Secure attachment to significant other
Resilience to manage everyday stress
Ability and knowledge of where to seek support when needed

Features of the immediate context

Risk factors

Access to means of causing self-harm
Being alone
Social exclusion
Alcohol and drugs
Previous self-harming

Protective factors

Access to social support
Social inclusion

Family Factors

Risk factors

Family members who self-harm
Family conflict
Separation and divorce
Parenting difficulties
Single parent family
Parental/partner illness
Parental/partner alcohol/drug misuse
Sexual/physical/emotional abuse or neglect
Unemployment/poverty/low socio-economic status
Debt
Housing insecurity
Domestic abuse and violence
Pressure from family to achieve at school/work unreasonable expectations

Protective factors

Supportive relationship
Harmonious family relationships
Low level of material or social hardship
Good role models within family and friends

Peer group

Risk factors

Arguments with friends
Bullying
Friends who self-harm
Loneliness/social isolation

Protective factors

Stable and secure friendship group

Wider culture and community

Risk factors

Minority status
Challenges in relation to race, culture or religion
Problems with acceptance of sexual orientation or identity
Coping with a disability and or long-term condition
Media portrayals of self-harm or suicide which may lead to emulation by vulnerable people

Adapted from: Hertfordshire Children’s Trust Partnership: Self-harm and suicidal behaviour guide for staff working with children and young people, 2010.

4. Spotting the signs of self-harm

Self-harm may begin in response to a range of issues (see risk factors mentioned previously) including:

Family relationship difficulties
Difficulties with peer relationships e.g., break-up of relationship
Bullying

Self-harm behaviour in other people (contagion effect)
Self-harm portrayed or reported in the media
Difficult times of the year e.g., anniversaries that serves as trigger
Trouble in school/college/university, work or with the police
Feeling under pressure from families or peers to conform/achieve
Exam pressure in students
Financial pressures
Times of change e.g., parental separation/divorce/relationship change/parenting
Self-managing mental health conditions using over the counter medication

Things to look out for:

It may be hard to know if someone is self-harming as there may not be any warning signs. However, some changes in behaviour that could occur include:

Changes in eating/sleeping habits, weight or appearance
Increased isolation from friends/family
Changes in activity and mood e.g., more aggressive or less engaged than usual
Lowering of achievement in work/studies
Talking about self-harming or suicide
Drug or alcohol abuse
Expressing feelings of failure, uselessness or loss of hope
Giving away possessions
Signs of physical injury that are out of the ordinary
Risk taking behaviour
Significant changes in dress e.g., covering up, bio-oils, very dense tattoos.

Of note, the relevance of individual signs and risk factors may vary according to the age of the person.

Northamptonshire Children & Young People’s Service Hospital and Outreach Education Northamptonshire Toolkit for supporting children and young people presenting with Self-Harming Behaviours, or Intent to Self-Harm, Northamptonshire County Council, Nene CCG, Northamptonshire Healthcare NHS Foundation Trust, NHS Corby CCG, LGSS, Northamptonshire Young Healthy Minds Partnership (2014).

Oxfordshire Adolescent self-harm forum – Self-Harm: Guidance for Staff within school and residential settings in Oxfordshire (last revised January 2016)

5. Self-help and helping

This section is extracted from distrACT self help resource to offer clinicians something they can print and out and offer to clients.

Self-Harm: Self Help App – distrACT – Quick and discreet access to information and advice about self-harm and suicidal thoughts (https://www.nhs.uk/nhs-app/)

5a. Self-help:

Do you want to stop hurting yourself? Learn about self-harm and how you can feel better without harming yourself.

What is self-harm?

Self-harm can be a way of dealing with deep distress and emotional pain. It may help you express feelings you can’t put into words, distract you from your life, or release emotional pain. Afterwards, you may feel some relief — at least for a little while. But then the painful feelings return, and you feel the urge to hurt yourself again.

Self-harm includes anything you do to intentionally injure yourself. Some of the more common ways include:

Cutting or severely scratching your skin
Burning or scalding yourself
Hitting yourself or banging your head
Punching things or throwing your body against walls and hard objects
Sticking objects into your skin
Intentionally preventing wounds from healing
Swallowing poisonous substances or inappropriate objects

Self-harm can sometimes include less obvious ways of hurting yourself or putting yourself in danger, such as driving recklessly, abusing alcohol, taking too many drugs, or having risky sex. Regardless of how you self-harm, injuring yourself might feel like the only way you know how to:

Cope with feelings like sadness, self-loathing, emptiness, guilt, and rage
Express feelings you can’t put into words or release the pain and tension you feel inside
Feel in control, relieve guilt, or punish yourself
Distract yourself from overwhelming emotions or difficult life circumstances
Make you feel alive, or simply feel something, instead of feeling numb

But it’s important to know that there is help available if you want to stop. You can learn other ways to cope with everything that’s going on inside without having to hurt yourself.

What some who self-harm say about their actions and feelings:

“It puts a punctuation mark on what I’m feeling on the inside!”

“It’s a way to have control over my body because I can’t control anything else in my life.”

“I usually feel like I have a black hole in the pit of my stomach, at least if I feel pain it’s better than feeling nothing.”

“I feel relieved and less anxious after I cut. The emotional pain slowly slips away into the physical pain.”

Consequences of cutting and self-harm

The relief that comes from cutting or self-harming is only temporary.

Relief from cutting or self-harm is short lived and may be followed by followed by other feelings like shame and guilt. Meanwhile, it could keep you from learning more effective strategies for feeling better.

Keeping the secret of self-harm is difficult and lonely. Maybe you feel ashamed or maybe you just think that no one would understand. But hiding who you are and what you feel is a heavy burden. Ultimately, the secrecy and guilt affect your relationships with friends and family members and how you feel about yourself.

You can hurt yourself badly, even if you don’t mean to. It’s easy to end up with an infected wound or misjudge the depth of a cut, especially if you’re also using drugs or alcohol.

Self-harming can stop you looking for alternative coping strategies. Learning other ways to deal with emotional pain could help some people to reduce or stop self-harming, reducing the risk of other linked health concerns such as major depression, substance misuse, or suicide.

Self-harm can become addictive. It might start as an impulsive thing, or something you do to feel more in control, but it can become a more compulsive behaviour that is difficult to stop. It can become habitual, or the first thing you turn to when things get difficult. People will often turn to their usual habits as ways of coping, and this can leave us feeling that we have no other options. Developing healthier strategies gives us more options for more effective habits of coping.

The bottom line is that self-harming may be a short-term option, but it’s unlikely to help with the issues that made you want to hurt yourself in the first place. Even though it might feel difficult sometimes, with the right support, it may be possible to stop self-harming. No matter how lonely, worthless, or trapped you may be feeling right now, there are other, more effective ways to cope with difficult emotions to discover that can help you overcome the underlying issues that drive your self-harm.

Positive ways to stop self-harming:

Tip 1: Confide in someone

If you’re ready to get help for self-harm, the first step is to confide in another person. It can be scary to talk about the very thing you have worked so hard to hide, but it can also be a huge relief to finally let go of your secret and share what you’re going through.

Deciding whom you can trust with such personal information can be difficult. Choose someone who isn’t going to gossip or try to take control of your recovery. Ask yourself who in your life makes you feel accepted and supported. It could be a friend, colleague or relative. You don’t necessarily have to choose someone you are close to. Sometimes it’s easier to start by talking to someone you respect, such as a tutor, mentor, religious leader, counsellor, your GP, a mental health professional, or someone on a crisis line or at the Samaritans – someone you feel has a little more distance from the situation and won’t find it as difficult to be objective.

When talking about self-harming:

Focus on your feelings. Instead of sharing detailed accounts of your self-harm behavior focus on the feelings or situations that lead to it. This can help the person you’re confiding in better understand where you’re coming from. It also helps to let the person know why you’re telling them. Do you want help or advice from them? Do you simply want another person to know so you can let go of the secret?

Communicate in whatever way you feel most comfortable. If you’re too nervous to talk in person, consider starting off the conversation with an email, text, or letter (although it’s important to eventually follow-up with a face-to-face conversation). Don’t feel pressured into sharing things you’re not ready to talk about. You don’t have to show the person your injuries or answer any questions you don’t feel comfortable answering.

Give the person time to process what you tell them. As difficult as it is for you to open up, it may also be difficult for the person you tell, especially if it’s a close friend or family member. Sometimes, you may not like the way the person reacts. Try to remember that reactions such as shock, anger, and fear come out of concern for you. Let the person know that what you’re sharing may be a shock to them, but you’re looking for help – ask to continue the conversation another time if the other person feels distressed or you’re interrupted. It may help to show this article to the person you choose to tell. The better they understand self-harm, the better able they’ll be to support you.

Talking about self-harm can be very stressful and bring up a lot of emotions. Don’t be discouraged if the situation feels worse for a short time right after sharing your secret. It’s uncomfortable to confront and change long-standing habits. But once you get past these initial challenges, you’ll start to feel better.

Tip 2: Identify your triggers

Understanding what triggers you to self-harm is a vital step towards recovery. If you can figure out what purpose your self-injury serves, you can learn other ways to get those needs met – which in turn can reduce your desire to hurt yourself. Self-harm is most often a way of dealing with emotional pain. What feelings make you want to cut or hurt yourself? Sadness? Anxiety? Anger? Loneliness? Shame? Emptiness?

If you’re having a hard time pinpointing the feelings that trigger your urge to self-harm, you may need to work on your emotional awareness. Emotional awareness means knowing what you are feeling and why. It’s the ability to identify and express what you are feeling from moment to moment and to understand the connection between your feelings and your actions. Feelings are important pieces of information that our bodies give to us, but they do not have to result in actions like cutting or self-harming.

The idea of paying attention to your feelings rather than numbing them or releasing them through self-harm may sound frightening. You may be afraid that you’ll get overwhelmed or be stuck with the pain. But the truth is that emotions quickly come and go if you let them. If you don’t try to fight, judge, or beat yourself up over the feeling, you’ll find that it soon fades, replaced by another emotion. It’s only when you obsess over the feeling that it persists.

Tip 3: Try new coping techniques

Self-harm is your way of dealing with unpleasant feelings and difficult situations. If you’re going to stop, you need to have alternative ways of coping so you can respond differently when you feel like cutting or hurting yourself.

If you self-harm to express pain and intense emotions, you could:

Paint, draw, or scribble on a big piece of paper with red ink or paint
Start a journal in which to express your feelings
Compose a poem or song to say what you feel
Write down any negative feelings and then rip the paper up

If you self-harm to calm and soothe yourself, you could take five minutes to capture things that make you feel calm or soothed. Having a list of things you can turn to can be really helpful at moment when things feel overwhelming.

Some examples might include:

Take a bath or hot shower
Pet or cuddle with a dog or cat
Wrap yourself in a warm blanket
Massage your neck, hands, and feet
Listen to calming music

If you’re self-harm because you feel disconnected or numb, you could:

Call a friend (you don’t have to talk about self-harm)
Take a cold shower
Hold an ice cube in the crook of your arm or leg
Chew something with a very strong taste, like chili peppers, peppermint, or a grapefruit peel
Go online to a self-help website, chat room, or message board

If you’re self-harm to release tension or vent anger, you could:

Exercise vigorously – run, dance, jump rope, or hit a punching bag
Punch a cushion or mattress or scream into your pillow
Squeeze a stress ball or squish Play-Doh or clay
Rip something up (sheets of paper, a magazine)
Make some noise (play an instrument, bang on pots and pans)

If you are really feeling the urge to harm, some temporary substitutes that might help in the moment:

Use a red marker pen to draw on your skin where you might usually cut.
Rub ice cubes over your skin where you might usually cut.
Place rubber bands on your wrists, arms, or legs, and snap them instead of cutting.

How to tell someone about self-harm

It can be difficult to know how to talk to your friends, family or a health professional about self-harm. But many people feel more supported and less alone after talking to someone.

Tips to help you tell someone about self-harm

find someone you can trust – such as a close friend, family member, trained volunteer, health or other professionals
decide on the right time or place to talk to someone – it may feel easier to write something down, talk online or call and practise what you want to say first
let the person know that what you’re sharing may be a shock to them, but you’re looking for help – ask to continue the conversation another time if the other person feels distressed or you’re interrupted
try to talk honestly and openly – be clear about how you’re feeling, why you’re asking for help and things they may be able to do
let the other person ask questions – but do not feel you have to answer them all right now
decide if you want to show the other person any injuries or scars – if you’re talking to a health professional they may want to check if you need treatment

https://www.nhs.uk/mental-health/feelings-symptoms-behaviours/behaviours/self-harm/how-tell-someone-about-self-harm/

Self-harm: Good practice guidelines for staff:

Work with the person: listen and accept them and their self-harm
Find ways of dealing with your own feelings about self-harm, whether through clinical supervision or teamwork
Do not make stopping self-harm a goal of treatment
Do not withhold treatment or care as a condition of stopping self-harm
Provide good physical and nursing care for wounds
Encourage people to learn alternative coping strategies that give them a sense of control over managing their distress.
Develop a safety plan where necessary
Learn from people with lived experience – through training and information

https://www.mentalhealth.org.uk/sites/default/files/suicide-self-harm.pdf

5b Pathway of recommended actions for responding to self-harm

Discover or informed about self-harm / suspected self-harm

Step one

Deal with medical requirements

Actions:

Is urgent medical attention required? (e.g., heavy bleeding/ overdose/ unconscious/ suicidal?)
If urgent medical attention required, call 999
Administer first aid where required by appropriately trained personnel. Self-inflicted injuries should be treated with first aid as per the organisation policy
Keep calm and be reassuring

Step two

Talk to person

Actions:

Talk to the individual to gather information (see prompt questions and information about self-harm on pages 11-13)
Explain confidentiality (see toolkit on page 10)
Check-in with individual to see if they have spoken to anyone about their self-harm before e.g., GP/counselling services
Where individual is known to social care or mental health providers, encourage them to talk about this to existing community support

Step three

Seek advice or referral from an Emotional Wellbeing or Mental Health services (if required)

Actions:

If required, seek advice from an adult mental health provider (see page 28)
Advice and referrals can be discussed with a GP or the Adult Mental Health Wellbeing Team – see page 28
The out of hours and weekend Crisis Support Service can be found on page 28

Step four

Continue conversation, log incident, and agree next steps

Actions:

If your organisation has an Incident Log or designated safeguarding lead informed them of incident
Ask the individual what help they want/what they would find helpful
Discuss best course of action with individual
Consider, where appropriate, speaking to the individual about what they find helps them cope with difficult emotions
Continue talking to individual; it may be useful to share resources for additional support and information with them (see useful resources and coping strategies)
Where appropriate, follow safeguarding procedures

5c. How can I support someone who has self-harmed?

The most important thing is to be there for someone, and to listen. Don’t be scared to make mistakes; the thing people normally need the most is emotional connection.
You may have spotted someone’s self-harm rather than them telling you about it. The person you’re talking to could be feeling vulnerable, with feelings of guilt, shame, and isolation.

Here are some tips for having that first conversation

Stay calm. You might feel angry that someone you care about is hurting their own body but reacting with anger can shut the conversation down. That person you care about needs your kindness right now.
Acknowledge their emotions. Self-harm is a sign of serious emotional distress. You can ask open questions about their feelings. These can be as simple as ‘How are you feeling?’ or ‘What are you feeling?’. Remember, this is about them expressing their emotions. You might feel you need to urgently understand why they’re doing it, but it’s usually best to give them time and space to talk in their own words.
Show care and concern. Focusing on people’s emotional distress can help people feel cared for and heard. We know that caring relationships are key to helping people who self-harm.
Be non-judgmental. There is a lot of stigma around self-harm. People can feel apologetic and embarrassed, which can add to their distress and make them less likely to speak about it. Let the person in your life know they don’t need to be apologetic or say sorry to you. You’re there to listen and support them to find a way through.

If you are unsure on how to start the conversation, we have some suggestions on how to help someone open up about their feelings, including tips on how to become a better listener.

Supporting someone in the longer term

Here are some tips on how you can give ongoing support to someone in your life who is self-harming.

You don’t need to have all the answers. People often don’t want you to solve their problems when they open up. They want someone who can be understanding and won’t be judgemental. You might not feel like you’re doing enough by just listening, but it’s the most important thing you can do.
Remind people of coping strategies. In times of heightened emotional distress, people can get caught up in the present. It can help to gently remind someone what’s worked in the past and how it might help now.
Have patience. People who have self-harmed have told us that it helps when supporters don’t expect them to stop self-harm immediately and permanently. Recognise it could take some time for them to feel better.
Help them access further support. It can be hard to reach out to support from a GP (usually the first port of call for getting help from the NHS with mental health), or other local sources of support. You can give them a helping hand, for example by offering to be there with them when they make a phone call, or to go along to their appointment with them. Of course, if you’re supporting a young person as a parent or a teacher then your role in ensuring they get the support they need from their GP and/or school/college/university is particularly important, and this process will be more hands-on.

https://www.samaritans.org/how-we-can-help/if-youre-worried-about-someone-else/how-can-i-support-someone-who-has-self-harmed/

5d. Assessing risk

According to Prof Nav Kapur’s (et al) research into the effectiveness of risk assessment in self-harm prevention, it has come to light that most frequently used risk scales are not suitable to predict outcomes successfully. The importance of the therapeutic relationship in developing an individualised Support Plan cannot be overstated.

A multicentre study on self-harm is currently looking at the importance of safety plans and the effectiveness of Biopsychosocial Assessments. NICE guidelines are currently being reviewed in line with this research.

See below National Suicide Prevention Alliance Workshop – Self-harm during COVID-1919:

https://www.nspa.org.uk/resources/webinar-self-harm-during-covid-19/#webinar

The role of frontline professionals:

Every individual must be treated in an open minded and compassionate manner, with a non-judgemental and supportive approach. Self‑harm is, in essence, a means of communicating distress, and the task of all professionals is to help the person reveal more about the underlying issues. People who self‑harm may feel shame or embarrassment and staff need to validate their distress and assure them that help is available. Asking about self‑harm does not increase the likelihood of suicide, and indeed it’s much more likely to lead to a reduction in suicidal risk.

The following might be helpful tips:

take all self‑harm seriously and listen carefully, in a calm and compassionate way
take a validating and non-judgemental approach
help the person to identify their own coping strategies and support network
offer information about support services
ask permission to talk to family members/friends and
offer appropriate support to family and friends as necessary.

Try to avoid the following:

reacting with strong or negative emotions
becoming irritated with your client/patient
using terms such as ‘manipulative’ or ‘attention seeking’
becoming frustrated and
focusing too much on the self‑harm itself, rather than the underlying issues.

Accuracy of risk scales for predicting repeat self-harm and suicide: a multicentre, population-level cohort study using routine clinical data – Sarah Steeg, Leah Quinlivan, Rebecca Nowland, Robert Carroll, Deborah Casey, Caroline Clements, Jayne Cooper, Linda Davies, Duleeka Knipe, Jennifer Ness, Rory C. O’Connor, Keith Hawton, David Gunnell & Nav Kapur – BMC Psychiatry volume 18, Article number: 113 (2018)

Safety planning:

In developing a safety plan, it might comprise of:

Individualised strategies/activities to instil hope
Calming/distracting activities
Restriction of access to common means of suicide
Contacts for social and crisis support

Please consult the Risk management guidelines within your professional setting.

https://stayingsafe.net/home

https://www.getselfhelp.co.uk/docs/SafetyPlan.pdf

https://stayingsafe.net/sites/default/files/BlankSafetyPlan.pdf

5e. Confidentiality and information sharing and having mental capacity means being able to make and communicate your own decisions. Someone may lack mental capacity if they can’t: understand information about a particular decision and this would need to be considered when engaging with vulnerable adults. The Mental Capacity Act (2005) applies to people aged 16 and over. A person must be assumed to have mental capacity unless it’s established that he/she lacks mental capacity. Refer to Essex Safeguarding Adults Board – Mental Capacity Act and Deprivation of Liberty Safeguards (www.essexsab.org.uk) and please seek guidance from your safeguarding lead within your organisation if a mental capacity assessment is required.
Safety always takes priority over confidentiality; do not make promises about confidentiality you cannot keep.
The conversation can consider what action the person can take to minimise risk e.g., talking to a positive friend, counselling, speaking to a school nurse and/or parent(s)
There should be a clear explanation about what is going to happen and why, and the choices available to the individual

It’s helpful to consult the Southend, Essex, and Thurrock Adult Safeguarding Guidelines if unsure around safeguarding concerns. For people aged 18 and over refer to Essex Safeguarding Adults Board – Reporting Concerns (essexsab.org.uk) For young people, refer to Concerns about the welfare of a child (escb.co.uk)

Ensure transparent communication

It’s essential to maintain clear communication with the individual throughout all interactions explaining clearly what has been done, who has been told and next steps to be taken, all of which should be decided in collaboration with the person as much as is possible. This should take into consideration the age and understanding of the individual.

5f. Talking to someone who is self-harming – some conversation prompts

Every person is an individual and their experience of self-harm is going to be unique. Talking about self-harm is not easy, however the below prompts give some suggested phrases for guiding the conversation. The language, wording, choice of questions asked and general approach to the conversation may need to be adjusted according to the age and understanding, mental capacity and special needs of the individual. The level of detail asked may need to be adjusted according to the individual situation and this may take place across several conversations.

Confidentiality

Possible prompt questions

“I appreciate that you may tell me this in confidence, but it’s important that I let you know that your safety will always be more important than confidentiality. If I am sufficiently worried that you may be feeling unsafe or at risk of hurting yourself, part of my job is to let other people who can help you know what’s going on. BUT I will always have that discussion with you before and let you know what the options are so that we can make these decisions together”

Starting the conversation/ establishing rapport

Possible prompt questions

“Let’s see how we can work this out together. I may not have the skills to give you the help you need, but we can find that help for you together if you would like”

Use active listening e.g. “Can I just check with you that I have understood that correctly?”

The nature of the self-harm

Possible prompt questions

“Where on your body do you typically self-harm?”

“What sort of self-harm are you doing?”

“What are you using to self-harm?”

“Have you ever hurt yourself more than you meant to?”

“What do you do to care for the wounds?”

“Have your wounds ever become infected?”

“Have you ever seen a doctor because you were worried about a wound?”

Reasons for self-harm

Possible prompt questions

“I wonder if anything specific has happened to make you feel like this or whether there are several things that are going on at the moment?”, e.g., peer relationships; bullying; exam pressure; difficulties at home; romantic relationship breakup; substance misuse; abuse

Coping strategies and support

Possible prompt questions

“Is there anything that you find helpful to distract you when you are feeling like self-harming? Perhaps listening to music, playing on your phone, texting a friend, spending time with your family… reading, going for a walk etc.”

“I can see that things feel very difficult for you at the moment – and I am glad that you have felt able to talk to me. Is there anyone else that you have found helpful to talk to before? Is there anyone else that you think maybe good to talk to? How would you feel about letting them know what’s going on for you at the moment?”

“How could we make things easier for you at school?”

“What feels like it’s causing you the most stress at the moment?”

“What do you think would be most helpful?”

Speaking to parents/family/partners (where appropriate)

Possible prompt questions

‘I understand that it feels really hard to think about telling your important others, but I am concerned about your safety and this is important – would it help if we did this together? Do you have any thoughts about what could make it easier to talk to your loved ones” (please consider the adult’s right to confidentiality)

Ongoing support

Possible prompt questions

“Why don’t we write down what we have agreed as a plan together… then you have a copy that you can look at if you need to remind yourself about anything. Sometimes when you are feeling low or really want to self-harm it’s difficult to remember the things that you have put in place- this can help remind you….”

5g. Dos and don’ts of talking to someone about Self-harm

Do

Make time. React calmly without anger or judgement – talk honestly about the effect their self-harm may have but in a way that shows compassion. Talking will not increase the chance that the person will self-harm but not talking about it may make them feel unheard or alone
Listen to what is being said and check your understanding (see for examples of conversation prompts under ‘starting the conversation’)
Respond with concern rather than anxiety or distaste
Be interested in them as a person not just as someone who self-harms. Help them to think about their self-harm not as a shameful secret but as a problem to be sorted out together.
Find out how they’re feeling – are there ups and downs?
Are there underlying difficulties e.g., bullying, difficulties in peer relationships, conflict in intimate relationships?
Ask about coping strategies – when are they most likely to self-harm? What have they found helpful in distracting them?
Ensure that the individual is given the opportunity to direct the conversation, express their thoughts about self-harm and be involved in jointly agreeing plans for keeping safe and for further support
Act appropriately in line with policy of confidentiality – inform person first before informing others.

Don’t

Don’t tell them to stop self-harming or give them an ultimatum. Don’t expect them to stop overnight – it’s difficult and takes time, effort
Do not ignore self-harm however superficial it may seem to you, or assume someone else is already helping them
Do not make judgements or promises you can’t keep
Don’t make yourself responsible for their self-harm or become the person who is supposed to stop them
Don’t assume they want to stop self-harming. The person may simply want to reflect on it or learn ways to cover it up or limit it. (The Red Cross used to supply a trainer to Hockley when it was a Women’s Prison to teach cosmetic techniques for example)

6. Talking to someone who is self-harming – some possible distraction/coping strategies

Replacing self-harm with safer coping strategies can be a helpful way of responding to difficult feelings. Coping strategies are based on personal preference, whatever works for the individual is best for them. Talking to the person about what coping strategies work for them may be useful (see conversation prompts above). Different strategies may work for different individuals and may require time to become effective. Some strategies that may be helpful include:

Topic: Calming/stress relief/sadness and fear

Examples of activities

Going for a walk, looking at things and listening to sounds
Create something: drawing, writing, music, cooking, sculpture, crafts
Wrap a blanket around you
Going to a public place, away from the house
Keeping a diary or weblog (the child/young person should consider how to protect themselves online)
Watching TV or a movie
Getting in touch with a friend/Tell someone how you feel
Spend time with an animal
Listening to soothing music
Having a relaxing bath
Massage your hands
Breathing exercises
Plan an activity or trip e.g., volunteering, cinema, park

Topic: Releasing or managing emotions e.g., frustration and anger

Examples of activities

Clenching an ice cube in the hand until it melts
Shout and dance
Shake
Snapping an elastic band against the wrist
Drawing on the skin with a red pen or red paint instead of cutting
Sports or physical exercise, kick a football against a wall, go for a run.
Using a punch bag/pillows or other soft object
Listening to or creating loud music
Tearing up newspaper
Repetitive counting or writing

Topic: Restlessness/feeling need to control

Examples of activities

Write lists or a letter saying everything you are feeling, then tear it up
Tidy up/declutter
Take some exercise e.g., walking, sports, gardening, bike ride
Weed a garden
Clench then relax your muscles
Sing or shout loudly

Topic: Feeling shame

Examples of activities

Write a list of achievements of which you are proud, or times when you’ve felt good about yourself
Practice positive affirmations
Think about something good that happened this week, or a challenge that you faced – no matter how small it seems
Try to only spend time with people who support you and treat you kindly
Recognise when you are trying to be perfect and accept that making mistakes is part of being human
Remind yourself that there are reasons for how you behave – it’s not because you are ‘bad’.

The above coping strategies are compiled from a literature review carried out on this topic and are excerpts based on the following sources:

Harmless, Coping Strategies, viewed (2017) available at http://www.harmless.org.uk/ourResources/copingStrategies

Mind website

University of Oxford(2017), Coping with Self-harm: A Guide for Parents and Carers, accessed at https:/www.psych.ox.ac.uk/research/csr/research-projects-1/coping-with-self-harm-brochure_final_copyright.pdf viewed (2017)

Wester, K. and Trepal, H. (2005), Working With Clients Who Self-Injure: Providing Alternatives, Journal of College Counselling, Vol. 8, Iss. 2, p. 180-189.

Royal College of Psychiatrist Alternatives to self-harm and distraction techniques: Better services for People who self-harm, available at www.rcpsych.ac.uk/auditSelfHarm.htm (accessed 21/8/17)

7. Other factors to consider

What does ‘safe-harm’ mean?

Your clinician or mental health support provider may discuss ‘Safe harm’ or ‘harm minimisation’ with you. This is when someone self-harms in a safer manner e.g., using clean blades with advice not to share blades.[6] Though this is a recognised concept it should only be introduced/discussed with a person by an experienced clinician or mental health specialist.

Does this toolkit apply to individuals with neuro-diverse presentations and disabilities?

Where young people or adult with neuro-diverse difficulties or disability are self-harming the advice in this toolkit will likely need to be adjusted according to the individual. In addition to the possible reasons for self-harm listed earlier, there may be other reasons some people with neuro-diverse difficulties and disability may self-harm. For example, some people with severe learning disabilities may self-harm as a way of expressing pain from an underlying medical problem e.g., pain from an ear infection may be expressed by hitting the ear. [7]

It’s difficult to cover the broad range of individual needs and disabilities in this toolkit however generally speaking, where the person with neuro-diverse needs and disability is self-harming, you should consider seeking medical advice to look at the individuals holistically in developing a support plan.

Self-care

You may find it difficult or upsetting when discussing issues related to self-harm with someone. It’s important to look after yourself and seek help and support where necessary.

If you’re a professional, you should not work beyond your limitations, and always seek appropriate support or supervision. Where you wish to improve skills, knowledge, and confidence with regards to helping people who self-harm, further training is recommended.

8. Advice and referrals for support

Crisis support:

MH 24-7 community crisis response and care

Anyone in need can dial 111 at any time and select the option for mental health crisis (option 2).

Callers will be connected to trained staff who can provide timely and appropriate support and advice.

The service is for people aged 18 and over and aims to ensure those in need of support can access it quickly when they need it most.

The Crisis 24-7 Service will have the option to refer callers to one of our three Sanctuaries in mid and south Essex footprint
Face-to-face Emergency Assessments will be arranged within 4 hours and Urgent assessments within 24 hours.
The Sanctuaries will operate 6pm – 1am 7 days a week. They will also have an outreach programme delivered as follows:
- SE Sanctuary – 7 days a week (10am -6pm or 11am – 7pm depending on demand)
- SW Sanctuary – 5 days a week (9am – 5pm)
- Mid Sanctuary – 5 days a week (9am – 5pm)

The crisis service does not replace 999. Anyone in mental health crisis who requires serious or life-threatening emergency mental or physical care, should dial 999 immediately.

The crisis phone line is for people aged 18 and over. Anyone under the age of 18 or family members of anyone under the age of 18 in crisis, should call the Emotional Wellbeing and Mental Health Service on 0300 555 1201 (North East London NHS Foundation Trust).

Signposting to mental health pathways in mid & south Essex

A mental health crisis is different for everyone. The causes are different. How people feel is different. How people act is different. If you have a sense of being overwhelmed, being unable to cope and lacking control, then please seek help from someone as soon as you can. For more severe mental health needs, you should speak to your GP first. They may then refer you to a specialist mental health team if required. In some GP practices in mid & south Essex we have mental health practitioners who can be accessed for support and help.

If you are suffering from depression, anxiety, panic, post-traumatic stress disorder, excessive worry, or low mood, the NHS Improving Access to Psychological Therapies (IAPT) initiative in mid & south Essex offers free and confidential talking therapy and practical support for adults with these common mental health problems.

You can self-refer and do not need to see your GP first. This service is provided by the following providers in mid & south Essex:

VitaMinds provides support to adults 16-years and over, who are registered with a Basildon, Brentwood, Billericay & Wickford GP. VitaMinds is a FREE service and you don’t need to visit a GP to get help – the fastest way to get support is by simply clicking the Self Refer button or calling on 01268 977 171
Health in Mind is provided by Hertfordshire Partnership University NHS Foundation Trust in partnership with Mid and North Essex Mind and Chelmsford Counselling Foundation for anyone registered with a GP in mid Essex. You can also call the service on 01376 308704 or pick up a self-referral form from your GP surgery or asking your GP to make a direct referral.
Inclusion Thurrock offers a free psychological therapies service for adults 18+ registered with a GP in Thurrock. You do not need to be referred by a GP but can self-refer online or by calling 01375 898680.
Therapy For You offers psychological therapies service for anyone registered with a GP in Castle Point, Rayleigh, Rochford or Southend. You do not need to be referred by a GP but can self-refer into the service. Simply call 01268739128.

9. Useful information and contacts

Staff should be aware that when generally searching about self-harm online, some sites that come up may be pro self-harming. Therefore, care is required with online sites. The resources below are recommended for further help and resources:

Hub of Hope

Stay Alive App

Motivated Minds

CALM

Harmless

NHS Choices: Information and signposting to support services for those who self-harm.

Samaritans: A national charity aimed at providing emotional support to anyone in emotional distress. TEL. 116 123 (freephone 24-hour helpline).

Papyrus: A national UK charity aimed at the prevention of young suicide.0800 068 41 41

Self-Injury support

Childline: Trained counsellors who can talk to anyone aged under 19 about any issue they’re going through.

Rethink

National Self-harm Network Forum

Selfharm UK

Family Lives: A charity which supports parents with all aspects of family life

The Wish Centre: A charity which provides advice and online support for young people to support recovery from self-harm, violence, abuse and neglect.

Essex – Social care contact

Thurrock – Social care contact

Southend – Social care contact

Young Minds (including parents helpline)

Renew Counselling

Counselling Directory

BACP find a therapist

Find an NHS psychological therapies service (IAPT)

CBT Register

UK Council for Psychotherapy find a therapist