Responding to self-harm and suicidal behaviour in the school setting

Transcription

1 Responding to self-harm and suicidal behaviour in the school setting Lydia Senediak Clinical Psychologist

2 Suicide and self-harm Risk Factors Mental health issues Psychosocial risks - personal - family-based - interpersonal - socially-based Demographic and physical risks

3 Suicide and self-harm Protective Factors Strong family and peer relationships Higher IQ Personal skills - Coping cognitive style; sense of humour; ; good help-seeking Involvement in activities Sense of focus on future Spirituality/ faith Minimal family history of MH problems

4 Deliberate self-harm

5 Self-harm occurs on a continuum Body alterations Indirect self-harm Failure to care for self Direct self-injury {e.g. piercing/ tattooing} {e.g. smoking} {e.g. eating disorders, reckless behaviour} {e.g. cutting; burning, breaking bones, etc.}

6 Which young people?... No such thing as a typical young person who self-harms Most parents are unaware at first

7 The new generation of self-harmers Onset is often linked to the DSH of friends (contagion) Sometimes appear to be functioning well emotionally and socially For many, DSH will cease after 6 month 2 year period

8 Frequency of self-harm in young people De Leo and Heller (2004) Gold Coast: Year sample (n=3757) 6.2% met criteria for DSH in past 12 months. Far more prevalent in females (11% of the females; 1.6% of the males) Lifetime history of DSH was reported by 12% Main methods: cutting (59%); overdosing with medication (29%) Most do not seek help before or after. Those who do, usually consult friends

9 Other community-based studies Ross and Heath (2002) 13.9% life time prevalence of DSH Muehlenkamp and Gutierrez (2004) 15.9% life time prevalence of DSH

10 So how frequent is it?... Approx. 1 in 11 to 1 in 15 young people between the ages of 12 and 25 years will engage in deliberate self-harm in their lifetime. Studies indicate that the frequency is increasing.

11 Gender differences Girls significantly more likely to engage in cutting and self-poisoning Boys significantly more likely to engage in deliberate recklessness and self-battery Patton et al, 1997

12 Of the group that harmed themselves.. 32% reported at least 2 previous incidents of self-harm 36% reported their self-harm to others (i.e. 64% kept it a secret) 6% thought death was probable 6% indicated a serious attempt to end their lives Patton et al 1997

13 Age of onset. Majority begin between 12 and 15 years of age Approx % of the self-harmers say they started in the 6 th Grade or earlier (Ross and Heath, 2002) More recently, age of onset appears to be falling toward younger age (Fox and Hawton,, 2004)

14 The CASE study (2004) n= 30,437 youth under 20y., across 7 countries M = 3 indep.. factors/ F = 8 indep.. factors For males: family member who had attempted suicide or deliberately harmed themselves (all 7 countries); drug use (5 countries) For females: family member who had attempted suicide or deliberately harmed themselves (all 7 countries); a close friend who had attempted suicide or deliberately harmed themselves (all 7 countries); low self-image (6 countries)

15 Friends deliberate self harm Fights with Friends Schoolwork Problems DSH No DSH Fights with Parents PERCENTAGE OF LIFE EVENTS & PROBLEMS IN PREVIOUS YEAR SOURCE: Keely, H. (2005) Irish component of the CASE study [Total n = 3,900 (15 17 y. olds); DSH n = 333] [females > males all categories]

16 Reasons for self-injury: Broad themes Affect regulation ( to( cope ) Communication Group membership Control/ Punishment

17 Signs to look for DSH Overly secretive behaviour (e.g. when changing clothes; unusual amounts of time in the bathroom) Excessive isolation Refusal to participate in activities that might reveal DSH (e.g. swimming) Inappropriate clothing for the weather (e.g. constantly wearing long sleeves, etc.) Blood stained clothing Unexplained scars, bruising, cuts (or bandages/ covers) Possession (hoarding) of implements (e.g. razors, lighters, knives, etc.)

18 Considerations. Pattern of wounds Site on the body Use of a tool Place of DSH/ Social context Distorted thinking

19 Clusters/ Contagion Young people with self-injurious behaviour are more likely to be friends with others who also engage in self-injury If contagion becomes concern in a group setting (e.g. in boarding), brief exclusion of the key figure(s) ) is sometimes recommended. Return to the setting should be facilitated as soon as the young person s s behaviour has settled

20 Polarization Need to avoid us and them mentally Vulnerable groups especially at risk of: Rejection Ridicule

21 Responses from the School community Supportive Accepting Flexible Tolerant Strengths focus Critical Accepting More judgmental Less flexible Intolerant Problem focus

22 Self-injury as an adaptive mechanism Need to look at the meaning of self- harm for the young person Does it serve a function in their lives?

23 Responding to young people who self-harm Helpful Unhelpful

24 What young people say: It s s kept me going.. Without it I may not be here I I feel relief at the time and then really bad; like I ve I failed again, I m I m crap; I don t t want to stop but I hate the feeling afterward It works. I get to feel something real. When everything else seems so crazy and out of control, it s s the only thing I can control

25 Suicidal Behaviour

26 Indicators of greater suicide risk: Be more concerned if: Marked problems with sleep/appetite and social withdrawal Increased risk-taking behaviour Giving away possessions/ rituals around goodbyes Sudden increase in alcohol/ substance use Direct/Indirect comments containing hopelessness/ suicidal thoughts Hallucinations or delusions (extra concern)

27 Frequency: Australia Each year over 400 young people (aged years) die from suicide After motor vehicle accidents, suicide is proportionally the leading cause of death in this age group Suicidal ideation occurs in between 28-40% of young people Approximately 5-8% of young people report making a suicide attempt in any one year Most common method for young males in hanging; for females is hanging and overdose

28 Gender differences In year olds, for every female suicide there are 4.4 male suicides Females make many more suicide attempts

29 When? Most youth suicide attempts are prompted by disruption to meaningful relationships, often in relation to conflict with parents 40% of young people who attempt suicide report no clear precipitant A third did not alter their normal activities appreciably in the hours preceding the attempt Most attempts occur in the evening, at the place of residence

30 Clinically, what does this mean?

31 Engaging relevant staff I m m a class teacher -I m m already too busy - I m m not trained in this area - What can I do anyway?

32 - Observe - Communicate - Modify - Follow-up - Show concern

33 The priorities.. step: Is to facilitate a link to getting clinical help: (i.e. CLINICAL ASSESSMENT) 1 st step: 2 nd step: Get help: so the student can learn to manage the symptoms (school/ external help) Inform/ guide parents Restrict possible contagion to other students

34 Introduce coping strategies Monitoring (triggers, mood diaries, mood scales) Calming (music, reading, meditation) Distracting (movies, cooking, ) Exercising (walking, sport, punching bag) Reflecting (journaling, art, poetry, feel- good bag) Talking (to someone: family, friend, Lifeline)

35 Help me if you can I m I m feeling down.... How do you seek help from your friends without bringing them down too?...

36 Helping the self- harming person (not condoning it but helping them stay safe) Harm minimization Talk about it to someone they trust Work out the pattern (place/ time/ situation). Try to avoid triggers Use distraction (e.g. the 15 minute game ; Freeze-frame ) Try alternatives first (SEE LIST) Keep first aid kit + emergency contacts close Set limits: only enough to relieve THIS distress Avoid major arteries and organs Don t t share implements/ keep implements & wounds clean

37 Avoid Taking on too much Being TOO flexible and adaptable - allow for natural consequences to occur Thinking that they re faking it Making fun of them

38 Pastoral care staff and Integrated whole-school approach PREVENTION Teaching and support staff Student body [Boarding] Role of parents

39 Possible implications for School Counsellors Conveying information to those who need to know When treatment is refused? When treatment is compromised? When to discharge (i.e. complete treatment)?

40 Case study: Tim (history) Tim (aged 16 y.: Year 10) Intact family/ eldest of 3 children/ parents experiencing marital diffic Poor transition to High School; always felt different & alienated Current friends on fringe of the grade?? (some of these students are known to have their own MH problems). Tim is described as having major mood swings (home + school) Reports bullying in Year 8, which he feels was never fully addressed

41 - average academically, grades falling recently+++ - increasing -ve attitude in class and during sport - self -burning commenced 4 months ago when distressed re: relationship breakup Prev. Hx DSH: [1 x report of breaking arm with hammer in Y.8: blamed rugby injury] - Strengths: : music (plays trumpet)/ loves ancient history - Parents v. caring though a little intrusive/ anxious.

42 Tim - current presentation Referred by parents through Tutor Tim went home on Monday after grade peer called him an emo Secured a rope and pills with intent to suicide. Ax at A & E discharged (School to F/U) Tim s s mood remains flat; appears disconnected. Some suicidal ideation current (low intent) Believes his friends are the only ones who care ambivalent about counselling

43 One day Tim tells you.. He and his best friend (student at another local school) often chat on-line about feeling low/ life s s problems. With further questioning, it seems both boys have been self-harm (cutting/ burning) as way of managing overwhelming negative feelings. Tim says that he has only intermittent thoughts of suicide himself.

44 Where to from here. What immediate steps? Involving who??? Immediate Next few days weeks Broader concerns/ follow-up issues?...

45 Impacts on staff Anger Distress Helplessness Anxiety-Worry Frustration Sadness Dismissal/ Minimizing Rejection Nurturing-Protection

46 Counter-transference transference: resistance to getting well Clinical dilemmas world view appears in contrast to that of most School cultures e.g. rebellion against health-seeking [ sporty[ sporty ], domain e.g. withdrawn; poor motivation to participate/ achieve helplessness of the therapist reaction of others (Staff, parents, other students) fragmentation within the School community resource heavy possibilities of CONTAGION

47 Caution! Be clear about your own boundaries Try not to be seduced by: - the fear of losing them - the lure of rescue - the perceived negative response of others towards the identified student - internal and external pressure (administration; colleagues; parents; other students)

48 Caring for yourself Consider your own emotional well- being (psychological health, relationships, stress) Make sure you have your own supports available Watch your own physical well-being

49 Some resources (DSH) Treating Self-Injury: a Practical Guide by Barent W. Walsh

50 Thank you Best wishes for the future!