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Self-harm

More than 24 000 teenagers are admitted to hospital each year in the UK after deliberately hurting themselves. Most have cut, burned, severely scratched, bitten, scalded or poisoned themselves, or pulled their hair out. Recent research suggests that one in ten teenagers self-harm, so if you're teaching an average sized class, chances are you'll have at least one or two self-harmers in your classroom at any time.

These shocking figures are a troubling indicator of the emotional difficulties many young people experience today. Worse yet, such statistics may not adequately reflect the scale of the problem, as many cases of self-harm are not presented in hospital accident and emergency departments.

In order to begin to offer support to young people who self-harm, it helps to know some background to the issue.

The National Inquiry into Self-Harm
In response to the growing concern about levels of self-harm among teenagers in the UK, the Mental Health Foundation and the Camelot Foundation are running the first UK inquiry into self-harm in young people aged 11 to 25.

This inquiry published its first interim report in September 2004. Alarmingly, it suggests that self-harm among young people is far more prevalent than ever before and that UK rates of self-harm are the highest in Europe.

Defining self-harm
Broadly defined, self-harm refers to the deliberate attempt to physically injure oneself without causing death. The National Inquiry focuses specifically on self-mutilation (e.g. cutting behaviours), self-poisoning, burning, scalding, banging, and hair-pulling.

Although clearly damaging, alcohol and drugs misuse, eating disorders, unsafe sex and other excessively risky behaviour, such as dangerous driving, are not generally classified as self-harm.

The prevalence of self-harm
It's virtually impossible to know exactly how widespread self-harm is among young people in the UK but, judging from the studies that have been done and the data collected so far, it is almost certainly on the increase. Latest figures from the children's charity ChildLine show that during 2002-03, 1 per cent of callers to the helpline (1 122 young people) rang specifically because they were self-harming. Another 2 per cent (2 223) spoke about self-harm to the counsellor even though they rang for a different reason. Of those ringing ChildLine out of concern for a child they think may be self-harming, only 7 per cent rang about a boy while 93 per cent rang about a girl.

What are the risk factors?
There are certain risk factors associated with self-harm which have been somewhat thoroughly studied within adult populations. These include:

A history of self-harm
Unemployment
Alcohol and drug-related problems
A general sense of hopelessness

However, the risk factors are not so well known in teenage or younger populations. Judging from personal testimonies collected by the National Inquiry into Self-Harm, risk factors for self-harm in younger populations seem to involve a number of common themes, including:

Eating disorders
Physical, emotional or psycho-sexual abuse
Depression, paranoia or obsessive-compulsive disorder
Low self-esteem and self-worth
Bullying

ChildLine and other support lines for children believe that unvented emotions such as anger and frustration may often be behind self-harm, which provides an unhealthy but seemingly cathartic outlet for the build-up of these feelings. Other factors that can lead to self-harm may include stress arising from a difficult home environment or family relations or a general sense of having no control over life.

Groups at risk
Young Asian females appear to be at particular risk from self-harm. Young women of all races are at least three or four times more likely than young men to deliberately harm themselves. While this would seem to justify targeting girls for preventative education and support in schools, the male self-harmers should not be overlooked. Also, friends of self-harmers seem to be at increased risk of starting to self-harm — another reason why prevention strategies should be discussed with all students.

It's impossible to predict who in your classes will self-harm. Experts suggest that all populations, across all demographics, are potentially at risk. Perhaps most sobering is the fact that the average age at which self-harm begins is 13.

Understanding self-harm
For most people, the notion of hurting oneself deliberately is a baffling one. Many assume that consciously inflicting injuries on oneself must be a means of seeking attention. Yet those who use self-harm as a way of 'coping' with difficult emotions or situations often deny that it is a cry for help. For some, self-harm is a release that doesn't, or needn't, attract the attention of others. It can be performed in private, dealt with in private and then covered up with clothing. What should be fully understood is that self-harm is not a form of attempted suicide, although research does suggest that those who self-harm are 100 times more likely to go on to commit suicide.

Self-harm can be a way of seeking relief; where many people cope by, say, crying on another person's shoulder, self-harmers also cope by injuring themselves. Many people vent off emotions by participating in extreme, or 'adrenaline sports'. And just as many 'adrenaline junkies' tend to take progressively greater risks in sporting, self-harmers can also take increasingly greater risks. The need for an increasingly intensified experience is a fairly common human trait. In some cases those who repeatedly self-harm can become increasingly tolerant of the pain they cause, therefore needing to inflict ever more dramatic harm on themselves.

Helping a self-harming pupil
It's a good idea to find out if your school has a policy on what to do if a child confides in you that they are self-harming. There are times when a teacher, in the best interests of the student concerned, cannot and should not guarantee confidentiality. A judgement will need to be made in each case, remembering that, while the trust of that child should not be shattered, his or her personal welfare is ultimately at stake.

Children who self-harm require emotional, and sometimes medical, support. Specialist health care providers such as counsellors can offer targeted advice and specific help. While teachers do not have final responsibility for the care of a child who self-harms, there are ways they can help.

Simply being available, whenever possible, to talk to a child who self-harms can make all the difference, as feelings of isolation are often part of the problem. Work with these students in particular on communication skills, and focus on the following:

Let them know that self-harm is very common and that individuals who do it are by no means alone.
Make sure that they know who they can go to in your local area for expert help (see 'Further Information' below).
Some practitioners suggest asking children who self-harm to think about what changes they would like in their lives and environment in order to stop harming themselves.

Practical avoidance techniques
Identifying triggers for self-harm can help students to recognise when they might feel the urge to harm themselves and to take avoiding or distracting action. Many self-harmers have found the following helpful:

Counting backwards can help bring the mind to attention and prevent a self-harm episode. Focusing on the immediate environment and thinking about something they can see, smell, hear, taste and touch is another way of redirecting the mind away from self-harming.
Simple deep breathing techniques can also prove calming and distracting.
Some people who have cut themselves in the past have reported that marking themselves with a red, water-soluble pen rather than drawing blood or rubbing ice (for a short while) in the place where they have the urge to cut can help them avoid self-harm. If the urge itself cannot be eradicated, the goal should be to minimise the harm done.
Encourage known self-harmers to be wary of making bad decisions when in a frenzy of emotion. Pausing to think before taking action or succumbing to a knee-jerk response to events is sound advice for all students and doesn't single out self-harmers.
Encourage at-risk students to write a list of all the people who can help them and other places they can turn to in times of desperation. These could be friends, family, teachers, support lines such as Childline or the Samaritans, or related websites. Make sure that they write relevant contact details for each item on their support list and that they either keep it with them all the time or keep copies in various accessible places.

Dealing with the aftermath
Unfortunately even your best efforts cannot prevent recurrences of self-harm in all at-risk pupils. Because of this, it is important to help equip self-harmers with knowledge that can help them deal with the consequences of a relapse.

Reiterate the need for cleanliness to avoid infection and other complications. Shallow or superficial cuts should be cleaned using antiseptic and blades should not be reused.
Self-harmers need to know basic first aid, so consider providing all pupils, particularly self-harmers, with details on where they can learn it.
Encourage self-harmers to dial 999 if they are at all concerned about the injuries they have inflicted, and especially if the bleeding looks serious.
Vitamin E has been shown to reduce the appearance of scars. Creams and lotions containing Vitamin E can be bought from most good health stores.

Anger management and self-affirmation
Spending some classroom time on basic anger management can be invaluable for those whose anger causes them to self-harm, as well as for the whole class. This may be covered in your school's personal, social and health education provision, but explore alternative ways of venting anger such as through vigorous exercise or comic relief. Even using a punching bag or screaming into a pillow, while not the ideal way to channel frustrations, is far preferable to self-harm and may help prevent it.

Exercises that help promote a positive self-image are equally valuable. Keeping a journal or using creative writing as a therapeutic tool can greatly help those who self-harm. Allowing a quiet, calm time in the school day during which children can do this can help them to tease out troubling issues that could, in some, lead to a self-harming episode. Encourage a child at risk of self-harming to make notes about their feelings and emotions and about what's going on in their lives when they feel the urge to harm themselves. As we all need to get to know ourselves and to become self-observant, these are good habits for all students, not just those at risk of self-harming.

Another idea is to get students to record themselves saying something self-affirming and positive. When they feel troubled and vulnerable, playing this positive message back can help them spring back emotionally. If possible, arrange for this recording to be done at school.

Issues for schools
The widespread prevalence in our culture of various forms of body modification, such as cosmetic surgery, body piercing and tattooing, can lead more vulnerable or susceptible children to think that they aren't socially acceptable unless they permanently alter themselves physically. This is an issue that can be addressed across the curriculum without necessarily mentioning self-harm.

A message that is reinforced in the Healthy Living Blueprint, and one which teachers should work into the curriculum wherever possible, is the need for every child to view their body (and mind) as something to care for, support and nurture. At the end of the day, one of the most important lessons teachers can convey to their students is the importance of physical, mental and emotional health throughout life.

Further information
There are many websites that can offer both you and your pupils expert help and advice on dealing with the issue of self-harm. A search for self-harm on any reliable search engine will prove fruitful, but these websites are particularly good starting points:

For further information about the National Inquiry visit: www.selfharmUK.org
ChildLine: www.childline.org.uk
Mind: www.mind.org.uk
National Children's Bureau: www.selfharm.org.uk
National Self-Harm Network: www.nshn.co.uk
Young Minds: for professionals www.youngminds.org.uk/professionals/, for parents www.youngminds.org.uk/parents/, for young people www.youngminds.org.uk/young people/index.php

In addition, help and support can be found from:

GP surgeries
NHS Direct: 0845 4647, www.nhsdirect.nhs.uk
Childline: 0800 1111
Samaritans: 08457 909090
Parentline Plus: 0808 800 2222
Saneline (for those experiencing mental health problems): 08457 678 000

Therapeutic Storywriting: A practical guide to developing emotional literacy in primary schools, by Trisha Waters (published by David Fulton Publishers), offers teachers guidance on using creative writing as a therapeutic tool in the classroom.

BBC coverage: You can find articles about the progress and findings of the National Inquiry into Self-Harm on the BBC news website.

This article was commissioned by TeacherNet's editorial team, independently of DCSF policy teams.