Adolescent self-harm

Welcome to the Australian Prescriber Podcast. Australian Prescriber. Independent, peer-reviewed, and free.

My name is Dr Ashlea Broomfield, and I'm your host for this episode. I'm with Dr Joel King, who is a child and adolescent psychiatrist at the Melbourne Clinic down in Melbourne. Welcome to the podcast today, Joel.

Thanks, Ashlea.

Joel, in your article for Australian Prescriber, you wrote a really interesting piece on adolescent self-harm. I was really interested in nutting out with you the key factors that differentiate self-harm as a behaviour, as opposed to self-harm with suicidal intent.

It's actually a really, really difficult determination. I think one of the things we first have to realise is that many people, adolescents as well as adults, self-harm, but without the intention of ending their life. They sort of tend to do this when they're very overwhelmed with negative feelings, such as shame, guilt, frustration, anger, embarrassment, or loneliness. They don't know what to do about it. Often these feelings are too much, and they don't have great ways of dealing with them.

So, self-harm becomes a way of dealing with it. It can take many forms including scratching with your nails, or cutting with scissors, or a razor, or glass, or punching walls, or head banging or burning. Some people have sort of a few that they use, but they tend to stick to a set that works for them. We're absolutely not sure how or what happens, or why this is the case, but many people report that after self-harming they feel a sense of numbness or maybe calmness, or distraction from their inner pain.

I think what is really hard though, and especially for the busy practitioner, is determining between a situation where there is suicidal intention, and when there is not. There's no easy or well-validated way for doing this, including various risk assessment tools, and that's really unfortunate. So, there are a lot of things, in my practice, when I see a teenager who's self-harmed. I'm trying to, well first of all, assess for major psychiatric disorders such as depression, psychosis or substance use disorders. Because we know that these are associated with increased suicidality.

I'm often trying to see if there are changes in the self-harming behaviour, change in method or the frequency, and this often includes escalating risk. Some teenagers can actually talk about their self-harm. I try to approach this in a non-judgemental way, and I assumed that there must be a good reason for it. I was taught never to ask why. It's pretty simple, because if people knew why they did things, they probably could figure it out a lot quicker and probably wouldn't need to see me.

So, instead I ask questions like, what led to this? Or what stopped you from dot, dot, dot. And then what happened? Sometimes they get stuck, and then I kind of hone it in and try to make it a bit more binary for them, and ask questions like some people harm themselves to numb the pain they feel, but don't actually want to die. Was that the case for you? Sometimes people, particularly teenagers who have problems with verbal expression, find it easier with those sorts of questions.

I'm also very interested in whether they'd been planning on harming themselves for some time or whether it was impulsive, and maybe there was something that went wrong recently, maybe with family or at school with friends. I'm also trying to figure out whether they can project themselves into the future in a meaningful way, or whether they've completely lost hope.

I've had some discussions with patients where I'm actually looking at admitting them to a psychiatric [3.50] unit. But then they tell me they don't want to be admitted because they have an English sac the next day, and then they have band practice, and then there's a friend's 18th birthday. So, those are situations where I'm a lot more comfortable.

Yeah, I tend to agree with you, Joel. This brings me to my next point, in that often a young person is brought in by their family members or caregivers, really distressed about what they found. They may have found a cut or a scar, and are really concerned about what to do about it, and sometimes can be dismissive or talk about it as being histrionic. In my general approach, in those sorts of situations, is to say if someone is doing a behaviour that means as though they're hurting themselves significantly that causes physical disconfiguration or pain, then, yes, this may be an expression of emotional distress and a cry for help, but we need to treat that seriously. This person does need assistance, in terms of managing that distress and helping them to develop safer ways of managing that.

Yeah, I think it's not only families who do it, Ashlea, I think it's also us in the health profession. Certainly working in various hospitals and health services, I've heard this phrase of, "Oh, this is behavioural." I'm thinking to myself, "What does that even mean?" You know, I can't even define that, because behavioural simply means it's an adjective describing behaviour.

So, I think you're right in that people can say, "This is acting out, this is histrionic, or this is behavioural," and just give these sorts of slightly judgemental and really not understanding ways. They're not really going, "What is this about?" But what is driving behaviour, and taking our time to expand on that.

I often think that mental health is often the art of making the simple complex, and the complex simple. In this case, I think it's a situation of this is a behaviour and we have to sort of explode it, and try to really explore the different alternatives for it.

Yeah. What are your little tips for our listeners about the phrases to use with family members or caregivers, or ways to explain this to distressed people around the young person, or the young person themselves?

First of all, dealing with families, it takes a lot of time and a bit of skill. We do actually have to speak to people and the parents and whoever else is in the household, rather than having a sort of an individualistic, "I must see this one person on their own." I think that really, if we have that sort of attitude where we're actually looking at them in the context, family context, the home context, we come up with solutions a lot faster as well.

Sometimes I find that there are issues with parents. It could be that parents are well-intentioned, or, you know, the brother and sister are well-intentioned, or whoever else is in their household, like a grandparent. They're usually well-intentioned and want to help, but they don't know how. This is really frustrating for everyone. They just go, "Why is my teenager doing this? Why is my child doing this? This is illogical, it's wrong, and I don't know what to do about it."

So, their parents are part of the problem or part of the solution. So in any situation, you really should be involving them. A lot of parents want to be part of the solution. I think there's a next question about confidentiality, that often comes up. I deal with this by clearly explaining the limits of confidentiality at the start of assessment. I make this really terrible joke. I just say, "Look, if there's a risk to your safety, to someone else's safety, to my safety, that trumps everything." Most teenagers will politely laugh at my dorky joke.

If it does come up where I have to break confidentiality, say, for example, the teenager is engaging in very deep cutting with significant blood loss each time, and the parents are oblivious to it, I clearly explain why I'm breaking confidentiality, why I'm going to get the parents involved, and how concerned I am that I'm not doing this frivolously, I'm doing this because I really am concerned. Then I ask the teenager how they would prefer me to do it. Would they prefer to be in the room? Or not in the room? And are there things they want me to emphasise? Or not so much emphasise? So, they still are included in the story.

When I get the parents in the room, I emphasise that this isn't anyone's fault. One other thing, is that everyone is trying really hard and takes great courage for a teenager to talk about these things. I have to tell everyone that's great that we can talk about this openly, and that when things are known, they can be managed. The other thing I often emphasise, that I would say, but the great thing is at all of you are here right now and that makes all the difference.

That sort of empowers people. They go "Look, you know, well, this is something, we can do something right now about this." Then I give an explanation of why I think the self-harm is taking place. So, the family realises, "Okay, this is actually a logical behaviour." I also offer to see them again soon to support them, because learning to manage self-harm, both individually and as part of a family, takes time. A lot of our work is really teaching families a different way of being with each other, and this is a start.

I like how you said that it takes time and being up front with that from the beginning. Could you talk our listeners through the traffic light system?

Traffic light systems in healthcare aren't new. A large chunk of risk management in mental health is actually done by the patients and their parents in the home. I just want to make clear, it's not a magic wand or a special pill that gets rid of self-harm. The basic premise is that when self-harm does occur, everyone is really stressed out and has difficulty thinking straight. This really does actually include clinicians sometimes.

In these situations, teenagers are often overwhelmed and unable to produce a coherent description of their emotional state and needs. When you're drafting a traffic light system, you as the clinician talk with the patient and the family and help identify early warning signs towards self-harm. This means trying to figure out what feelings or behaviours occur at green, orange and red, and what the responses should be at each stage.

The teenager should be the one to define what each colour looks like, with everyone else adding their observations. So you might have a teenager who says, "Orange light means that I'm pretty stressed, but I'm not completely overwhelmed." Then mum might say, "Also, I noticed that you tend to be very irritable, and you don't go out with your friends as much, which is really unlike you."

Then we try to figure out what helps the teenager feel less stressed and overwhelmed. So this might involve listening to music on a playlist or going out for a walk or a run. Those things can be really helpful, but it has to be specific to the young person. Then the clinician, with the family and young person, writes or types up the plan, and everyone says, "All right, let's give this a go." Because I emphasise that this is a living document and not set in stone, and you need to stick it then on the fridge, so everyone's literally on the same page and it's very accessible.

So when the teenager says, "I'm orange lighting or I'm red lighting," everyone in the family knows where this document is, and can follow it and understand it as well. It shouldn't be just tucked away in a folder somewhere, that's not the point. If something on the document doesn't work so well, that's okay. Let's revise the document, let's create the version 2.0. Because in the end, the document is just a communication tool, and good communication is always ongoing.

Now I've used the word family and parents a lot. Of course this can involve other people as well. Other caregivers, or if this is happening at school a lot, it's worthwhile getting key members of the school staff involved with the young person, knowing about that as well.

In the article you spoke about different ways that young people may be able to alleviate their distress.

There are a range of distraction or substitution behaviours that you can use. Sane Australia has a good list of these on their website, and includes distraction techniques of calling a friend or wrapping a blanket around you, or making noise with pots and pans, as well as substitution behaviours, such as flicking elastic bands on your wrist or drawing on your arm with a pen, or holding ice cubes. These do cause some form of pain, but are less likely to cause serious damage.

One of my personal favourites is actually doing push-ups, because it's really hard to injure yourself to barely doing them, but you can still get a good build-up of muscle ache. A lot of these techniques can actually be found within the dialectical behavioural therapy framework called DBT framework. The important thing to remember is that everyone is really different when it comes to their sensory preferences and what works for them and what doesn't work.

So, you're doing a bit of trial and error until the patient finds a set of distraction, or substitution behaviours, that sort of work for them. Sometimes a referral to an occupational therapist, who is trained to perform sensory assessments and offer essentially modulation strategies like some of the ones we've mentioned before, can help.

Yeah, and an element of that is the trust.

Yeah, I couldn't agree more. A lot of young people, they feel very, very alone with their emotions, and also their self-harm as well. Certainly the beginnings of really getting moving forward is the trust of understanding, of feeling less alone, with all these difficult feelings.

I wasn't aware of the link between sleep and self-harm until I read your article, and I was just keen for you to give a bit of a summary about the link between sleep and self-harm.

So, sleep is really, really, really important. There is a growing body of evidence which links sleep, or lack of sleep, or problems with sleep, with self-harm. There are two major studies that have sort of looked at this recently. The first study was published in 2014, and this group looked at 9,000 adolescents who completed questionnaires about sleep, mental health, reading, writing difficulties. The outcome was actually a hospital admission due to deliberate self-harm over one decade.

They found that sleep problems are common, and sleep problems in adolescents were associated with a two-fold increase of later admission for self-harm. A different study in Norway, published in the British Journal of Psychiatry in 2015, looked at 10,000 adolescents. Again, sleep problems were significantly associated with self-harm. So, I think that's really quite important. We do need to talk about sleep with teenagers and their parent.

So, I guess the summary of that is to, not just focus on the self-harm as an isolated issue, but look at it in the context of the young person and their entire lifestyle and environment.

Yeah, exactly. We know that there are so many determinants to good physical and mental health, which are often correlated with each other as well. Sleep is one, making sure that we get enough exercise and diet are also real important ones as well. You're right. It's actually a rather general holistic approach that we have to have towards people's mental health.

That's unfortunately all the time we've got for this episode. Thank you so much for coming along, Dr Joel King.

Thanks, Ashlea.

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The views of the hosts and guests on the podcast are their own, and may not represent Australian Prescriber or NPS MedicineWise. I'm Ashlea Broomfield, and thank you for joining us on the Australian Prescriber Podcast.