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The recent National Institute for Clinical Excellence guidelines on self-harm said thousands of patients were being offered inadequate care by the NHS ­ Margo Fyfe outlines the important role GPs have

One in 10 15- to 16-year-olds self-harms1. A proportion will be trying it as a 'fashion trend', a way of getting in with the crowd, but there are individuals for whom it is a genuine way of coping with life.

House et a · 2 claim self-harm is a major growing problem in the UK. Others argue that the higher profile self-harm has gained in recent years means more young people are seeking help.

The number of women who self-harm outnumbers men 2:1 but in adolescence this is more like 3:1. It is most common in females aged 15-19 with young males peaking between 25 and 29.

There is, of course, no exclusion of younger or older age groups. There is little evidence to suggest a specific social class is more likely to self-harm. The most common methods remain overdosing closely followed by cutting (mainly of the arms and legs) and burning.

Self-cutting behaviour is often repetitive and can become addictive over a prolonged period3, the withdrawal feelings being alleviated by the action of self-harm.

Following an episode of self-harm, the person will often report feeling lonely and isolated3.

There is some suggestion that self-harming may eventually lead to suicide, but it may also be the beginning of a maladaptive coping strategy. The correct addressing of the behaviour when it is first brought to our attention is therefore paramount.

There are many factors associated with self-harming behaviours some of which are listed in the box on the left.

First contact

The first time a young person asks for professional help, it is most often from their GP.

The approach is usually as a result of pressure from concerned friends, family or teachers to seek help rather than continue to indulge in a behaviour that our society views as undesirable.

Although it is widely recognised that early intervention with these vulnerable young people is in their interest it is not always easy to achieve. For a variety of reasons they may not ask for, or desire, assistance. Such reasons include:

· being too scared to ask because of past experience of negative responses

· being ashamed of what they do.

Displaying any negative feelings at

what the person has done to their

body can halt any further effort by the individual to confront their self-harm.

Some advice on how to handle such an initial consultation follows.

Possible first response

· Look at the young person's injury.

· Do not convey critical judgment.

· Ask what they would like from you ­ do not make assumptions.

· If they are having particular difficulty putting what they want to say into words, offer to let them write it down for you.

· Ask if they wish to reduce or stop the self-harm.

· Ask when they began to harm themselves (look for triggers).

· Ask if they remember how they coped before they self-harmed.

· Ask how they feel about their scars (is there comfort or discomfort from the reminders of their self-harming actions?).

· Ask about past responses to their

self-harm and how they felt and dealt with this.

Let them give you information at their own pace ­ do not press for all the details.

As the professional the young person has turned to for help you must go through the steps of risk assessment and mental health assessment so you can decide whether to refer them to the local community mental health team. This is in line with the new self-harm guidelines4.

Control

The suggestions above are starting points only but they put the element of control back to the young person so that they can go at their pace and not feel unimportant or pushed aside. The issue of control is very important as often their self-harming behaviour is the only thing they feel they have any control over. Remember if they are asking for help then they may not feel they have their actions under control any more. Avoid telling them 'how lucky they are' to have good things in their life, or comparing them with those less fortunate.

Margo Fyfe is nursing officer for the Mental Welfare Commission for Scotland, and former leader of the Glasgow adolescent deliberate self-harm service

Factors associated with

young people and self-harm

·Peer/family relationship problems

·Boyfriend/girlfriend problems

·School/college/university problems

·Bullying

·Parental alcohol/substance misuse

·Young person's alcohol/ substance misuse

·Experience (past or present) of abuse

·Mental illness in the young person

·Parental mental health problems

·Parental unemployment/young person's unemployment

Treating self-harm

More robust research is needed to establish conclusive data on what works.

The quarterly findings of the National Inquiry into Young People and Self Harm found young people who self-harm will engage in the following interventions:

·Brief problem-solving therapy

·Conventional psychiatric care

on a more intensive basis, such as outreach specialist clinics, longer-term contact, specialist clinics.

·Drug treatment (in instances of evidence of depression or other psychiatric illness)

Useful websites

www.nice.org.uk

www.selfharmuk.org

www.nshn.co.uk

References

1 Hawton K et al (2002). Deliberate self-harm in adolescents: self-report survey in Schools in England. BMJ. 325,7374,1207-11

2 House A et al (1998). Deliberate self-harm. Effective Health Care. 4,1,2-9

3 Lynn F (1998). The Pain of Rejection. Nursing Times, July 8, vol 94, No27

4 National Institute for Clinical Excellence (2004). Self-harm: the short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care

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