World Mental Health Day (10 October 2018) is a worldwide initiative dedicated to global mental health education, awareness and advocacy. This year's theme, "Do you see what I see?" challenges perceptions about mental illness in Australia and encourages everyone to look at mental health in a more positive light, in an effort to reduce stigma and make way for more people to seek the help and support they deserve. Part One encourages teachers and students to look at mental health in their schools, and headspace has outlined common indicators of self-harm in schools. Part Two explains the self-harm cycle and how teachers and schools can respond.

While self-harm may be an effective short term coping mechanism for some people, it is likely to increase the person's negative feelings towards themselves, thus serving to exacerbate symptoms and distress.

Self-harm Cycle

Figure 1: Self-harm Cycle (Adapted version out of From Harm to Calm 2012)

The self-harm cycle above illustrates a pattern of negative feelings, which may increase over hours, days or weeks and then be relieved temporarily by self-harm. The negative feelings may begin to build up again, and if the young person does not find other ways to cope, the self-harm may become more frequent or ritualised.

It is important to understand a young person may not be able to ‘give up’ their self-harm until they have new skills or coping strategies. A harm minimisation approach (safety as a priority, hygienic wound care, keeping wounds covered) is best in a school setting. It is important to understand this experience when supporting a young person who is self-harming. Attempts to help a young person stop using self-harm should be done in collaboration with them, supporting and assisting them to find other means of dealing with their distress. Illustrating this cycle and identifying and discussing their self-harm ‘triggers’ can be one way of supporting young people to know where and how they might break the self-harming cycle.

Reduction in self-harm usually will not occur until the underlying issues triggering the emotional distress are addressed. Mental health professionals can advise you on how to support the young person at school and may offer individual therapy where required.

Are Self-harm and Suicide Linked?

The difference between self-harm and a suicide attempt is the intent. In the vast majority of cases, self-harm is a coping mechanism, not a suicide attempt. It may seem counter-intuitive, but in many cases people use self-harm as a way to stay alive rather than end their life.

There is however a relationship between self-harm and suicide that does need to be considered. Sometimes people injure themselves more seriously than they intend to, and this can put their life at risk. Determining the intent behind the self-harm can be particularly difficult in children and young people as they are more likely to act on their feelings without much consideration or planning.

Young people who self-harm are at a much higher risk of attempting suicide at some time in the future than those who don’t self-harm, even if they’re not suicidal at the time. This doesn’t mean they will attempt suicide, but rather that their risk is higher. It is important to encourage anyone who is self-harming to seek help from an appropriately trained mental health professional to address any underlying emotional or mental health problems.

Social Contagion

‘Social contagion’ refers to the influence a student’s self-harming has on others, perhaps by encouraging others to self-harm either directly or indirectly. Students may share experiences directly or via social media. Their need to belong or connect to others may influence vulnerable students to engage in self-harm.

The evidence for social contagion is now emerging. Jacobson and Gould in 2007 found that it is possible that younger adolescents may initiate self-harm for social reasons but maintain it for internal reinforcement.

Self-harm and Disabilities

For children with intellectual disabilities, self-harm is a significant issue due to its high prevalence and persistence. Children with specific genetic syndromes, more severe levels of intellectual disabilities, Autism Spectrum Disorder and impulsive or repetitive behaviours also appear to be at greater risk of demonstrating self-harm. However, that is not to say that self-harm is inevitable for any child with an intellectual disability.

Children with intellectual disabilities may self-harm to:

• communicate pain
• gain sensory stimulation
• experience reinforcing responses of others to their self-harming behaviours (positive and negative reinforcement).

When attempting to reduce the frequency and severity of self-harm and/or potentially eradicate the behaviour in children and young people with disabilities, the following should be considered:

• ensure the child receives a thorough medical examination to rule out any health conditions causing pain or discomfort
• provide the child with a calm, safe environment
• schools, parents and carers should examine the potential influence of their environment, and how their own response to the young person’s self-harming behaviours may be inadvertently reinforcing.

it is important to remember that when it comes to intervention, the safety of the child is paramount.

Treatment of Self-harming Behaviours

There is little firm evidence about agreed upon pharmacological and therapeutic interventions that are directly associated with young people ceasing their use of self-harming behaviours.  Exploring the underlying problems, in an appropriate therapeutic relationship, that have led to the self-harm may help guide the young person to better manage their emotional distress and equip them with more adaptive coping strategies for the future.

A Victorian study (Moran et al 2012) of 1,943 young people, between 15 to 29 years old, examined self-harming behaviour. The results are particularly relevant for schools given the large sample size, the longitudinal nature of the study and the non-clinical population.

The results from this study found that:

• more girls (10%) than boys (6%) reported self-harm.
• of the individuals who participated in the adolescent and young adult phases of the study:
  • 90% did not report self-harm during either phase
  • 7.4% reported self-harm only in adolescence
  • 1.6 % reported self-harm in young adulthood (little difference between sexes at this age)
  • 0.8 % reported self-harm in both age groups
  • adolescent girls reporting self-harm in more than one phase were at especially high risk of self-harm as young adults
  • there was a substantial reduction in the frequency of self-harm during late adolescence.

This study provides some hope for children and young people who are self-harming, knowing that most self-harm is usually resolved in late adolescence to young adulthood.

What Can the School Do?

While clinical treatment will vary according to the circumstances, it is important to build a ‘team around the learner’ involving the school staff, family and mental health services. This collaboration to support the child or young person should ensure clear communication between the involved parties; the identification (and appropriate documentation) of shared goals, and agreed interventions; and the development of an individual learning plan which will increase the young person’s engagement with school and assist to build their resilience.  Regular review and open discussion between all parties, including the child or young person, for example, the sharing of an agreed safety plan, will optimise safety and better promote positive mental health.

Young people who resort to self-harm to manage their emotional distress are usually not able to easily regulate their emotions, nor are they equipped with many positive coping strategies. To be able to reduce the self-harm, they need to build up a toolkit of alternative ways to better manage stress and to deal with their ongoing emotional distress. Schools can encourage greater resilience and healthier coping strategies by providing opportunities for all young people to learn new skills through:

• relaxation
• self expression through creative and visual arts and through music
• breathing techniques and yoga
• peer support groups
• physical exercise and sport activities
• monitoring of diet and nutrition, rest and sleep,
• developing problem solving skills
• discussing/sharing concerns, celebrating small successes.

If schools include some or all of the above strategies in their general curriculum and extra-curricular activities, young people will build resilience and the school environment will be more conducive to solving problems and better managing potential crises without them becoming critical incidents.

As part of discharging their duty of care, school staff also need to be careful when offering advice to students. It is important that school staff limit their advice to areas within their own professional competence and within the role that has been allocated to them by their Principal or Director. It is vitally important that school staff avoid giving advice to students in areas that are unrelated to their role or where they may lack expertise.