Self-Help not Self-Harm

Category: WorcestershireOn February 12th I attended a public event in Worcester entitled Self-Help not Self-Harm. As usual for Worcestershire’s events, it was well organized and well attended by both the public and professionals of all kinds.

The event was run by the Worcestershire Health and Care NHS Trust, which abbreviates itself oddly to HACW instead of the more pronounceable WHAC. There’s no good reason to be unpronounceable, as far as I can see, and as the South London and Maudsley NHS Foundation Trust (SLAM) demonstrates.

Amazingly, the main presentation is already available online, a promise often made at these kinds of event but not so often kept.

I arrived early hoping for a cup of tea before the event started, only to find that almost everyone else had arrived even earlier for a cup of tea before the event started. So I took my place in the queue behind another chap. After a moment or two a third chap joined behind me. At this point I looked around the room, and to my surprise the three of us in the queue seemed to be almost the only men in the place. On looking more closely I spotted a few more, but even so I think we were thoroughly outnumbered.

This was only the first surprise in an evening that turned out to be surprising in several ways.

The event turned centred on a presentation by a community psychiatric nurse (CPN) who works in Worcestershire’s child and adolescent mental health service (CAMHS) and who is experienced in helping young people who harm themselves.

You can hear her for yourself, making some of the same points she made in the presentation, in this 5-minute segment from independent local radio station Signal 107 on the morning of the event: 40% rise in self-harming Worcs teens

CAMHS

The large numbers attending made the event a little late starting.

While we were waiting, the projection screen displayed a looping presentation about CAMHS. I didn’t pay a great deal of attention. Part of the presentation was a strip cartoon showing what happens to a patient who’s treated by the service. After seeing it for maybe the third or fourth time, I suddenly wished I’d being paying more attention.

If I remember right, the process seemed to start with a family receiving a letter telling them to attend a CAMHS appointment. And if I remember right, the family consisted of just a mother and daughter with sad faces. Is this really how CAMHS operates? Does it really randomly target single-parent families with appointment letters out of the blue? Perhaps I didn’t remember it right. I can’t find the strip cartoon online to check.

Anyway, the CAMHS web pages definitely describe a perfectly normal referrals process, with self harm one of the clinical criteria for referral to Tier 3 (specialist secondary care).

Curiously, there’s no obvious link from the main CAMHS web page to the separate Self Harm web pages.

Awareness

Self-Help not Self-Harm is the title of an awareness campaign this month, February 2015. The main message seems to be that self harm is on the rise:

“There has been a 40% increase in the numbers of children and young people (aged 10 to 14) self-harming in Worcestershire over the last few years.”

Me, I’d simply call people aged 10 to 14 children. Perhaps that just shows how much I need awareness. I am aware that people who harm themselves don’t magically stop doing it at the age of 18, but this was only referred to in passing — it was a CAMHS presentation, and despite the widespread success of services that treat psychosis over an extended age range, no one seems keen to extend the idea to other areas of mental health.

There was no explanation of why awareness helps (as opposed to, say, just creating moral panic), or who it is who needs to be made aware. No one in the room admitted to having been unaware beforehand, and no one in the room looked to me to be aged 10 to 14.

Little of the content of the presentation was about self help. Indeed, one slide defines self harm as:

“an act done to oneself with the intention of helping oneself”

I think this is probably true, and people who repeatedly harm themselves do so because it helps more than it harms. But the broader issue of how to stop children doing something that they find helpful just because we don’t like the idea that they do it wasn’t really addressed.

The message to the audience was:

“Take responsibility for what you can do to change your actions!”

But we in the audience weren’t harming ourselves! Is this what we’re meant to say to children? It implies that self harm is just irresponsible behaviour, not a mental health problem, yet CAMHS is a mental health service.

So some of the basic messages from the event seemed poorly thought out. Self harm does raise difficult questions with no clear answers, but I don’t think that’s an excuse for muddying the waters further.

Arm writing

In practical terms, the awareness campaign’s central idea is arm writing. We should write reminders on our arms of things we like. Apparently, if we all do that children might stop doing the harmful things we don’t like.

For example, on the presentation slide the first photo is someone’s arm with this written on it:

“FAMILY ♥”

It’s not that this person used to self-harm but then took responsibility and decided to join a lovely family instead. The arm has no scars. Its owner’s lovely family didn’t come into being because he or she took responsibility for self-harming.

I’ve not noticed any of the photos of arm writing anywhere in the whole campaign showing scars from previous cutting. For all I know, there might be some 10 to 14 year old children somewhere who have stopped harming themselves because of arm writing, but nothing in the presentation or in the wider awareness campaign convinces me. To me, the arm writing photos are blatantly fake. Even if a few of them are genuine, no one can tell which ones they are. Enough of them are fake to make the whole thing blatantly fake.

So the message to children seems to be that behaving in a way that’s blatantly fake is better than behaving in a way that’s actually helpful (even though at the same time slightly harmful). Maybe it’s my lack of awareness, but I can’t imagine that message working.

Wellbeing

A confused section of the presentation covered wellbeing and resilience, drawing on the five outcomes from the 2003 Treasury green paper, Every Child Matters. It’s in the years since 2003 that self harm in children and young people has become so much more common, but the presentation didn’t explore any possible link between worsening rates of self harm and failed government social policies.

The green paper doesn’t actually mention resilience, either, but the presentation went on to describe factors associated with good resilience, the first of which is being female, we were told.

This drew an appreciative chuckle from the predominantly female audience. Back in 2003 the green paper had noted that self harm (like eating disorders) is more prevalent among girls, but our presenter felt sure the research evidence on this is wrong, which is an interesting position to take in these evidence-based times.

It isn’t hard to find research that concludes boys are more resilient. For example, here’s a paper that describes gender differences in the responses of schoolchildren in the two years following an earthquake in Italy in 2009: Resilience in adolescence

“These findings are compatible with a resilient ‘protective mechanism’ for males.”

The list of factors associated with resilience in the presentation is attributed to “McDougalleral 2010”, probably a garbled reference to the book Helping Children and Young People who Self-harm by Tim McDougall, Marie Armstrong and Gemma Trainor (who might be referred to as McDougall et al., thus causing the confusion).

However, that book isn’t the original source, as it in turn cites another book by Brigid Daniel and Sally Wassell, possibly one of their three workbooks, Assessing and Promoting Resilience in Vulnerable Children, which deal with different age groups. The associated factors for each age group are different, and in any case it’s unlikely that these workbooks are themselves the original source, so I gave up trying to find out where the list really came from.

The headline finding that being female makes you resilient doesn’t stand up to much scrutiny. I suspect it would be more accurate to say that you can define “resilient” in a way that makes it seem to apply more to girls, or you can define it in a way that makes it seem to apply more to boys, whichever takes your fancy. Anyway, it was good for a laugh.

Treatments

The CAMHS service provides several treatment strategies.

There seems to be a general feeling that cognitive behavioural therapy (CBT) would be helpful, even though it wasn’t clear that it’s actually available. Instead, various distraction techniques that definitely aren’t CBT are taught. It wasn’t clear that patients and their parents or guardians are being properly informed about the difference between distraction and CBT.

It seems likely to me that CBT would be helpful in some cases, because there’s evidence that self harm can be linked to depression, and CBT is helpful for depression while distraction isn’t. So I would have been happier if some differential diagnosis were going on to determine which kind of treatment is best for each individual patient. I’m sure it does happen to some extent. For example, someone referred for self harm who turns out to have psychosis must surely be referred on to have the psychosis treated, but the presentation didn’t dwell on this kind of personalization.

The presentation includes a word cloud listing some distraction techniques. The big word in the middle, which shows it’s the most important, is:

Singing

Seriously. Singing.

Another treatment strategy is mindfulness, which is a bit like Buddhist meditation without the Buddhism. We were shown a short animated video about it:

Even without playing the video you can see from the still image what it’s about. You’re supposed to sit by the roadside in a desert while everything in life passes you by. Then you won’t self harm. Great, huh?

I’ve no idea what real Buddhists make of this. According to some, a better idea is to be fully present and become the flow of your life rather than making your self absent and sitting apart from it as in the video. The presentation didn’t touch on this troubling detail.

Social media and risk

At one point the presenter reminisced about her childhood, remarking that the big difference nowadays is the influence of social media in children’s lives. You can hear her make the same point in the podcast above.

This made me think about my own childhood, wondering what it would have felt like to indulge in risky behaviour that could cause me harm. Why didn’t I do that when I was a child?

Then it hit me that I did do that! I was running around barefoot in the woods, digging tunnels (well, my friend from next door and I dug a tunnel once), and later riding around the streets on bikes. I set off to school alone and on foot each morning from about the age of six, and within a few years using public transport on my own. I was managing risk to myself from a very early age, and in those days so was practically every normal child.

So I suspect social media isn’t to blame. I think what’s changed is adult perceptions of risk, causing children to learn their personal risk management in ways that adults can’t interfere with. Sociologist Frank Furedi explains the new “bedroom culture” like this:

“Risk-averse attitudes which verge on paranoia emerged as one the defining features of contemporary child-rearing culture. Apprehensions about children’s health and safety, particularly regarding sex predators have led to new limits imposed on children’s freedom to explore the outdoors. This confinement of children indoors has been associated with the growth of a phenomenon frequently described as the bedroom culture. So the main driver of this process was not digital technology and the social media, but the prior development of an indoor childhood culture.”

Nonetheless, the awareness campaign has a presence of sorts on Twitter and Facebook. I say “of sorts” because the Facebook page isn’t actually public. You have to log in to see it, and then Facebook can track you and suggest new online friends who also have an interest in self harm, which is nice. And oddly, the self harm Twitter campaign is on the trust’s main account, not where you might expect it on the separate CAMHS account.

As far as I can tell, you can see all there is to see on the public Twitter account without logging in to Facebook. I didn’t look for activity on other social media sites (the ones children mainly use), but there aren’t any obvious links to them.

Discussion

The presentation was followed by a sort of panel discussion. The panel consisted of the main presenter, a psychologist, and a trainee psychologist who might as well not have been there. She only made one statement, if I remember right, and I don’t remember what she said.

Panel discussions can be excellent, but what I want is to form an impression of the differing points of view of the panel members. So, to make that happen, each question from the audience has to be addressed by all the panel members in their different ways. This didn’t happen.

The panel seemed quite pleased that CAMHS has a single point of access (SPA). But audience members pointed out that it isn’t the only single point of access. Someone suggested a single, single point of access to provide access to all the single points of access. This seemed to puzzle the panel. (Actually, for the public it’s supposed to be 111, but no one thought of that.)

A revealing interaction with the audience took place when the panel were talking about their Facebook page. Someone pointed out that children don’t use Facebook much because “we” (meaning adults and official bodies) are there. This comment was just blanked.

So a while later the commenter tried again, making the same point. Again she was blanked. The panel wouldn’t hear what they didn’t want to hear!

There was a more embarrassing example of the same thing when a mother in the audience spoke about her difficulty getting any help, or any response at all from services for her two adopted children, both of whom self harm. She became quite emotional, understandably.

The psychologist took it upon himself to reply at great length, displaying an almost psychopathic lack of empathy and shame and talking instead about other things. It was the low point of the evening.

Nuts and bolts

The nuts and bolts of this event were just great — nice cup of tea, posh biscuits, classy venue, free parking.

The presentation, too, was really good, unusually good, in the way it was put together. To break up the slides there was that little video clip, and also a couple of audio segments that I haven’t mentioned. And the slides are available online. And there are references. OK, so there was a typing error in the references, but hey, there are references!

The big difficulty was in the content. That video clip promotes a weird approach to life. The audio segments were just people reading prepared statements. The self-help in the title doesn’t really exist, and the focus of the campaign is to push children towards statutory services. The only help that does exist seems to be based on trying not to think about it, for example by singing. Official policies dating from 2003 are still being cited despite demonstrably not working for this particular problem.

The underlying reason for the big difficulty seems to be an inability to listen. Instead of hearing what real people say, instead of responding to their needs in an integrated, personalized way, an outdated, CAMHS-limited, top-down, one-size-fits-all approach seems to have been cobbled together — more appropriate to North Korea than to Worcestershire.

That, in case you haven’t already worked it out, I didn’t much like.

 

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About Rod

Chairman of the Gloucestershire charity Suicide Crisis, Vice Chair of Relate Gloucestershire & Swindon, and an enthusiast for public involvement in the NHS.
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