Last year, an NHS agency warned that self-harm was reaching "epidemic" proportions, with growing numbers admitted to casualty departments. The problem can be particularly difficult to tackle in schools, where teenage girls have been known to set up "cutting clubs", and where teachers can be bewildered and disgusted by children who deliberately hurt themselves. So is it a growing problem or are we just becoming more aware of the issue? Can we dismiss it as teenage attention-seeking, or is it more deep-seated? And if a pupil comes to you with cuts on their arms, what's the best thing to do?
What is self-harm?
Self-harm is the term used to describe deliberately injuring yourself. The most common method is by repeatedly cutting the skin (usually the arms or legs) with knives, razor blades or scissors. But some people burn or scald themselves, pull out hair or eyelashes, jump from heights, strangle themselves, swallow sharp objects or take poisons. Often they try a combination of techniques. And at the extreme end of the scale, self-harmers gouge out eyes or amputate nipples or fingers.
A particular problem for schools?
The figures for self-harm appear to be rising alarmingly, and young people are particularly at risk. Around 24,000 under-18s are treated in casualty departments every year as the result of self-inflicted injuries. But this may be only about a tenth of the number affected. Most self-harm happens in private, and many don't seek medical help. Government research in 2002 found that 215,000 11 to 15-year-olds may have harmed themselves at some time, and recent figures from ChildLine show that calls about self-harm have increased by around 65 per cent in two years. Which all suggests that, in an average class of 20 pupils, two will deliberately harm themselves during their teen years.
Nor is it just a problem for secondaries to worry about: a report published in September last year by the national inquiry into self-harm found that children as young as five could be deliberately banging their heads or grazing their knees in the playground. "We don't know if self-harm is growing or whether there's just more people seeking support," says Caroline Roe, secretary of the National Self Harm Network, "but around half of the people using our website are young people. So it's clearly a massive area."
Who is most at risk?
There is no one type of self-harmer. "It's not all about kids dressed in black," explains Dr Marcia Brophy, project manager for the national inquiry into self-harm. "We can't just look for risk factors and then find a target group. There doesn't seem to be a typical self-harmer, just a very wide range of ages, backgrounds and reasons for doing it."
But the figures show that girls are more likely to self-harm than boys. A study of 15 and 16-year-olds carried out in 2002 by researchers at Oxford University's department of psychiatry found that girls were four times more likely to deliberately hurt themselves. The rate is particularly high for girls living with one parent, and Asian girls, though no one is yet sure why. Self-harm is more common among those who have been bullied and is strongly associated with physical and sexual abuse. Recent evidence also suggests a strong link with poverty. But it's not just an issue for teenage girls: figures collated by North Lanarkshire schools between 1999 and 2002, for example, found that at primary level boys were more likely to harm themselves than girls.
Why do it?
Just as there's no simple formula for working out who might self-harm, so the reasons why young people do it are often complicated. The idea that it's a thrill-seeking "cutting craze" is wrong; it's much more likely to be connected to long-term distress. In a research project carried out in 2002 by the children's charity NCH, all the young people interviewed said their self-injury was a result of childhood traumas including rape, unwanted pregnancy, bullying, parental divorce and bereavement. Exam stress, relationship problems, worries about sexual identity, perceived pressure from parents and lack of self-confidence can also play a part.
Contrary to popular myth, self-harm is not an attention-seeking ploy, or a cry for help. Most of it happens in private, in bedrooms or school toilets, and most young people are careful to cover the evidence. "It's simply not a case of trying to get attention or indulging in copycat behaviour," says Dr Brophy. "Our research shows that more than 90 per cent of cases are hidden and take place in isolation." And despite the fact that, statistically, those who self-harm are a hundred times more likely to go on to commit suicide than those who do not, most young people who hurt themselves are not suicidal but are simply trying to cope with their feelings.
"Self-harmers are often bad at social problem-solving," says Louise Carpenter, senior child and adolescent mental health officer for North-east Wales NHS Trust and self-harm specialist. "They tend to have a narrow view of the world and find it hard to look at the positives. So they resort to dysfunctional ways of coping."
The feelgood factor There are, though, some common factors that help explain why young people self-harm. Many say it makes them feel more in control. Research has shown that one common trait, for example, is careful preparation and cleaning up; having tissues, antiseptic and plasters to hand and following a well-rehearsed routine. Others report feelings of overwhelming relief from their problems or suggest it makes them feel more alive.
But the reasons why someone starts self-harming may be different from why they keep on doing it. Just like alcohol or drugs, self-harm is addictive.
When we feel pain our bodies release endorphins, natural morphine-like chemicals that act as painkillers, which explains why many people say they feel euphoric after hurting themselves. Those who self-harm repeatedly could well be addicted to this rush of endorphins.
Keeping quiet... Young people who self-harm are often wary of going to hospital. And their fears may be justified. A report in 2004 by the National Institute for Clinical Excellence found that half of those seeking treatment for their injuries received no follow-up care or psychological assessment, while some NHS staff, especially in overworked casualty departments, were unsympathetic. In extreme cases, doctors stitched up self-inflicted wounds without anaesthetic.
But schools are not much higher on the list of sympathetic institutions.
Statistics from the Samaritans and the Centre for Suicide Research at Oxford University show that nearly half of young people who hurt themselves have tried to find help, but find it difficult to talk to teachers because they are too embarrassed, or feel their problem is not important enough.
Others are worried that a word in the ear of a favourite teacher may soon become a painful "official" experience: one girl found with lacerated arms was repeatedly asked to dredge up her worries for the PE teacher (who discovered the cuts), then her year tutor, pastoral head, head teacher, school nurse and, finally, a community paediatrician.
"It can be very difficult for a school," says Louise Carpenter. "If a child is found with a knife in the toilets, for example, then obviously the school has to respond. But often these children don't know how to describe what they're feeling; they can't talk about it, which is why they're cutting themselves. And by taking away the knife, the school is also taking away one way for that child to cope."
...or speaking out?
Despite not necessarily wanting to talk about their own case, a recent poll of young people on a self-harm web forum showed that 82 per cent of respondents would like self-harm discussed more openly in their schools.
And while some said it was a subject they had covered in PSHE, others said it was something they had learned about the hard way from their own or a friend's experience.
The national inquiry into self-harm points out that self-harm is rarely covered specifically by initiatives such as the healthy schools standard or the DfES healthy living blueprint, and has called for more open discussion and better training for teachers. But some experts warn that it can be a fine line between putting ideas into some pupils' heads and providing necessary information. "Self-harm can be catching, so it's important not to glamorise it," says Amanda Allard, senior public policy officer for NCH.
"You have to try to normalise it, putting it into a spectrum with other behaviour that's not necessarily so good for us, such as too much drinking."
Schools that do tackle the problem often put staff training top of the list. Knowing how to spot tell-tale signs - is someone wearing long sleeves on a hot day? - and how to access local support services is a start. But it's also necessary to prepare staff for the distressing nature of self-harm. "People often feel a lot of revulsion, but it's important not to let these feelings show," says Ms Allard. "Teachers must understand the complicated factors involved, and they need to be aware of just how common it is in school."
You are not alone Because the issues underlying self-harm are so complex and varied, the "right" response will vary from case to case. "It should be unique to each person," says Caroline Roe. "Some might need putting in touch with services such as helplines or web forums, some might want hands-on, face-to-face support."
The National Self Harm Network finds its email support particularly popular with young people, some of whom might be blocked from using online self-help forums by parental control facilities on their computers. But its advice to schools is to start with the basics. "A bit of kindness and sensitivity is needed," says Ms Roe. "It's important not to see someone who self-harms as a problem, because that negativity will feed back. Schools need to take time to listen and to make someone feel valued. And whoever makes the intervention, even if they say the wrong thing in the right way, can have a massive impact on breaking the cycle of harm."
Home truths Most specialists believe the best way to deal with self-harm is to take a whole school approach that offers everyone (staff, students and parents) the chance to develop effective ways of coping with stress, anxiety and unhappiness. This may include anything from developing communication and social skills through "circle time" to finding ways of improving self-esteem and positive thinking. Peer support programmes, such as buddy schemes, are also important because many self-harmers prefer to confide in someone their own age.
But some schools report difficulties in getting help from parents to tackle self-harm. Sometimes they are unwilling to admit there's a problem, and refuse to seek professional advice. And sometimes they don't want difficulties at home - which may be one of the underlying causes of the self-harm - to come into the open. Just as importantly, many young people don't want their parents involved. "Talking to parents can be really damaging," says Caroline Roe. "Try taking time, taking a deep breath, and remembering that self-harm is about staying alive. Then you might not feel you need to break a confidence by calling in parents. And be aware of your limitations. If you don't feel able to deal with a case, then seek support."
In the fold Sometimes getting that support isn't easy. Many schools lack funding for specialist posts such as a school nurse, while voluntary organisations can be overwhelmed with calls for help. Some LEAs are beginning to tackle self-harm in partnership with specialists such as educational psychologists and social workers, but training provision for schools and individual teachers is patchy.
There are, however, some basics any school can tackle while setting up a more structured programme of support. Making sure everyone's aware of potential triggers, such as transition to senior school, options and exams, is a good start. Teenagers interviewed by the national inquiry into self-harm also recommended simple measures, such as covering self-harm in school magazines, providing a free telephone link to a support organisation or offering first aid equipment for students to treat their own wounds.
If a case is discovered, the important thing is not to focus on the injuries, but on the underlying problems; too much attention to the cuts and bruises might encourage someone to repeat the harming. Many specialists also advise trying to find alternatives to excluding a self-harmer, even if they are consistently found in school with a knife. "Schools sometimes assess the risk and decide to keep the child at home," says Louise Carpenter, "but you are possibly removing them from their most important source of safety and security. For many young self-harmers, being part of the school network is what keeps them going."
Not all bad news
There's no easy "cure" for self-harm: the national inquiry collected evidence from 50 and 60-year-olds who still hurt themselves in times of particular stress. But experts suggest that our increasing willingness to talk about the problem should help young people feel less isolated and give them more information about support networks.
"There are so many stereotypes and wrong ideas," says Dr Brophy. "If we can encourage even a basic understanding then young people will feel less isolated when they go for guidance. In the long term it means friends and family are more aware and open to talking about the problems underlying self-harm, even if they struggle to deal with the self-harm itself." And many teenagers show impressive commitment, and ingenuity, in trying to stop themselves self-harming. Recent postings to a self-harm web forum included "115 things to do instead of self-harming", advocating distractions such as playing online Scrabble.
Perhaps surprisingly, the 2002 report by NCH suggested we should be encouraged by the stories young people had to tell, concluding that "overwhelmingly, the message is that self-injury is a means of self-protection, not self-destruction". Researchers quoted a conversation with a young person who helped them look at things in a new light. "People always look at the negatives of self-harm," she said. "Whereas they should actually look at the positives, and the positive is that the person is still alive."
Main text: Steven Hastings Photographs: Lauren ShearSPLAdditional research: Sarah Jenkins
The Issue returns on April 15
Did you know?
* 24,000 under-18s are treated in casualty departments every year as a result of self-harming injuries
* Children as young as five may be deliberately hurting themselves by banging their heads or grazing their knees
* Girls are four times more likely to self-harm than boys
* Repeated self-harmers can get addicted to the endorphins released by the body when they hurt themselves
* A poll on a self-harm website found that 82 per cent of respondents would like self-harm addressed more openly in schools
* The national inquiry into self-harm is jointly run by the Mental Health Foundation and the Camelot Foundation. Its research focuses on 11 to 25-year-olds and is keen to hear from young people whose lives have been affected by self-harm. Reports, information and advice can be downloaded from the website: www.selfharmuk.org; tel 020 7828 6085.
* The National Self Harm Network has resources, including a discussion forum, for self-harmers, their families and professionals. Its website also lists local and regional support organisations: www.nshn.co.uk.
* Childline in Partnership with Schools (Chips) offers advice and information on peer support programmes and emotional health issues: www.childline.org.uk; tel 020 7650 3230, Scotland 0870 336 2910, Wales 0870 336 2935.
* Children's charity NCH works with schools on mental health issues: www.nch.org.uk; tel 020 7704 7000.
* Young Minds has a helpline for those concerned about the mental health of a young person: 0800 018 2138; www.youngminds.org.uk.
* The Samaritans offers support programmes for schools on a range of mental and emotional health issues. Helpline 08457 909 090; central office 0207 734 2800.
* The Royal College of Psychiatrists publishes a CD-Rom for 13 to 17-years-olds and their teachers, addressing a variety of mental health issues, pound;14.99. See www.rcpsych.ac.uk for more details.