Young people who self harm by cutting

History and her feelings

Hayley may have needed considerable courage to consult; missing this opportunity to discuss her situation, by being dismissive or (inadvertently) patronising, may heighten her sense of isolation and risk further escalation of self harm.

After dealing with her concerns about acne and suggesting a topical skin preparation (and review) ask permission to talk about the scar and show that you are interested in her emotional wellbeing.

Aim to create a non-judgmental environment where Hayley can sense that you are genuinely interested in her as an individual.

Explain that the consultation is confidential, unless serious concerns for her safety mean that you must act, but that you would always discuss this with her first. Explain that you could seek advice from your local safeguarding clinical lead without identifying Hayley in the first instance, unless your concerns require immediate action.

Establish when the cutting started, its frequency, and her usual sites (may include thighs, breasts, abdomen). Ask about feelings (such as feeling sad, low, overwhelmed, isolated, empty) and how the cutting links to the feelings.

Has she identified any triggers? Is the cutting becoming more frequent? Is it changing (cutting deeper, for example)? How does she feel after cutting?

Are there particular worries or problems? What about friendships, school, family? What else does she worry about?

Does she do anything else to deal with the feelings that lead to cutting (other forms of self harm, drinking, using drugs)?

Ask about sleep, eating, and weight patterns and how she feels about herself.

Has she had thoughts that life isn’t worth living? How pressing were these thoughts and did they trigger specific ideas of what she might do? Has she ever acted on these thoughts?

Who else might she talk to or find supportive? Has she considered telling a parent? What might have prevented this? Does she think her parents might have guessed there is a problem?

Ask what other questions she has. Consider that she may not want to stop cutting at the moment but appreciates your support.

Consider your knowledge of her extended family; do you have concerns about family background or parental mental or physical health.

Examination

Ask if you can examine the scar and if there are other areas she thinks you should examine. She may be worried about infection or scarring but feel ashamed or embarrassed. Touch validates your concern and acceptance.

Observe her appearance. Is she anxious, low, withdrawn? What is her level of self care?

What not to miss

Those most at risk of suicide—young people who are socially isolated, being abused, or exploited (box).

Safeguarding concerns—is she safe in her current domestic arrangement?