When practitioners are working with adults going through challenging times, they should be especially aware of signs that may indicate self-harm, thoughts of self-harm or a deterioration in a person’s mental state.

Factors that increase vulnerability to self-harm

In particular, they should be alert to factors that can increase someone’s vulnerability, for example, mental health needs or demographic factors such as poverty or homelessness.

All social workers, not just those working in mental health services, should be aware that rates of self-harm are higher in marginalised groups, for example, ethnic minorities, sexual minorities, asylum seekers, people in the criminal justice system and those who have lost loved ones through suicide.

People sometimes harm themselves when they are under stress for a variety of reasons. These include domestic abuse, financial abuse or other forms of exploitation, financial difficulty/poverty, separation and loss.

If you discover that someone has started to self-harm, it could indicate that something in their life is upsetting them and they might benefit from having some support.

If self-harm is suspected or needs to be considered as a possibility, you should be prepared to explore this in social work visits, assessment or interventions.

Practice tips

• Try to be calm and reassuring. When asking questions, try to do this as sensitively as possible.
• Say clearly that you are asking questions to help and that the person is not in trouble. Tell them that you can provide or arrange for support. If possible, ask whether they have been supported by mental health services before and try to obtain their consent to share information with other mental health professionals.
• As part of an assessment, you should make sure you are clear about what support or involvement, if any, the person has had from other services in the past, either in relation to their mental health generally or self-harm in particular. This information might be included in the referral to your team, it might already be available in records held by your organisation or you may need to make contact with other organisations to find it out.
• When people have moved from another area or have been transferred from children’s services to adults’ services, contacting their GP is a good way to find out what care, support or treatment they have had in the past, as well as asking the person themselves during the assessment.
• Always treat the person with respect and dignity and try to give them as much control over what happens next as you can.
• Check if they are willing to share anything with you which they think may have contributed to them hurting themselves. This might relate to recent stressors such as difficulties at home, having had an argument with someone or losing a job, or it might relate to their psychological state such as feeling low in mood.
• In some cases, it may be necessary to sensitively unpick whether the harm relates to self-harm or has been caused by another person. Inevitably, this requires careful handling. To have this kind of conversation, the person must feel comfortable speaking to you and, where possible, they should be given the option to have someone they know and trust present to support them if this would help.
• It can be hard for people to tell someone that they have harmed themselves. Feelings of shame and the fear of rejection can be factors. Acknowledge how difficult it might have been for them to share this information with you.
• Remain calm and non-judgmental, be prepared to listen and give them time to talk. If someone has harmed themselves, there will be a reason for this, but they might not understand why they have done it. It is important to try and work collaboratively with them and for them to feel in control of what happens next.
• People do not always recognise that the behaviour and actions of others are abusive. Sometimes the harm you are investigating will have been directly caused by others, but sometimes others’ abusive behaviour will have precipitated self-harm. Where you suspect abuse in either form, you will need to probe the person’s use of language, for example, when they say someone has “borrowed” money from them, do they really mean that they have stolen it, or when they say that somebody “pushed” them, do they mean that they struck out?

Practitioners should remember that people who self-harm do not always do so as a result of mental illness; levels of risk can also be affected by social isolation and adverse life events.

Psychosocial stressors can have a significant impact in terms of self-harm, sometimes involving people who are already regularly involved with adult social care. It is worth taking the time to ask questions and act on any answers that suggest someone is at risk of self-harm.

If you have a Community Care Inform Adults licence, log in to access the full guide and read more detailed information on the signs that social workers should look out for and what to do if self-harm is confirmed.

Useful resources on self-harm

• Samaritans, freephone 116 123
• Mind’s self-harm webpage provides information about helplines and other sources of support
• Young people’s suicide prevention charity Papyrus
• Training and support organisation Self Injury Support.
• Online support forum run by the National Self Harm Network.

We understand that the issues set out above will apply to some practitioners, so please consider making use of any of the resources listed above that you feel would be helpful to you.

By Beverley Samways

There is a large body of research that seeks the lived experiences of people who self-harm.

This has informed our understanding as to why people hurt themselves and the sorts of responses that are most effective.

The vast majority of self-report studies with people who self-harm reported that emotional distress in response to adverse experiences was a primary risk factor.

Bereavement is one of the adverse experiences mentioned in relation to self-harm.

Rhonda Lesniak’s 2010 research into the lived experiences of adolescent females who self-harmed reported that, “the loss of a loved one at a young age is common among adolescents who self-injure”.

Focus on environmental triggers

However, for someone with a severe learning disability who is hurting themselves, emotional distress in relation to adverse experiences is much less likely to be considered as an explanatory factor.

Instead, the focus tends to be on immediate ‘triggers’ in the environment: what might the individual be trying to communicate about their needs or wants, including in relation to pain and sensory processing?

This is illustrated by the standard focus in behaviour charts of what happened ‘just before’ self-injury, as the primary way of analysing why it might have happened.

Whilst immediate triggers are important to consider, the small amount of research asking people with learning disabilities about their own self-injury found that participants rarely talked about triggers.

Instead they talked about their self-injury in relation to experiences of emotional distress that often happened in response to adverse experiences, including bereavement.

The role of grief

In 2021-22, three teenagers with severe learning disabilities and a history of self-injury participated in an eight-month research project to understand the emotional factors relating to their self-injury.

Grief was found to be a significant factor for one participant, whilst there was some evidence of loss or separation anxiety for the other two.

Loss is an experience easily neglected for people with learning disabilities.

Somehow, when a person with learning disabilities loses someone close to them, the idea that their grief might need to be processed and journeyed can get lost.

If they cannot speak about their loss, where does it go?”

With no intentional support to process the feelings of loss and grief, self-injury can become an option of last resort for providing an immediate release, or numbing, of overwhelming emotion.

The need for active bereavement support

Without active support for loss and bereavement, people with learning disabilities run significant risk of experiencing disenfranchised grief, which can lead to expressions of distress through various behaviours, including self-injury.

Owen Doody wrote, in 2014: “Disenfranchised grief occurs when an individual experiences a loss but that loss is not openly acknowledged, socially supported, or openly mourned. Thereby the person experiences a loss, but has no socially sanctioned right to grieve.”

It is very common for staff to struggle to support a person with severe learning disabilities with a bereavement.

This is rarely because staff are callous or insensitive, but much more likely to stem from anxiety about how to support the person with their feelings, particularly if they have little or no spoken communication.

Challenges for staff

It is often a struggle for support staff to know whether, and how, to communicate with people with learning disabilities about bereavement.

As Robin Grey wrote (2010), “people can make huge efforts to protect the person with learning disabilities from loss in the misplaced belief that they will not be able to hold its emotional reality”.

Instead, it can feel more manageable to look for an immediate trigger than consider that a person may be expressing complex feelings in relation to the loss of a loved one.

A trauma-informed response

However, individuals with learning disabilities do grieve and they do not spontaneously recover: they need active support to work through their grief, just as anyone does. How can we respond?

• Where ordinary behavioural analysis and interventions are not adequately helping an individual to reduce their self-injury, trauma and attachment-informed specialist help should be sought to consider the role of previous adverse experiences and emotional distress, including loss or bereavement.
• In addition, where a person with severe learning disabilities is bereaved (even if it was many years ago), staff teams should be offered tailored support through workshops and reflective practice to identify atypical expressions of grief and develop the bespoke and person-centred emotional support the individual needs.

Beverley Samways is the founder of the consultancy Unique Connections, which works to improve the lives of children and adults with learning disabilities who self-injure, including through working with schools and care providers. She recently completed a PhD, funded by the Economic and Social Research Council, entitled Non-spoken stories: an ethnographic account of the emotional lives of three teenagers with severe learning disabilities who sometimes self-injured.

References

Doody, O (2014) ‘Loss and grief within intellectual disability’, Frontline, 95

Grey, R (2010) Bereavement, loss and learning disabilities : a guide for professionals and carers Jessica Kingsley.

Lesniak, RG (2010) ‘The lived experience of adolescent females who self-injure by cutting’, Advanced emergency nursing journal, 32(2)

Samways, B, Heslop, P, & Dowling, S (2022) ‘Self-reported explanations for self-injury by people with intellectual disabilities: a systematic review of qualitative studies’, International Journal of Developmental Disabilities, 1–15.