• An interpretative phenomenological analysis of the experience of self-harm repetition and recovery in young adults

      Armstrong, Marie; Majumder, Pallab (2016)
      Six young adults (aged 19-21 years) with repeat self-harm for over 5 years were interviewed about their self-harm, why they continued and what factors might help them to stop. Interpretative phenomenological analysis identified six themes: keeping self-harm private and hidden; self-harm as self-punishment; self-harm provides relief and comfort; habituation and escalation of self-harm; emotional gains and practical costs of cutting, and not believing they will stop completely. Young adults presented self-harm as an ingrained and purposeful behaviour which they could not stop, despite the costs and risks in early adulthood. Support strategies focused on coping skills, not just eradicating self-harm, are required.; © The Author(s) 2016.
    • CAMHS self-harm teams and crisis/liaison teams; What CAMH nurses bring to the acute moments in young people's lives

      Armstrong, Marie (2019)
      This chapter focuses on one of the places where young people who self-harm are in contact with services, the general hospital. This includes their experience in the Emergency Department and on hospital wards-usually paediatric wards where young people under the age of 16 are admitted overnight, as recommended by NICE guidelines (NICE 2004).
    • Experience of self-harm and its treatment in looked-after young people: An interpretative phenomenological analysis

      Armstrong, Marie; Majumder, Pallab (2017)
      OBJECTIVES: We report the first Interpretative Phenomenological Analysis examination of self-harm and experience of clinical services in young people in the public care system. METHODS: Qualitative interviews with 24 looked-after young people. RESULTS: Prevalent themes were 1) Changes in care placement, 2) Feelings of anger, 3) Not wanting/feeling able to talk, 4) Developing coping techniques, 5) Clinical services: A relational mixed bag (subthemes: feeling (i) patronised, not listened to, (ii) nothing being done, (iii) comfortable/able to talk). CONCLUSIONS: Placement change and anger were highly salient to self-harm in this group and experiences of clinical services depended on individual relationships with clinicians. Implications include increasing compassion in therapeutic relationships, recognizing and managing emotional dysregulation and increasing support during placement changes.
    • An interpretative phenomenological analysis of young people's self-harm in the context of interpersonal stressors and supports: Parents, peers and clinical services

      Majumder, Pallab; Armstrong, Marie (2018)
      Rationale: Self-harm in young people is of significant clinical concern. Multiple psychological, social and clinical factors contribute to self-harm, but it remains a poorly understood phenomenon with limited effective treatment options. Objective: To explore young women's experience of self-harm in the context of interpersonal stressors and supports. Method: Fourteen adolescent females (13–18 years) who had self-harmed in the last six months completed semi-structured interviews about self-harm and supports. Interpretative phenomenological analysis was undertaken. Results; Themes identified were: 1) Arguments and worries about family breakdown; 2) Unhelpful parental response when self-harm discovered and impact on seeking support; 3) Ongoing parental support; 4) Long-term peer victimization/bullying as a backdrop to self-harm; 5) Mutual support and reactive support from friends (and instances of a lack of support); 6) Emotions shaped by others (shame, regret and feeling ‘stupid to self-harm’); and 7) ‘Empty promises’ - feeling personally let down by clinical services. These themes were organised under two broad meta-themes (psychosocial stressors, psychosocial supports). Two additional interconnected meta-themes were identified: Difficulties talking about self-harm and distress; and Impact on help-seeking. Conclusion: Parents and peers play a key role in both precipitating self-harm and in supporting young people who self-harm. The identified themes, and the apparent inter-relationships between them, illustrate the complexity of self-harm experienced in the context of interpersonal difficulties, supports, and emotions. These results have implications for improving support from both informal and clinical sources.
    • Nursing children and young people who self-harm

      Armstrong, Marie (2017)
      Nurses in schools, hospitals, prisons and community settings come into contact with children and young people who harm themselves. This chapter explores some of the myths and realities about self-harm and uses an evidence-based framework to guide nurses and other professionals who are required to assess, treat and support children in both front-line services and residential settings. Self-harm is heterogeneous, which means that it signifies different things in different people. Current evidence for the assessment of self-harm and clinical interventions are discussed. The development of mental health nursing in relation to self-harm is also described. Case vignettes are used to illustrate the different ways in which self-harm is understood and how a variety of nursing interventions can be used to meet young people's needs. (PsycINFO Database Record (c) 2017 APA, all rights reserved) (Source: chapter)
    • 'Our Care through Our Eyes'. Impact of a co-produced digital educational programme on nurses' knowledge, confidence and attitudes in providing care for children and young people who have self-harmed: a mixed-methods study in the UK

      Armstrong, Marie (2017)
      OBJECTIVES: (1) To determine the impact of a digital educational intervention on the knowledge, attitudes, confidence and behavioural intention of registered children's nurses working with children and young people (CYP) admitted with self-harm.(2) To explore the perceived impact, suitability and usefulness of the intervention. INTERVENTION: A digital educational intervention that had been co-produced with CYP service users, registered children's nurses and academics. SETTING: A prospective, uncontrolled, intervention study with preintervention and postintervention measurement, conducted at a large acute NHS Trust in the UK. PARTICIPANTS: From a pool of 251 registered children's nurses and 98 participants were recruited to complete the intervention (response rate=39%). At follow-up, 52% of participants completed the postintervention questionnaire, with 65% (n=33) of those reporting to have completed the digital educational intervention. PRIMARY OUTCOME MEASURES: Attitude towards self-harm in CYP was measured using a 13-item questionnaire; knowledge of self-harm in CYP was measured through an adapted 12-item questionnaire; confidence in different areas of practice was measured through Likert Scale responses; self-efficacy for working with CYP who have self-harmed was measured through an adapted version of the Self-efficacy Towards Helping Scale; clinical behavioural intention was measured by the Continuing Professional Development Reaction Questionnaire. Semistructured interviews were undertaken with a purposive sample of participants. RESULTS: For those who completed the intervention (n=33), improvements were observed in knowledge (effect size, ES: 0.69), confidence, and in some domains relating to attitudes (effectiveness domain-ES: 0.49), and clinical behavioural intention (belief about consequences-ES:0.49; moral norm-ES: 0.43; beliefs about capability-ES: 0.42). Qualitative findings suggest participants experienced skill development, feelings of empowerment and reflection on own practice. CONCLUSIONS: The effect of the intervention is promising and demonstrates the potential it has in improving registered children's nurse's knowledge, confidence and attitudes. However, further testing is required to confirm this.
    • 'Our Care through Our Eyes': A mixed-methods, evaluative study of a service-user, co-produced education programme to improve inpatient care of children and young people admitted following self-harm

      Armstrong, Marie (2015)
      Introduction: Within Europe, the UK has one of the highest rates of self-harm, with a particularly high prevalence in children and young people (CYP). CYP who are admitted to paediatric hospital wards with self-harm are cared for by registered children's nurses who have been identified to lack specific training in caring for this patient group. This may impede the delivery of high quality care. Therefore, this study aims to co-produce, implement and evaluate an education programme for registered children's nurses to improve their knowledge, attitudes and confidence when caring for CYP admitted with self-harm.; Methods and Analysis: This mixed-methods evaluative study will involve a three-stage design. Stage 1: A priority-setting workshop will be conducted with 19 registered children's nurses. A Delphi technique will be used to establish consensus of information needs. Stage 2: An online educational intervention will be co-produced with 25 CYP and 19 registered children's nurses based on the priorities identified in Stage 1. Stage 3: The intervention will be implemented and evaluated with 250 registered children's nurses at a single hospital. Online Likert scale questionnaires will be administered at baseline and postintervention to assess levels of knowledge, attitudes and confidence in caring for CYP who self-harm. Descriptive and inferential statistics will be used to analyse the data. Statistical significance will be assessed at the 5% (two-sided) level. One-to-one qualitative interviews will also be undertaken with approximately 25 participants to explore any perceived impact on clinical practice. An interpretive descriptive approach will guide qualitative data collection and analysis.; Ethics and Dissemination: This study aims to develop, trial and evaluative a service-user, co-produced education programme for acute hospital registered children's nurses to improve the care of CYP admitted due to self-harm. The study has ethical approval from the National Health Services Research Ethics Committee and full governance clearance.; Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/
    • Repeat self-harm among children and adolescents referred to a specialist service

      Armstrong, Marie (2013)
      Self-harming (e.g., self-cutting or self-poisoning, irrespective of suicidal intent) is common among young people. We studied 586 consecutive referrals (474 individuals) to a specialist self-harm service over five years. We found that young people who repeated self-harm, compared to those that did not, tended to have complex family and personal histories including mental illness, substance misuse, and child abuse. Although many factors are likely to interact, regression analyses revealed factors that act independently as predictors of repeat self-harm. These included being female, not having both biological parents as the main caregivers, and caregivers that appeared uncooperative. Other significant independent factors were multiple social agencies being involved, if the young person used more than one method of self-harm or abused alcohol. © 2013 Copyright Taylor & Francis Group, LLC.
    • Self-harm by children and young people: Care and compassion

      Armstrong, Marie (2012)
      Understanding self-harm through the views of children and young people and myths, misconceptions and the link between self harm and suicide. Risk factors for, and compassionate care of, children and young people who self harm are discussed. The role of the nurse in the care, management and treatment of young people who self harm is emphasised. 40 references
    • Self-harm in young people: A perspective for mental health nursing care

      Armstrong, Marie (2004)
      Aim: This paper addresses the assessment and management of self-harm in young people by a nurse consultant-led self-harm service in the UK. The purpose of the paper is to present some of the theoretical perspectives of the service and how these have influenced current practice with this group of young people. Background: Self-harm in young people continues to be a serious concern for health services globally. Rates of self-harm in teenagers in the UK are among the highest in Europe. The current literature offers information on the nature of self-harm and some evidence of specific interventions mainly from a 'psychiatric perspective'. This paper examines the development of a locally based nurse-led self-harm team involved in the care of this group of young people. A sociological view of children and young people is applied in examining the way society construes self-harm and the formation of the behaviour as a deviant act. Self-harm is considered in the context of transition through adolescence and the growth of self-identity. Conclusion: The locally based child and adolescent mental health service has drawn together the evolving nurse consultant role, mental health nursing and medical sociology. This integration of people and theory will enhance the services understanding of self-harm in young people. At an international level, there is a need to consider the sociological dimensions of self-harm in young people as a way forward for mental health nurses who are involved in working with this group of people.
    • Self-harm, young people and nursing

      Armstrong, Marie (2006)
      Nurses in schools, hospitals, prisons and community settings may come into contact with children and young people who harm themselves. This chapter explores some of the myths and realities about self-harm and uses an evidence-based framework to guide nurses who are required to assess, treat and support such children in both frontline services and residential settings. Self-harm is heterogeneous, which means it that it means different things to different people, therefore current evidence for the assessment of self-harm and clinical interventions are discussed. The development of mental health nursing in relation to self-harm is also described here and case vignettes are used to illustrate the different ways in which self-harm is understood and how a variety of nursing interventions can be used to meet young people's needs.
    • A sequence analysis of patterns in self-harm in young people with and without experience of being looked after in care

      Armstrong, Marie; Majumder, Pallab (2017)
      Objectives:Young people in the public care system (‘looked-after’ young people) have high levels of self-harm. Design:This paper reports the first detailed study of factors leading to self-harm over time in looked-after young people in England, using sequence analyses of the Card Sort Task for Self-harm (CaTS). Methods:Young people in care (looked-after group: n = 24; 14–21 years) and young people who had never been in care (contrast group: n = 21; 13–21 years) completed the CaTS, describing sequences of factors leading to their first and most recent episodes of self-harm. Lag sequential analysis determined patterns of significant transitions between factors (thoughts, feelings, behaviours, events) leading to self-harm across 6 months. Results:Young people in care reported feeling better immediately following their first episode of self-harm. However, fearlessness of death, impulsivity, and access to means were reported most proximal to recent self-harm. Although difficult negative emotions were salient to self-harm sequences in both groups, young people with no experience of being in care reported a greater range of negative emotions and transitions between them. For the contrast group, feelings of depression and sadness were a significant starting point of the self-harm sequence 6 months prior to most recent self-harm. Conclusions:Sequences of factors leading to self-harm can change and evolve over time, so regular monitoring and assessment of each self-harm episode are needed. Support around easing and dealing with emotional distress is required. Restricting access to means to carry out potentially fatal self-harm attempts, particularly for the young persons with experience of being in care, is recommended.
    • Uncovering key patterns in self-harm in adolescents: Sequence analysis using the Card Sort Task for Self-harm (CaTS)

      Armstrong, Marie; Majumder, Pallab (2016)
      Background: Self-harm is a significant clinical issue in adolescence. There is little research on the interplay of key factors in the months, weeks, days and hours leading to self-harm. We developed the Card Sort Task for Self-harm (CaTS) to investigate the pattern of thoughts, feelings, events and behaviours leading to self-harm.; Methods: Forty-five young people (aged 13-21 years) with recent repeated self-harm completed the CaTS to describe their first ever/most recent self-harm episode. Lag sequential analysis determined significant transitions in factors leading to self-harm (presented in state transition diagrams).; Results: A significant sequential structure to the card sequences produced was observed demonstrating similarities and important differences in antecedents to first and most recent self-harm. Life-events were distal in the self-harm pathway and more heterogeneous. Of significant clinical concern was that the wish to die and hopelessness emerged as important antecedents in the most recent episode. First ever self-harm was associated with feeling better afterward, but this disappeared for the most recent episode.; Limitations: Larger sample sizes are necessary to examine longer chains of sequences and differences in genders, age and type of self-harm. The sample was self-selected with 53% having experience of living in care.; Conclusions: The CaTs offers a systematic approach to understanding the dynamic interplay of factors that lead to self-harm in young people. It offers a method to target key points for intervention in the self-harm pathway. Crucially the factors most proximal to self-harm (negative emotions, impulsivity and access to means) are modifiable with existing clinical interventions.; Copyright © 2016 The Authors. Published by Elsevier B.V. All rights reserved.
    • What do young people who self-harm find helpful? A comparative study of young people with and without experience of being looked after in care

      Holland, Josephine; Sayal, Kapil; Majumder, Pallab; Armstrong, Marie (2020)
      Background: Self-harm amongst young people is an increasing problem, with looked-after young people at higher risk. Despite this, little research exists on what young people who self-harm find helpful. Method: One hundred and twenty-six 11–21 year olds (53 who had experience of the care system and 73 who did not) were recruited from the community and NHS. All participants had self-harmed in the past 6 months. Participants completed an Audio Computer-Assisted Self-interview (ACASI) regarding their views about the support they had received, how helpful it was, and what further help they felt they needed. Results: Looked-after young people reported the three most helpful sources of support were Child and Adolescent Mental Health Services (CAMHS), friends and pets and the least helpful were CAMHS, Accident and Emergency (A&E) and Social services. For non-looked-after young people, CAMHS, counselling and Harmless (user-led support service for self-harm) were most helpful and CAMHS, cognitive behavioural therapy (CBT) and general practitioner (GP) were the least. Compared with the other group, more looked-after young people had received help from A&E and CAMHS, whereas more non-looked-after young people had accessed GPs, parents, psychological therapies, self-help books and websites. More looked-after young people found support groups helpful, and more non-looked-after young people reported that distraction techniques, medication and their siblings were helpful. Conclusion: Young people who self-harm have mixed views about CAMHS. Differences in the pattern of access and preferences for support between looked-after and non-looked-after young people should be reflected in service availability and commissioning. © 2020 Association for Child and Adolescent Mental Health