We are the Association for Child and Adolescent Mental Health, or ACAMH for short. And this is ACAMH Learn. Be aware that the following episode involves themes of self-harm and suicide. [MUSIC PLAYING] Seeking autonomy and social connection, risk-taking, and identity-making, the brain in adolescence is unique. It's primed to absorb and learn from the environment, and that means the teenage years are a chance to improve or shift young persons trajectory. This new series of Inside the Teen Brain explores how neuroscience can inform our understanding of young people's home, school, and life experience. In conversation with leading professionals, we answer three big questions-- what's the background? So what? And now what? I'm Dr. Jane Gilmour, and this episode is called Self-Harm, Supporting the Overwhelmed Teenage Brain. [MUSIC PLAYING] Well, our first question asks, what's the background? Self-harm has been recorded historically across different cultures and different species, but certainly in our contemporary Western context, the behaviour typically evokes an emotional response. A young person who harms themselves may trigger anger, condemnation or panic from loved ones. The behaviour certainly needs consideration. Houghton's influential review argues that self-injury may escalate and in some cases result in suicide. The incidence of self-harm increases sharply after puberty and peaks between 13 and 15 years old. It's described in up to 20% of young people with reported rates increasing. And so it's a topic that must form part of our understanding of the adolescent experience. We know too from self-report and imaging data that young people experience emotion with an increased intensity during the teenage years. Likely because of this and the new complexity of their emotional experience, data show that emotional literacy falls at this time. Add to the mix, established literature showing that adolescents are drawn towards risk taking, particularly in emotional contexts. If we consider that self-harm is often understood as a method to regulate emotions, we start to understand why rates of self-harming are higher in this demographic. Other characteristics of the teenage brain are relevant here too. Teenagers may moderate their behaviour to come in line with peer norms. Fitting into a group can be positive, of course, improving outcome, as we discussed in another episode on education. But this dynamic may also be negative. For example, girls, in particular, are more likely to self-harm when they are exposed to it in their real world or online community. Some of the usual suspects in mental health are also key to our understanding family dysfunction, previous trauma, and genetic vulnerability. For example, Dennis Ourgin, one of our guests, today describes an association with previous sexual abuse and low pain threshold in young people who self-harm. The current literature offers valuable context, but of course, questions remain. For example, in another ACAMH Learn series, we've discussed the singular importance of sleep for adolescents. The episode is called Sleep the Balm of Hurt Minds if you're interested. Sleep and its relationship with self-harm and impulsivity may be fruitful areas of investigation in the future. So there's no doubt that this is a complex and concerning issue, and it's perhaps appropriate that we have two guests joining us today. We welcome Michael Kaess, a professor of child and adolescent psychiatry and director of the University Hospital for Child and Adolescent Psychiatry and Psychotherapy in Berne. Among many of his numerous special interests are the detection and intervention of risk-taking and self-harm. This polymath guest aims to integrate different literatures and translate them into evidence based practise. Our second guest, Dennis Ougrin, also has an impressive multidisciplinary accomplishments in education, academia, and clinical practise. He is professor of child psychiatry and co-director of the Wolfson Institute of Population Health at Queen Mary University of London. As consultant psychiatrist, he headed the delivery of a novel community service and has designed and led trials of his innovative self-harm assessment protocol. More of these later. So with an expert panel of this calibre, we're certainly well armed to answer our next big question-- so what? [MUSIC PLAYING] All right. I wondered, Michael, if I could start with you and ask some questions about why are teenagers more likely to self-harm than any other demographic. I've touched on some themes, but you may want to go into those in more depth, or perhaps take another perspective. Yes, so I thank you very much, Jane. The themes that you put on the table were mostly appropriate, I think. So teenagers usually self-harm in states of overwhelming emotional situation, and I think that young individuals tend to get into emotionally overwhelming situations more quickly for several reasons. There is a brain maturation reason, but there's obviously also a reason that has to do with social maturation. If it might be my first relationship breakup as a teenager. It might be my first huge conflict with my parents. So there's a lot of things going on in adolescence that may bring a young person into an emotionally overwhelming situation, and that is associated also with often a lack of coping skills. So I have not yet learned how to cope with these kind of situations. I've not learned all the skills that I can use to stabilise my feelings, and I might also not have learned that even if I'm feeling really bad at the moment, things might become better again. So very quickly, adolescence may get into a situation where things feel very hopeless, where feelings get so bad that they feel that they'll never get better. And whether adolescents just feel, I need to change something no matter how. So it needs to end. And that's often where self-harm comes into play. So just want to get rid of this overwhelming bad feeling. And you touched on something really important there. The idea of the firsts, and they are emotionally drenched, the first breakup and so on. And you don't know that you will get through it and come out the other side. And you also said that there are some brain vulnerabilities there that intersect, if you like, with those social experiences. Can you touch on that a little bit? Yeah so the adolescent brain functions in a way that allows gain of autonomy and identity-forming and relationship-building to other people of the same age. That also means that the adolescent brain creates a lot of emotions because emotions are driving our actions. They give impulses for action. So if I'm angry, I go into a fight. If I'm anxious, I withdraw, or I hide. And if I'm happy, I'm having an approach impulse. So adolescents create a lot of emotions, but at the same time so their brain areas where emotions are created, for example, the limbic system, they become very active. But at the same time, the prefrontal cortex, so this is an area in the brain that actually allows us humans to control our emotions and to not act upon our emotions every time we feel them. This area is still quite immature. Yeah? That means that in adolescence, we are more prone to act on our emotions, and we have less abilities to control our emotions, and particularly, the impulses that are associated with our emotions. And that sets teenagers up to a certain enhanced risk of any kind of risk taking and self-harm behaviour because-- and now, we get back to first and the negative emotion. So if they have this negative emotion, although they might understand that self-harm is not going to solve their problem, they act impulsively. So it doesn't matter. It needs to go away. I need to do something now. And that has something to do with impulse control. And that certainly is something that also is subject to brain maturation in a certain way. And so that vulnerability in an emotional context is very important because outside of that emotional context reasoning, certainly even in by mid teenage year 16 or so is actually quite good. Thinking about risk taking in a cold, calm context can be very clear. So that same young person outside of that emotional storm could realise and rationalise and understand this self-harm perhaps is not a way of resolving the problem, but in that emotional spot, it's hard to find that because of that vulnerability, because of those emotional centres drowning out any rationality. So I think the underlying differences in the neurobiology of adolescents, the developmental neurobiology, really could have of interesting manifestations as well. And so one of those is that young people tend to be significantly more influenced by peers, and therefore, this contagion effect seems to be especially prominent in young people. And so exposure to self-harm or suicide-related themes, which I have to say used to be primarily limited to interpersonal communications, but now is not limited to it. And if you want, you can have exposure to this material 24/7 on social media and the internet. That's an important part. And the other very interesting thing, which I think is also a manifestation of this state of developmental neurobiology of young people is a sort of cognitive differences and the way that young people think. And Jane, you're probably significantly younger than both Michael and myself. So you can remember your teenage years significantly better. But even Michael and I, I'm sure if we cast our minds back to our teenage years, we will remember our dichotomous thinking, lots of ruminations and jumping to conclusions and all of these cognitive differences that if you work clinically with young people, with self-harm, you will recognise. And they certainly-- because obviously, it sounds to me like you are very keen on so what? So what should we do. Then that as part of psychological therapies, that's a very important and central part is helping young people to recognise some of these thinking patterns and behavioural patterns and working with them to see how they could become more helpful to them. And I'm really enjoying that the idea of thinking about a cognitive pattern that's specific to the adolescent years because that-- you touched on it in terms of an identity, trying on an identity which can be quite extreme as part of the developmental process. So for example, I'm someone who self-harms, could be something that is explored, if you like, not necessarily consciously, but it's something that they may connect to because in the teenage years, young people do explore extreme positions. And then one hopes with a positive and a healthy process, they'll come into a more adaptive and moderate position, if you like. So I really like that idea of thinking about a cognitive position of a young person that may make them vulnerable. Just at this point, just to say here that again, for listeners who I think are junior researchers and clinicians, what is important is to understand that you're absolutely right that adolescence is the time of identity formation. But also what is also important to understand is that it's a time of identity instability. And so what we often see in junior doctors and researchers is this idea that somehow they see teenagers as fully formed adults. But that is not true at all. They just forming their identities. And therefore, in all teenagers, not just the ones who self-harm, it's unstable. And so one really has to acknowledge that and work together with young people, not assuming that they are already fully formed and set in stone. That's super important to any psychological therapies and any psychological development. It's important to also say that what we are, just talking about is a little bit of the prototype of a self-harming adolescents. But the variety you know of this in adolescence is huge. So for me, as a researcher, it was always most interesting at the beginning of my career to also recruit and examine so-called healthy control participants, because then you sometimes also see that there are teenagers that are perfectly functioning so well, reflecting sometimes quite impressive identity. They know who they are, and they can reflect on their emotions and they can control their emotions. So what we are saying is that there's a certain risk in this phase, and that is obviously distributed across the population. For some, it's much stronger than for others. And here, risk factors come into place, for example, adolescents who have been exposed to severe and chronic adversity, whether it was in the family, or it could be bullying or other things. They often develop less emotional regulation capacities and also less stable identity, and that contributes to them being more on the risky side of the spectrum. Yeah, and I'm interested in the idea of exploring the community sample, if you like, of young people who apparently have no difficulties. Are there a comparison group but who may be exploring ideas in that way? But your key issue here is there are some somewhat familiar risk factors I think we'd all see working in mental health. Can you describe what it is about a particular young person, given that they are in that risky context? Why do they turn to self-harm? And why not another coping strategy? So I mean, in terms of risk factors, there are hundreds of individual risk factors. It's intellectually interesting to find them, but clinically, it's not very useful. I think we know about 100. And identifying one more with a small odds ratios is not going to solve this issue. I don't think. What the thing is more useful is just to think about risk factors in broad groups of these risk factors. And when you see a young person clinically, then you have to think, well what are these-- what individual specific to this individual young person risk factors exist. And of course, you have to consider psychiatric disorders in young person depression, anxiety PTSD, ADHD, autism, very important, psychosis, which could be linked with very severe and dangerous self-harm and suicide, eventually. Individual psychological differences, so emotional dysregulation, impulsivity, for example, alexithymia, so difficulties identifying and expressing emotions. That, I think, could be very crucial to understand and identify, especially in kids with autism, substance misuse and so on. That allows individual risk factors. Then you have to think about family, a whole group of family risk factors. What Michael was saying, this is the time of the first major conflicts in validation, in some unfortunate and tragic cases, abuse and neglect in the family, parental mental illness, experience of care looked after children. I think you were referring to some of my work, and Michael has done some interesting work on looked after children too where they actually show significantly higher pain threshold so it doesn't hurt them in the same way. Then there are an important group of social risk factors that are to do with bullying, and now, these days, cyberbullying as well. Very importantly, exposure to self-harm and suicide related activities and themes in their peers, both face-to-face and online. Social isolation, a great range of these sort of social risk factors, and then of course, historical, historical risk factors. So again adverse childhood experiences are very important here, previous self-harm, which is the strongest predictor of future self-harm. And so really, when you think about that I think the more useful thing is just to think about these big groups of risk factors and trying to identify what they mean for this particular young person, their family. And then I think, very importantly, and for whatever reason, I think, many researchers and clinicians tend to focus on the risk factors, but forget about protective factors. Yeah, absolutely. I was going to say because what now is really saying, well, what do we do? What can we put in place? And I do think it's neglected. So this is really helpful. So if we think about protective factors, how would you-- Well that's the thing. So for I think it's another question. Why is it that so many researchers do risk factors and socially protective? There must be something about the architecture of our brains that tends to focus on problems. And from the savanna in Tanzania where we all came from. Well, it's because we had a conversation with my colleague Umar. We had a conversation about this very topic and about the idea of that sort of negativity bias. We do look for things that are dangerous in our environment, and it's somehow translated into the literature. And then once you are relying on these literature-- bodies of literature, you're somewhat required to draw on the body of literature. So it does become tautological. But let's break that cycle and go for and consider that. Yes. Good. So in terms of the strong protective factors that we know about is having at least one supportive adult seems to be very important for the young person. It could be a family member. Doesn't have to be. Clinically, that if there is a teacher or somebody else that the young person relates to and who is a stable and sensible person in their life, that's incredibly important. Young people who don't have a single, stable, supportive adults, tend to do badly. And when we come to interventions, I wanted to highlight work by our colleague called Cheryl King, who is based in Michigan, who's done some very interesting work on creating a youth support network around the young person. And that consists of trusted adults. And that seems to be an important thing for preventing death in young people. Then, of course, there is an issue of emotional literacy and regulation skills. And as Michael says, not all teenagers have deficits in that. Some are remarkably well regulated and emotionally literate, perhaps better than I am. Then I think an important protector risk factor is school connectedness. So we know that kids who are well integrated with other kids in schools and the school systems do well. An interesting area, which again, I think seems to be neglected, is kids with strong spiritual, religious, or maybe cultural meaning systems. They tend to do better, I think, than kids who lack this aspect. And then of course, what I think is most modifiable in our case is access to timely and validating support. I just wanted to highlight the issue, maybe talking about broad categories. So for me, really, it's some kind of social support and belongingness that is really the most protective factor. It can be an adult person. It can be peers. It can maybe be the psychotherapist or somebody. It really is about some kind of social support. And my former supervisor and boss, he was not he was not somebody who did psychiatry based on a lot of data. So what we do today. But he was this kind of older, he was an observer. And he always said, Michael, suicide death is always preceded by social death. So subjective social death. So, he always said, an individual needs to feel already dead, so which means not connected to other individuals and to the world anymore before he's or he or she is prepared to die by suicide. And I think there's some truth in it because most of our data also show that feeling connected to any other social individuals and still having the feeling to maybe also be a loss for these individuals is something that is very protective. Yeah, I mean, it's a very poignant phrase, and it really does make sense about that connectivity being fundamental to us as human beings. And it does also point towards some really broad interventions that would benefit all schools. Let's say you did a whole school intervention. That does increase belongingness to a whole school community, which would particularly benefit those at risk young people. But the "rising tide lifts all boats" theory would mean the whole community would be better. If you think about bullying, whole school intervention and focusing on the bystander effect improves young people's outcomes. We've talked a lot developmentally, and we know that most people-- young people who self-harm will recover and they improve. So do you think that's simply a mechanism of them experiencing and tolerating emotions better, or is it that the intensity of the emotion settles and, therefore their experience of self-harm will decrease because the need is lesser? How do we make sense of the tail off in that demographic where self-harm is less evident? What's happening? Is it the social connectedness? Are they finding a social area? What's happening? Well, I think if I might say something to that, I think we need to be. Well, we need to distinguish different groups. So you're absolutely right, Jane. Most individuals will stop self-harm at one point in their life when they transition towards adulthood. But we need to distinguish a few groups here. So there is this group, probably the biggest group of adolescent self-harmers who will stop self-harm because they just settling. So they learn to regulate their emotions better, which might include both having less intense emotions but also being able to cope with them. I think that's also a little bit of a circle. If I know that I can cope with my emotions and that the strong bad emotions will go away, that helps me with having less overwhelming emotions. So that's probably one group, and that's a matter of maturation in times. And so that some things settle. But we need to be a little bit careful. I mean, self-harm in adolescence has quite a strong negative prognostic value also for adulthood statistically. That does not mean for every individual but many individuals who self-harm despite stopping self-harm at one point might still struggle with the problems that were underlying self-harm in the first instance. For instance, for example, we know that individuals who self-harm often show symptom shifts to severe substance and alcohol abuse at one point. So they might stop self-harm, but they might use other maybe more socially accepted ways to regulate their emotions, which indeed are almost more dangerous because severe substance abuse is often far worse than for example, non-suicidal self-injury. I'm not trying to make panic because I think it's important message teenagers, but also for parents of teenagers to say, look, there's quite a big chance that things will settle and that your child will be well as an adult. But we still need to do interventions, and we also need to look and monitor carefully because there's also a certain risk of despite the self-harm. Seizures at one point, continuous severe problems. And I think that's such a beautifully balanced response. We're not talking about panic, but we need to be aware that it may be indicative of an underlying problem. And that underlying problem is what needs addressed. You talked about panic, which I think is an important and recognisable response for those adults around a young person who may discover that they're self-harming. And maybe, Dennis, you want to come on this one as well. If we think about a practical piece of advice for parents or teachers, or a support worker who may be the first responder in a situation where a young person has self-harmed, what could they do or say in that moment? What advice would you give them? Well, let me start with this, and I'd be curious what Michael has to say about this. I mean, it's a sort of slightly banal and stupid thing to say, I guess, because it's very difficult. But it's really very important, is to stay calm and non-judgmental with the young person. Now, that's a skill. It's not something that you can just tell the parent or an adult to do. It's a skill that needs to be practised. If you ask any clinician, you know that what makes things significantly worse is when the adult becomes dysregulated themselves. That really escalates stuff. That's the one thing that I wanted to recommend that adults practise. Then it's important to acknowledge the stress of the child. Again, it's a slightly banal word that's been misused greatly in terms of validating the child's experiences. But it really is important to acknowledge that. I can see you're really, really struggling at the moment, and you have to mean it. You can't just say this without meaning it. You have to really try to understand the child's distress and mean it and see the world through their eyes. I wouldn't say this just as an emotional, non-connected phrase. That will not work. It has to really come from within. And the way you do this also it's a skill, is to try to see the world through the child's eyes. Then it's important to ask directly about the safety, whether the child is thinking about killing themselves. We know from loads of research asking that question doesn't increase the risk of suicide, but it's very important to understand the child's current state and could actually be quite a release promoting in some ways. It's much worse to hold on to something you don't talk about. I think one thing that especially fathers and males are guilty of is trying to fix things immediately. So I've heard this multiple times when the child is or the young person is sharing their distress, and then the parent is saying, what you should do is A, B or C and D. I think mums are a lot better with that. So I think it's very important to train yourself to listen before fixing stuff. And that listening phase is super-- again, it's a skill. Just if you tend to jump into fixing stuff, just train yourself to listen before you maybe want to support the other person in fixing stuff. Because what you're doing is you're requiring them to put into words, possibly for the first time, what's going on. And actually, you're inviting that, sorting out some of their thoughts. Exactly. And this alexithymia, which I referred to in the beginning, I think is very important. So what I think is really very important to understand is that for many young people, emotions are experienced as this undifferentiated distress. And sometimes their action by self-harm or attempted suicide or some other behaviour replaces that sort of language that they can use. So identifying the feelings that the child experiences. And in that way, again the first responders and parents are very important. Even if you are not right, but trying to identify the feeling that the child experiences, just attempting to do it is very important and very validating for the young person. And then if you're not right, they might say, you're not right, or I don't know. I don't know Is the most common answer you will get from it from a teenager. But you need to understand that the young person who cannot identify and manage the emotions will act by self-harm, for example. And so the beginning of the regulation begins with identifying and putting into words what it is that they're feeling. One very important thing that parents could do is to reduce the immediate risk by removing means of self-harm. Now, again, that is something that is well known from literature. But I need to really emphasise a crucial point here. This cannot be done as a punishment to the child. So we often hear that the parent would say, because you are self-harming. That's it. No more pills, no more knives, no more sharps, nothing you can break. That's it. So that's a terrible idea to do this. Removal of means needs to come from a place of love and validation, and then it can work. And that tiny shift of emphasis could make a difference between the child who is self-harming more, self-harming less. That's very important. Dennis, ask-- yes, I agree with everything actually that Dennis said. I would like to add because that was very pragmatic behavioural advice. So what we often forget is that for the parents, we sometimes also need to acknowledge their feelings. And one of the major feelings that parents have is that they feel incredibly helpless. And feeling helpless makes you either very anxious but often very angry. And that what happens often with parents. They get really furious and angry towards their teenagers because they actually feel helpless and frightened. Imagine my child could die from self-harm, and I can't do anything. So one of the things that besides advice, a giving all these advices, I think, we need to do is we need to acknowledge and validate parents in their feelings. And while the teenager needs to learn and sit with the emotions and not self-harm, unfortunately, the parent needs to learn and sit with the emotions and not act immediately and do something impulsive as well. So in a way, I think parents and adolescents both have some similar skills to learn. They need to be able to sit on very comforting emotions and not act immediately. And then that's sometimes something that also works to bring them together in a way. And it's really interesting that you're saying that because as you're describing it, I'm thinking about there may be in the parents either a genetic vulnerability or an environmental experience that both parents and children are having, which means that talking about and experiencing and managing emotions will be particularly hard. So this is advanced-level parenting for any parent, but particularly for this group, it's important to acknowledge that parental experience, as Dennis is saying, is saying, it is very important to stay calm. You may not feel calm, act it, and you may become it, potentially. But the idea of practicing that because it might be scary to see your parent out of control when you feel out of control too but also recognising that parents experience will be really anxiety-provoking for them. So together, what an expert delivery of a to-do list and acknowledging of that experience as well, I think, we've hit all the marks there. I'm just conscious of getting an opportunity to talk a little bit about the formal assessment and interventions that both of you have touched on. Dennis, I'm thinking particularly here about the therapeutic assessment programme. Can you give us some headlines to invite us to find out more about this programme? Because it's an interesting and novel way of addressing self-harm. One thing that, I think, is fairly clear from several studies is that when professionals come to contact with young people who self-harm, either in emergency rooms or in community settings, or even inpatient settings, it's not enough to just do a risk assessment and the plan. It is, I think, fairly clear that a therapeutic component to this initial intervention is very important. It probably matters less what specific model you take, whether you do therapeutic assessment that my group developed or CBT formulation or some other therapeutic component to this. But what I think is important is to work with the young person and the family to develop this idea that what's going on is understandable under the circumstances, that it makes sense, that one thing leads to another, and self-harm has some positive and negative consequences as well, that there is a way to understand self-harm and how it came into this family's life, and also that there is hope, that there is a way to break these cycles and there are ways of coping in a different way. And if you can do these three tasks, when you first interact with the young person, then we have fairly consistent evidence that the young people and the family members are much more likely to come back and see you. I love your expression of creating exits, because it's implying that the young person is really writing their own policy document, which really plays to the strength of the teenage brain. And I think that's very generous to say there are lots of different ways of doing this. But I think in particular, your model recognises the agency that young person needs to feel and find. And that's particularly-- that may well explain some of the successes, certainly. Yeah. Well, I mean, that's an important part. So in therapeutic assessment, we create this with the young person and sometimes with the family member this cycle of that explains self-harm. And a very powerful part of therapeutic assessment is for the young person to answer the question, well, where would you like to break this cycle. And if the young person had worked with you to create it, they will know, and they will tell you. And that's a very powerful and engaging part for the young person tells you, oh, to me, it makes sense to break it in this particular part. And that could actually create a very nice relationship between the therapist and the young person and the family member and take you further with psychological therapy. Excellent. It's such a containing and hopeful framework, I think. And I think thinking about young people and families experience, that position will be very important too, very therapeutic in and of itself. I want to take a turn, perhaps as we come towards the end of this discussion, which we could, by the way, I'd very happily go on and discuss this for many more hours, because I think there is such a lot of gold dust within this conversation, and I'm hoping that our listeners we'll see and hear some of these themes and explore them in more depth because there's a lot more to be understood here. But I want to turn and think about our "now what?" question. So here-- and if possible from each of you-- I would one single practical tip. Now, I'm not looking for a funding idea or a service change. What could I do tomorrow as an adult, or a practitioner or a researcher that might improve my practise if I'm thinking about self-harm in particular? So Michael, maybe you would start what's your "now what? Yeah, I think Dennis said something that is very important and would probably make the biggest impact if we are not only talking about mental health practitioners but all adults who somehow get in contact with self-harming teenagers. I would wish that they all ask for risks in a non-judgmental way because I think that's terribly life saving, and we still lacking a majority of adults who feel confident to not look away or do the wrong thing-- really do the wrong thing. And so if we could achieve that from tomorrow, every adult just does this one correct thing, which means asking and trying to understand risks in a non-judgmental way, that would probably have the largest impact, much more than any psychotherapy or medication or any intervention. I mean, my tip is very similar to what Michael is saying. I would say that what I really want to see is a change from the question, how do we stop self-harm to two questions? What does self-harm do to this young person? What is good about this? What needs it is meeting? And then the second related question is once we identified what it is, how else can we meet that need? Brilliant. That's absolutely fantastic. I mean, a really fascinating and informative episode, as I say, with so many drops of gold in there that are ripe for further exploration, should I say. I'm so grateful for your time and expertise. Thank you, Michael and Dennis. [MUSIC PLAYING]