Risk Factor: A teenage girl who self-harms

Case notes

PRACTITIONER Steve Roberts, director of Radical Services, a therapeutic service for young people.

FIELD Residential child care.

LOCATION Penrith, Cumbria .

CLIENT  Renata,* a 13-year-old girl with a history of serious self-harm.

CASE HISTORY Renata had come to care provider Radical Services in a state of crisis. She had been in care for eight years and had a history of unsuccessful foster care and residential placements. Her local authority was having difficulties placing her because she frequently self-harmed. This behaviour was brought on by anxiety, particularly when around other young people or in stressful situations.

DILEMMA: Radical Services has various residential settings in urban and rural locations. A remote placement was available, which would have a calming effect but was far from medical facilities.

RISK FACTOR If Renata inflicted a serious injury on herself, medical services may not be able to attend the remote location in time to help her.

OUTCOME With support, Renata settled into the rural setting. After a period of 15 months, she developed healthy coping mechanisms.

* Not her real name

Self-injury is seen by some as “attention-seeking”. But individuals who habitually self-harm commonly do so as a way of coping with traumatic experiences, writes Mark Drinkwater. Steve Roberts is director of Radical Services, an independent provider working with young people with complex behavioural and emotional difficulties.

When Renata came to Radical Services she was in a state of crisis, having experienced repeated foster placement breakdowns. Her self-harming was particularly severe. “The behaviour included hitting and cutting herself,” says Roberts. She was engaging in extremely risky self-harm.

Radical Services has several single placement units suitable for such crisis work. An initial assessment looked at what triggered these situations. It was identified that part of the problem stemmed from the stress of being around lots of other people. So, a key issue in providing care for Renata was deciding where she would be best placed. Keeping her in a populated area would have risked escalating her anxiety and with that, more serious self-harm.

One potential residential unit was situated in a remote forest setting, but was far from any other facilities. However, the risk of placing her in this isolated location was that should she sustain a serious injury she would be far from emergency services.

Rural placement

Over the period of a year, this rural placement seemed to provide what Renata needed. Away from the anxiety-provoking scenarios she responded well to the tranquillity of the remote site.

Roberts feels that Radical Services’ success with cases like this is partly down to its use of the therapeutic model Transactional Analysis, which underpins its work. He says that the model emphasises an ethos that promotes respect for others and values healthy communication. “It helps young people to question their behaviour and staff to question and think about their responses,” says Roberts. “This really helps us to separate behaviour from the person and take the heat out of the one-to-one dynamic. It provides a basis for informing and reflecting upon our practice.”

After a successful 15 months in the remote placement, it was time to move on to the next stage in Renata’s development. Moving back to an urban environment was a big step for her, but as Roberts remarks: “You can’t live in a forest forever.” But there were risks involved in moving her once more. Roberts explains that continuity of staff was important in providing a consistent service for her, so the whole team moved with her.

In the urban setting some of the intense self-harming behaviours re-emerged. “She still has her old ways of coping with difficulties – the self-harm – but she is increasingly able to verbalise her problems and emotions and is now more likely to turn her anger outwards rather than inwards.”

Roberts acknowledges that at times working with young people with complex difficulties can be “a slow process,” but this case has made significant progress. “There is still some way to go but she is now talking about what she wants to be in the future which is more hopeful than the bleak fatalistic outlook that she used to hold for herself,” says Roberts. “There will still be really difficult times ahead but she now has some conscious sense of a future.”

More details of Radical Services

Independent comment

John Diamond, chief executive, Mulberry Bush Organisation – a charity that provides therapeutic residential care for children

Radical Services has responded with genuine flexibility to meet Renata’s needs. Renata’s life history is sadly typical of many children in the care system who, due to early multiple trauma, enact their experience through an inability to make relationships, multiple placement breakdown, and in her case self-harm as attachment-seeking behaviour.

The use of observation in the assessment process seems to have identified critical traumatic triggers for Renata. The service has responded with a placement to meet her psychological needs, rightly putting these before concerns about geographical distance.

The approach seems to work because the staff team have a clear underpinning theory base, which helps them orientate to the primary task of meeting Renata’s needs. We can assume that she also picks up on this containing ethos, which supports her recovery.

The staff team stayed responsive and moved to the urban setting with her. Although the return inevitably re-opened some of the original wounds, she now has a better experience of caring relationships, improved self-esteem, and the ability to convert acting out into verbal communication.

Arguments for taking the risk

● Forest placement offered a calm space: Renata arrived in a state of crisis. She needed a service that met her needs for a calm environment. The forestry placement offered this.

● Common approach important: Consistency is important in the therapeutic process. The use of a common approach, such as Transactional Analysis, in a small, consistent care team provides children with the focused care they need.

● Space to develop relationships: The time alone would give Renata the space to develop better coping skills and help her to form healthy relationships with support staff.

Arguments against taking the risk

● Too far from emergency services: There is no guarantee that there would be less self-harm in the forestry setting. If Renata engaged in serious self-harm, there would be a danger that she will be too far from emergency medical services.

● Resources: Providing high levels of support is an expensive option at a time when resources are limited.

● Over-reliance on isolation: Even if the rural placement was successful, it could make her reliant on the isolated setting and prevent a successful return to an urban setting.

This article is published in the 25 June issue of Community Care magazine under the heading Out of the forest into the light