Deliberate self harm (DSH) is a common problem among adolescents in both community and clinical samples[1–4]. This paper uses Hawton’s definition of DSH as ‘a non-fatal act in which an individual deliberately intended to cause self-harm through injury, ingestion of a substance in excess of the prescribed or therapeutic dose, ingestion of an illicit/recreational drug that was an act the individual regarded as self-harm or ingestion of a non-ingestible substance or object’. DSH covers a spectrum of behaviours, from an act of minor self injury to reduce emotional pain at one end of the spectrum, to attempted suicide at the other. While most young people who have self-harmed do not die by suicide, DSH is a risk factor for suicide in the years ahead[6, 7], with over 40% of young people who die by suicide having a history of DSH. Most young people with DSH do not present to medical services[1, 2], but for those who do, an opportunity is provided for intervention which may reduce risk of future suicide.
Young people who engage in DSH, whether in clinical or community studies, report high levels of depression, anxiety, and relationship stresses, including family conflict[9, 10]. Communication problems and family relationship difficulties in particular have been found to be associated with DSH[11, 12]. A study comparing 52 adolescents who had presented to Accident and Emergency departments following DSH with 52 hospital-based controls with no history of DSH showed a strong association between the absence of a family confidante and adolescent self harm. The authors suggested that poor communication within the family may lead the young person to feel socially isolated, and their problems to appear insurmountable, with DSH being perceived as their only option. Having a good relationship with parents has been reported as being a protective factor against suicidal behaviour and suicide in adolescents, but research in this area is sparse.
It is not possible to be clear about the nature of the association between family communication/relationship problems and adolescent DSH, as few prospective studies have been carried out in relation to this topic. Previous research has, however, found that poorer family functioning results from the occurrence of depression in adolescents, and that impairments to functioning may persist beyond six months after the depressive episode. More specifically, it has been postulated that DSH behaviours have a ‘ripple effect’ on families[16, 17]. A qualitative study by Raphael et al. involved in-depth face to face interviews with parents of young people who had self-harmed, and gives particular insight into the emotional and practical challenges faced by parents in response to DSH activity. These parents reported that self-harm by their son/daughter was extremely traumatic for them, leading to feelings of helplessness, anger, grief, guilt, and failure. Participants voiced concerns about their ability to cope as parents when their young person was discharged from hospital, and questioned their own parenting skills and competence. In some cases, parents argued with one another as to how to manage the child’s DSH and try to prevent future incidents, or left their jobs in order to support the child. Some participants also reported experiencing somatic and psychological symptoms following the initial DSH incident (e.g., depression, insomnia), as well as interruption to their usual routines (e.g., being unable to go to work). Furthermore, participants reported a perceived lack of information and support for themselves from health services, leading to increased feelings of hopelessness and confusion.
These findings were echoed by those of a focus group study for parents and carers of young people with DSH who attended the Children’s University Hospital, Temple Street, Dublin. The participants described the damaging effect of the DSH on their relationship with their adolescent. One parent said ‘your trust is gone and it’s difficult to build that up with them again’. Another qualitative interview study with 12 parents described them as having ‘a strong and lasting emotional reaction’ to their young person’s DSH. These parents reported that they were ‘walking on eggshells’, and having marked difficulties setting limits and maintaining boundaries with their young people.
Previous research examining the broader effects of adolescent mental health disorders (covering a wide range of difficulties, including mood disorder, schizophrenia, and obsessive-compulsive disorder) has described the subsequent difficulties encountered by parents as ‘caregiver burden’[20–22]. This concept includes two aspects, the first being ‘subjective burden’, which relates to the parent’s own perception of the challenges that they are confronted with, and varies according to factors such as child and parental gender, socioeconomic status, and the child’s psychiatric condition and symptoms. The second, ‘objective burden’, refers to disruption to the structure of family life, such as reductions in leisure time, increased financial strain, deteriorating communication and social relations within the family, and changes in household routines[20, 22–24]. Given the nature of the aforementioned emotional issues and practical difficulties that arise as a result of DSH, it is possible that the concept of caregiver burden may be applicable to parents whose child has experienced DSH, regardless of their child’s specific psychiatric diagnosis. In view of the above evidence, it is likely that the association between family communication and relationship difficulties and adolescent DSH is a complex and circular one, and that family relationships can have both detrimental and protective roles.
In 2006, a support programme for parents and carers of young people with DSH was developed by the DSH Team in the Children’s University Hospital, Temple Street. It is called the SPACE programme, and was developed in response to requests for Support by Parents And Carers of young people with DSH who had presented to the Accident & Emergency Department of the hospital. The programme was developed with input from parents, who advised on its format and content. It is an eight week group programme, run for one and a half hours on one evening per week, which is both supportive and psycho-educational, and covers areas deemed important by the focus group parents, such as family communication, skills for parenting adolescents, and information about mental health difficulties in young people. The programme aims to provide support to parents to enable them to support their young person. It is run by two facilitators who are members of the DSH Team in Children’s University Hospital, Temple Street. The programme has been evaluated in a non-controlled pilot study, and appears to be effective in improving parents’ feelings of well-being, improving their satisfaction in their parenting role, and improving family communication. It is currently being evaluated using a randomised controlled trial (RCT).
The aim of this research is to present a cross-sectional, pre-test demographic and psychosocial profile of the parents who participated in the evaluation of the SPACE programme, focusing on parental well-being, family communication, parental satisfaction, perceived social support, the child’s strengths and difficulties, as well as a number of adult and child characteristics. Potential relationships between these factors will also be examined.