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A Strengths-Based Group Program on Self-Harm: A Feasibility Study

Article  in  The Journal of School Nursing · August 2010

DOI: 10.1177/1059840510368801 · Source: PubMed

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TITLE: A strengths-based group program on self harm: A feasibility study

AUTHORS

McAllister, Margaret, 1. BA, MEd, EdD, RN, MHN, FACMHN

Penelope Hasking 2. BA(Hons), PhD

Andrew Estefan3. BN, MN, RN, PhD

Kerry McClenaghan, 4. PGDip Community, MCounselling, RN, MHN

John Lowe5. BSc, DPubHlth

AFFILIATIONS AND POSITIONS

1. Associate Professor in Nursing, School of Health and Sport Sciences, University of the

Sunshine Coast

2. Senior Lecturer, School of Psychology, Psychiatry & Psychological Medicine, Monash

University

3. Assistant Professor, Faculty of Nursing, University of Calgary

4. School Based Youth Health Nurse, Sunshine Coast, Queensland

5. Professor of Public Health, Head of School School of Health and Sport Sciences,

University of the Sunshine Coast

ACKNOWLEDGMENT

The authors wish to acknowledge the support of University of the Sunshine Coast,

Queensland Health, University of Calgary and Monash University.

CONTACT

Dr Margaret McAllister

University of the Sunshine Coast

Maroochydore, 4558

Email: mmcallis@usc.edu.au

Ph: 61 + 7 5456 5032

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ABSTRACT

Every day in Queensland, Australia, student services within schools are

responding to a child who has deliberately self-injured. School Based Youth Health
Nurses are in a prime position to effectively intervene, mitigate the risk and promote
healthy self-caring behaviours. Whilst these nurses have a wide scope of practice, and
implement many relevant health promotion programs, there are no programs that focus
specifically on self-harm.
This feasibility study of a program to assist young people so that they find safer
alternatives to self-harm took place in 2009. The school nurses were engaged in half
hour one to one interviews using a semi-structured schedule.
The study found strong support for the program. It was identified as much
needed, the training component was seen as essential, innovative in its strengths
orientation, likely to be engaging for many young people and appropriate in length and
structure. Challenges included: garnering support from within the whole school for
such a program and accessing the young people who would be most likely to benefit
from the program. Changes suggested included: providing a name for the program that
would be youth-friendly, and including an assessment phase to select appropriate group
members.

KEY WORDS

Self-harm, self-injury, school nurses, empowerment

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Self-harm, defined as deliberate and voluntary self-injury that is not life threatening

(Hawton, 2008), is a major health and social problem within Australia. It affects from 4-8 %

of Australians across the lifespan (Steenkamp & Harrison, 2000). Self-harm usually begins

between 13 and 18 years of age and, whilst frequently mild and transient, in some cases can

persist for up to 10 years (Hawton, 2008). While self-harm is not always associated with

suicidal intent, self-harm is a recognized risk factor for later more severe self-harm and

completed suicide (Connor et al., 2003). Up to16% will self-harm repeatedly and for those

who do not find a way to cease self-harm, 5% will die (Skegg, 2005), either through

accidental fatal self-harm or suicide.

Within Australia, like most parts of the developed world, there is evidence that self-

harm is increasing amongst the adolescent population (Hasking et al., 2008). Samples of

Australian secondary school students have indicated a range from 5.1%, 6.2%, and 10.5%

(Patton et al., 1997; DeLeo & Heller, 2004; Martin et al., 2005). More recent studies have

reported lifetime rates of up to 33% among secondary school students, with approximately

10% engaging in relatively severe self-harm (Hasking et al., under review).

Given the high rates of self-harm in secondary schools, a number of initiatives have

been implemented in an attempt to prevent self-harm and subsequent suicidal behaviour.

Actions to address the issue within schools have included: educating teachers and parents on

general mental health issues (Wyn et al., 2000); providing education to adolescents on high

risk behaviours in general (Patton et al., 2000); and providing psychological support to

adolescents with signs of anxiety and depression (Barrett et al., 2000; Spence et al., 2005).

Such general programs fail to address the issue of self-harm specifically, and while they

successfully increase mental health knowledge and foster positive attitudes, they have been

criticized for failing to incur positive targeted behavioural change (Harrell et al., 1999). We

argue that a more successful approach to preventing self-harm needs to: 1. target
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professionals most likely to encounter young people who self-harm and 2. focus on solutions

and strengths rather than problems and deficits. This paper presents the results of a study

investigating the perceived need and feasibility of a new solution focused program developed

for school nurses.

Since 2005 in Queensland, the school based youth health nurse program was enhanced

so that all secondary students in Queensland now have access to a School Based Youth

Health Nurse, including students enrolled in Schools of Distance Education. There are 115

positions in the program. These nurses work collaboratively within the school community by

supporting the teaching and learning to include health and wellbeing; providing health

consultations; advocating on behalf of young people and supporting the planning,

implementation and evaluation of health promotion activities and are oriented towards

prevention, health promotion, and early intervention.

Given their daily contact with young people in secondary schools, school nurses are in a

prime position to identify and intervene with young people at risk of self-harm repetition.

They are already skilled in health assessment, able to safely identify mental health risks and

appropriately refer students to specialty services. With solution focused strategies school

nurses will have the added tools to run effective intervention groups and enact positive

changes within their school. As school nurses are expected to provide research-informed

practice, it is important to develop and trial programs that will not only provide efficacious

outcomes but that will also be perceived as useful, feasible and acceptable to them.

Facilitated self-management groups are an innovative strategy for those who self-harm

because there are a number of features about self-harm that can be effectively addressed

through group involvement. Groups can help people connect with each other and to feel less

alone (Yalom, 1995). Bringing people together to talk, support and encourage one another

towards similar goals can be energizing. Also, the creative thinking and inherent altruism
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that characterizes young people and young peoples’ groups do not tend to be harnessed in

adult-oriented illness-services. Young people in groups can share good ideas, provide mutual

support, and experience being helpful and valued by others. Third, positive reinforcement is

readily available, as small changes can be noticed and appreciated by people who are aware

and who care. This can have a cascade effect, providing motivation, hope, commitment and a

sense of effectiveness. A simple change can be reorienting and constitute a major turning

point for people (Yalom, 1995).

Despite the recognised benefits of group therapy, only two studies have examined the

effectiveness of this approach for addressing self-harm. Wood et al (2001) conducted a

randomised controlled trial which showed the benefits of group therapy for a clinical

population who deliberately self-harm over treatment as usual. However, Hazell et al (2009)

in their Australian replication of this British study, found that standard treatment was slightly

better than the group therapy. These mixed results pose a problem when deciding which

factors might be best addressed in a program for a sample of non-clinical adolescents.

Further, group interventions conducted in clinical settings are not easily comparable with

those in non-clinical populations and there remains an urgent need to develop and evaluate

psycho-social interventions which have the potential to reach a wider range of at-risk youth –

especially those in schools.

A solution-focused approach

There is now a world-wide movement in taking a solution rather than a problem focus

to enacting changes in individuals and groups. The solution paradigm has now been applied

in many disciplines, such as psychology, social work and business, with exceptional results

(Allan, 2003; McAllister et al., 2008). Such a paradigm fits the school context very well

(Mahlberg & Sjoblom, 2005). Whilst the concepts are applied differently, essentially solution

focused interventions aim to emphasise and build upon strengths and resilience, and to act
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proactively and preventatively. When problems do occur the idea is to not simply seek to

identify difficulties, risk factors and disorder, but to act. As Seligman simply states (2002, p.

4) ‘Treatment is not just fixing what is wrong; it also is building what is right’.

The solutions focus emphasises an element to the problem solving method that is often

minimized or overlooked, and that is the solution generating phase (Johnson, 2005). In this

sense, it has a broader and more creative set of strategies which are not limited to problems.

Problem-centred approaches also tend to be bounded in the present (McAllister, 2007), which

is manifest in the exclusive focus on issues in the present, and the belief that clinical work

concerns only the present time, the time that one has with a client, and there is an unfortunate

lack of emphasis on the future.

In response to the perceived need for a more efficacious group-based intervention for

secondary school students we developed a structured and solution focused program for school

nurses to use. The aims of the program were to produce a program relevant for and targeted

to all young people not just those identified as being at risk of self-harming; to understand

what harm to self means broadly and specifically as well as to explore what good self-care

and help to others means. The program prompts reflection on how to take better care of self

and others, explains self-harm, and shows how to interrupt the self-harm cycle by focusing on

empowering young people to more effectively self-help, and thus to modify, create and

sustain a healthy environment for themselves.

A focus on fostering self-care as well as community-care is unique to the program and

its empowerment goal. Empowerment is defined as a process that fosters power in people for

use in their own lives, their communities and in their society, by acting on issues they define

as important (Page & Czuba, 1999). The way empowerment is conceptualised in the program

is illustrated in Figure 1.
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In order to strengthen self-belief, self-care and engagement with others, it was

important to teach the school nurses solution-focused principles and strategies. That is, the

focus is on activities that are: 1) engaging young people so that they feel listened to, valued

and integral to setting individualized goals; 2) building on existing or hidden strengths and

assets to help achieve those goals, in particular homing in on their desire to self-explore and

self-care, raising awareness of social networks and resources, and sharing creative ways of

coping, soothing, relaxing and motivating the self; and 3) encouraging the extension and

transfer of concepts learned in the group to their real-world settings. The group itself was

designed to include activities that are stimulating, fun, insight-raising, challenging and also

safe and supportive.

The current study

Although we believe our new solution-focused program may offer a promising

alternative to traditional resilience programs, its success is dependent on the support of school

staff. Prior to implementing such a program we aimed to explore the feasibility of the

program and the acceptability to school nurses. According to Lynskey & Sussman (2001), the

single-group case study is ideal for intensively exploring a single group of people’s reactions

to the process of a program. We identified one population of school nurses, located in the

Sunshine Coast of Queensland, and this became the single-group case. We presented the

program to these nurses in order to: 1. Explore with participants the acceptability of the

proposed program, and 2. To explore the extent to which it is possible to implement the

program as designed.

Method

Participants

Twelve school nurses participated in the study. They had a mean age of 40. All were

female. Most had been working as school nurses for 10 years. The minimum years of
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experience in the field were three. Most nurses worked part time in schools with anywhere

from 1000 to 2000 students.

The program

The solution-focused program was designed to be run in small groups of between 6 and

8 young people, facilitated by a school nurse. The delivery period was proposed as 6 weeks,

the length of a typical school term, and each week deals with a different theme (see Table 1).

Any young person at the age of 13 or 14, the age when self-harm is likely to begin, would be

eligible to participate in the group and entry would be dependent on how many groups the

nurse was able to run within the school term. Eligibility would not be restricted to young

people who self-harm. The program as described to school nurses included four phases:

training of facilitators, a delivery phase, post-group supervision for facilitators and an

evaluation phase.

Training of facilitators. It is crucial for the facilitators to be trustworthy, consistent, able

to utilize solution strategies that assist in setting goals, reframing, validating and supporting.

In order to prepare facilitators, a training session would be held to show how to use solution

focused strategies and work within the group.

Delivery phase. In the delivery phase, 6 weekly sessions were designed to empower

young people and provide them solution focused skills to understand self-harm, build self-

confidence, enhance self-care and foster a caring attitude toward others. In the first session,

all members of the group receive a journal that members are invited to use during and after

the group to help them remember key points, to answer questions posed during the session, or

to raise ideas they would like to discuss. Key concepts included throughout the sessions

include the use of ‘Skeleton keys’ and ‘obstacle courses’.

Sharry’s (2007) concept of ‘Skeleton keys’, an important coping strategy, are the tools

people can use to open all sorts of doors to new ways of coping. Examples of skeleton keys
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discussed within the group are: talking things through, laughter, relaxation and meditation

methods. The concept is explained and the group is invited to share strategies they think

might work well as skeleton keys. Throughout the sessions, a range of activities are designed

for members to search for and analyse the skeleton keys they identify in characters appearing

in carefully selected film-clips. The rationale is to make use of film’s potential therapeutic

power (Grace, 2005) to extend the critical thinking skills being developed in other aspects of

their school curriculum (Ayers, 1998, Queensland Studies Authority, 2008) and to encourage

participants to become more discerning consumers of media imagery. In addition, through

critical analysis of skeleton keys used by others, group members expand their own repertoire

of coping skills.

Obstacle courses were defined as turbulence, challenges and alterations in identity and

skills that many adolescents face. These challenges can be exacerbated in a culture that is

controlling, individualistic, when power is viewed as something that can’t be shared or when

there is a punitive reaction to risky behaviours. Feeling disempowered is about feeling as

though these factors are not within the person’s control, that change cannot be effected by the

self. Conversely, feeling empowered involves an awareness that hurdles are what makes life

challenging and fulfilling; that coping and adaptation to change takes preparation, support

and effort. When difficulties are encountered they can be shared with others so that they don’t

have to go through the same hardship and thus wisdom from experience can be shared.

Throughout the sessions, group members learn to identify obstacle courses, and to develop

skills to negotiate them in their own lives.

Throughout the program, information about self-harm is explained clearly and

carefully. That is, it is defined as a strategy used by a few people to manage or communicate

tension and emotions that commonly arise in adolescence. It is also explained that many more

people learn to use their skeleton keys to cope with the tension.
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Post group supervision. After each weekly session, facilitators will participate in a post-

group peer-supervision exercise. The aim of this exercise is to provide on-going evaluation of

the program and support for facilitators. The EARS technique (Berg, 1994) is used to assist

the supervisor to encourage the facilitator to critically and constructively reflect. It is where

you elicit examples of progress, then amplify and reinforce, and finally start again with a new

example.

1. Elicit: What has been better? What’s different?

2. Amplify: Who else noticed this change? Tell me more

3. Reinforce: Wow. That’s quite an achievement. How come you were able to do it?

4. Start over: What else is better? What’s different?

Evaluation phase. Bearing in mind the need for evidence-based practice, the program

as presented to school nurses included a built-in evaluation. Should the program prove

acceptable and feasible to school nurses, a pilot study would be implemented as a means of

conducting a process evaluation (exploring the acceptability of the program to group

members), an implementation evaluation (exploring whether the program was able to be

implemented as intended) and a preliminary outcome evaluation (to determine whether

positive changes arose regarding knowledge regarding self-harm, self-efficacy and self-care

strategies).

Interviews & Procedure

One week prior to the interviews, all of the participants were contacted by email or

telephone and reminded of the study and advised that information would be posted to them

within the next day or two. The information included a hard copy of the program, and the

power-point discussion material for each week was provided on CD. This allowed

participants time to familiarize themselves with the proposed program.

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All school nurses were interviewed individually in a quiet location at the school by the

last author, who was unknown to all. The semi-structured interviews were designed to elicit

the views of school nurses regarding: the need for a solution focused approach to addressing

self-harm within schools, the acceptability of the program in its current form, the strengths

and innovations in the proposed program, the perceived challenges in implementing such a

program, and any changes they would make to the proposed program. Interviews lasted

approximately 30 minutes and were recorded for later transcription and analysis.

Data were analysed using a Framework Analysis (www.natcen.ac.uk), an approach

often used in research that has a practice orientation. Consistent with this analytic framework,

data were analysed independently by all authors. Each author used notes to identify emerging

patterns, cross checked to find exceptions to themes, and generated tentative explanations for

the patterns of results. Themes identified by each author were compared and compiled to

extract the key themes present in the interview data.

RESULTS

The results are presented according to the key objectives of the study, that is: to identify

the perceived need, the acceptability of the program in its current form, the strengths of the

program , the challenges in implementing such a program as well as suggested changes.

Categories within these themes are also explained.

PERCEIVED NEED

When asked about the need for the proposed program, all participants were generally

positive in their response and were clear to identify a need for it. The perceived need for the

program was apparent through a reported lack of knowledge in school staff and a lack of

appropriate services available to young people who self-harm. There was acknowledgement

from all participants that self-harm was occurring within schools, that it involved a broad
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range of risky behaviours, from substance misuse and cutting to aggressive outbursts to ‘train

surfing’.

Lack of knowledge

Several nurses commented on the lack of knowledge regarding self-harm in the school

system. Participants explained that within the school there was need for greater information

and understanding amongst staff and students.

I’m not sure that many teaching staff have good working knowledge of self harm and the
impact that has on a young person’s engagement and learning and school (P5)

Others expressed a personal lack of confidence in the support being provided to young people

who self-harm.

I would worry sometimes that maybe the information or the support I was
giving them, you’d be worried about saying the wrong thing or doing the
wrong thing (P1)
Participants also acknowledged that self-harm made school staff anxious.

It’s been my experience, that schools don’t like the term of self harm and there’s a certain
anxiety around working with an identified group of young people who self harm (P5)

Absence of appropriate services

Most participants said that existing services were totally inadequate on the issue of self-

harm and that school support staff lacked referral options for young people in need.

There’s just nothing out there. I mean yes we can refer kids to agencies and so forth
and we can get some help with psychologists but to have something that is coming in at
a level where you’re just trying to help them help themselves rather than waiting until
something happens and then referring them off. (P1)

There was an identified need for early intervention strategies, not just because this was stated

policy and provided a rationale for nursing practice, but because participants could see the

inadequacy in providing programs only in reaction to existing problems within schools.

It seems to me to be something that’s not just a reactive program to when we’re finding
this many kids are having problems in this area, let’s do something. This is getting in,
early before they start doing other things. (P1)

The uniqueness of the program’s content and emphasis was valued.

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There are lots of programs around and excellent programs. I know there’s ‘rock and
water’ ... we do, ‘the girls excel’ program here which targets obviously girls, year 8s
and 9s and building up their self confidence in lots of different ways but I think this one,
I like it because it’s a little bit more specific. (P1)

PROGRAM ACCEPTABILITY

Having identified a need for the proposed program, we were interested in whether the

program, as proposed to school nurses, would be accepted by the school community. A clear

theme emerged regarding the necessity of first gaining wide-spread support. In addition,

nurses offered suggestions for increasing the acceptability of the program, such as by

broadening the definition of self-harm and trialing the program prior to wide-spread

implementation.

School support

Several participants stated that although as nurses they perceived a need for such a

program, its acceptability would depend on the support and ownership from the education

departments, principals, teachers and parents.

If they said, “Yeah well let’s do this program” you’d certainly get support from the
school, from all the teachers. Yeah they’re very supportive. (P1)

School nurses also felt that if the school had a sense of ownership in the program it would be

more widely adopted.

Schools have embraced all the other programs that the nurses run… So I
don’t think there’ll be a problem with that, so long as the school can have
the final say. So long as they, as I said before as long as it’s contained
within the school and it’s for their students and it’s run by the school
personnel. (P2)

Participants explained that school staff would be likely to consider that, even though self-

harm was perplexing and school-based strategies were inadequate, the issue be managed and

contained within the bounds of the school itself. Of major concern was that an external group

coming into the school might publicly expose a problem and then not be able to manage it.
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Thus school autonomy was seen to be crucial to the program’s acceptability and if the school

nurse supported it, the teaching staff understood it and could see the benefit, and there were

processes in place to manage contingencies, it would be acceptable.

A broad definition of self-harm

In order to promote the program’s acceptability, several participants encouraged a broad

definition of self-harm – one that did not single out cutting and deliberate self-wounding, but

was inclusive of a range of self-defeating or risky behaviours that could lead to ongoing

issues for the young person.

If it was opened up not just for the people who self-harm but self-harm in other ways or
are at risk or that sort of thing, then I think that, you’ll possibly get a lot better response
from the schools (P3)

It was also suggested that to improve program acceptability within the school, clear processes

could be developed. These included written inclusion criteria to assist in recruiting suitable

young people to the program and program flyers to be distributed to students and staff.

I think anything that you’re putting in a school, it’s really important to give the teachers a
lot of information about and get their involvement in so they get a little bit of, I guess
ownership as well. (P1)

FEASIBILITY OF THE PROPOSED PROGRAM

In addition to asking about the need and acceptability of the program, we were also

interested in whether the program as we proposed it would be feasible. In other words, would

it be viable to offer the program within the school system. The majority of school nurses

believed the program to be feasible. Themes regarding feasibility centered on the format of

the program and how well the program fit within the role of the school nurse.

Appropriate format

All participants perceived the program to be age appropriate, engaging, current and

topical. Regarding the length of the program, the consensus was that one hour a week for six
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weeks was appropriate to meet the aims of the program and to allow the program to fit within

the school term.

I think 6 weeks is a really good time for programs. I think some programs can stretch
out to 13, 14 weeks and they just go on and on and on and you can lose that
momentum whereas this, they’re taking something away. (P8)

Reflecting the need for early intervention, school nurses supported the program being offered

to students aged 13-14 years. Nurses also thought the program would be easy to use, noting “I

think it’s very easy to follow” (P6).

Group focus

The group focus of the program was also identified as acceptable, indeed a good fit for

the nurses as much of their daily work involves group activities and young people enjoy

activities that are peer-based rather than individual.

It fits in nicely especially when a lot of my job is health promotion. I run groups in
the school anyway so and I’ve got different age groups of students, they would fit in
and be implemented in with different groups. (P6)

STRENGTHS OF THE PROGRAM

From the interview transcripts we were able to extract themes relating to the strengths of

the proposed program, as noted by the school nurses. Themes regarding the innovative

content of the program, the solution-focused approach of the program, and the future-

orientation of the program were evident. Finally, participants endorsed the training of group

facilitators and saw this as vital component of the program.

Innovative

Aside from the expression of support for the program’s content and style, participants

made particular mention of the activities likely to be of interest to young people, including

the poetry, journaling, innovative use of media, and the engagement of the peer group within

sessions.
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I really like the narrative approach in the story telling and the way the program starts
with a story. That, I knew this young woman who did this and that, and now she’s off
at uni getting a degree in forensic science etc. That’s a lovely way to start. I think
that’s really engaging because that story of success, even though at that early stage in
her life she had all these problems she had to battle... I think poetry is fantastic with
young women. They write a lot of poetry. (P12)

Developmentally, the activities were seen as engaging as well as challenging, without

overloading young people with content and material that is preaching.

I like the movie, the clips, where young people can pull that to pieces and just flesh it
out a bit and just see where that aligns with them. I think that’s, that would appeal to
a young person (P7)

[the activities are] quite different and thought provoking, so definitely anything
different and interactive like that, I think would work quite well.(P10)

The group based discussion was felt to be especially relevant for young people who valued

being with their friends, having fun and brainstorming.

Friends supporting friends I get a lot of…I’ll see five or six people concerned about
one person…and I would normally work with a whole lot of them (P9)

Solutions orientation

The explicit solutions orientation was seen as innovative and positive.

There is a focus on the strengths rather than just looking at the negative side of it all
and the vulnerability. I mean it seems to look at both, the vulnerability and the
strengths which is really important. So I think it’s well balanced. (P2)

Related to this was the notion that the program not only fostered an appreciation of strengths,

but also fostered critical thinking among young people.

It allows for that critical thinking, coming up with their ideas. We’re not... it’s their
strengths. It’s their solutions to things. It’s very client centred I suppose, because it
allows them to come up with their own ways and also explore what they’re already
doing really well. I think a lot of young people don’t realise what they’re doing well
and we can point it out to them but they don’t take it on board until they actually can
see it: Empowerment (P6)

In relation to self-harm in particular the focus on issues other than the presenting problem

were seen as particularly important.

 17 
 

With a lot of the kids, their strengths have not been highlighted, so I think this is a
nice way to look at their way of coping, so, and I’m really drawn to the strengths
based approached. I think it’s really exciting. (P10)

The reframing towards self-care, rather than self-harm, was also valued.

It is focussed more on solutions. Whereas like other programs might have just one
particular session on self care, looking at how you’d cope with adversity, as in stress
management, those sort of things; but this is a whole program around those issues.
(P7)

Oriented towards the young person’s future

Participants noted that the program emphasised how young people could take the

information and use it in the future. This future orientation was seen as important.

I think it’s great particularly to finish up, there’s new beginnings and I think
sometimes it’s really important to allow them to celebrate who they are…So they
class it as a real celebration so, and an achievement, which I think a lot of them do
need to ... just who participated and where they’ve come to where they are and yeah
(P7)

Gives them something to take away with them when they’re finished, that’s cool (P9)

Support for the inclusion of pre-program training

The inclusion of training prior to delivery of the program was seen as necessary by most

participants. They suggested that this would help to promote nurses’ confidence in the

content and process of the program, and help them feel equipped to respond therapeutically

and effectively to a variety of sensitive issues that may occur for young people around the

issue of self-injury. In particular, the opportunity to see the content delivered by the trainer

was thought to be beneficial.

I would really like to see this presented by someone else first and just see how they
present it. I think if you’re just given the program and all the content and then say you
can run this, I’d like to see it in action. I’m a very visual hands on learner and even
though I’ve run other programs I think I’d like to see someone else present it first and see
how they handle it. (P1)

CHALLENGES

In addition to seeking the school nurses’ views regarding the positive aspects of the

proposed program we also sought opinions regarding challenges to implementing the

 18 
 

program, and suggestions for changes to the program. A number of challenges were

identified, including the challenge of overcoming myths and stigma, and the difficulty in

recruiting those youth most likely to benefit from the program.

Overcoming myths and stigma

An important issue was revealed in this interview process and that is that a myth about

intervention programs in relation to self-harm abounds within the school culture. Participants

termed this the ‘talk about it myth’. Participant Two explains:

[school policies in relation to this issue are ] based on fear... it’s that old belief system
that still a lot of people have out there that if you talk about it, people are going to do it.
So it’s breaking through that. It’s like Sex Ed - it’s taken years to try and break down
those barriers. It’s still unfortunately alive and well in some cultures. (P2)

Self-harm is a particularly sensitive topic, and one that provokes anxiety and uncertainty

among individuals who are not trained to address it (Crawford, Geraghty, Street & Simonoff,

2003). Participants suggested that the way to break down the myth and avoidance was to

convince key stakeholders of the benefits.

It will just need a couple of courageous leaders to take it on board and go with it and
it’ll be fine (P2)

Accessing young people in need

Another challenge was the difficulty in accessing and then sustaining young peoples’

participation in the program.

Students who need it don’t come to school often: the few, the students that I’m thinking of
that would benefit don’t come to school very often. So it would just be engaging those
kids very early to come especially on those days and keep them coming. (P1)

Ironically, the very people who might benefit from the program were the ones who were most

at risk of dropping out. Thus, a sensitive, person-focused approach was seen as crucial.

If it’s framed properly and the young person feels special and invited, then that’s not
an issue recruitment- wise. If they’re targeted and coerced into coming, that can be
an issue (P12)
 19 
 

There were several suggestions for overcoming this challenge. The first was through wide

recruitment.

Recruit widely – [The young people are] very reluctant to participate in something where
it’s identified that someone’s different ... once you’ve had a couple of kids go through and
find it useful, then it’s more likely to be promoted as being useful (P9)

The second was by engaging the young people at the very beginning, possibly through

posters, or personal contact and personal promotion of the group’s content and format.

Being able to engage those kids straight away and get them, within definitely the first
session, that this is something that they know, that they need to come back for, has to be,
so that first session, something magical has to happen in that first session for those young
people to say, “Hmm, this might be even worth turning up to school for.” (P10)

The final suggestion was to garner parental support – again through wide program promotion,

and an explanation of the evidence behind the program, the content process, format and

benefits.

You’d have to get the parents behind you in helping to make sure they get out the door
and physically come to school on those days. Hopefully after the first couple of weeks
they’d really settle into the program and they’d enjoy it and they’d to want to come for
that reason (P1)

SUGGESTED CHANGES

A better name

In line with meeting the challenges of interesting, engaging and sustaining participation

from young people likely to benefit from the program, most participants suggested a change

of name for the program.

I definitely think the title. I think the focus on the self-harm, particularly; I think that
would be off-putting to young people (P7)

Participant 12 expressed concern that a title emphasising self-harm would make it difficult to

market the group to the young people. She said “it needs something snappy”. She suggested it

needed to focus on empowerment, but in such a way that would be meaningful to young

people. She offered several creative marketing suggestions, including the production of

youth-friendly brochures, or a ‘skeleton key’ charm or key ring.

 20 
 

Post-group supervision

Whilst the program did include a process for post-group supervision, it was not clear

how that would be provided in schools in the longer term, though it was seen as important.

if I had any questions. How could I do that better, that sort of thing, or if I had a question
as I’m reading through it and researching it a little bit more. If they’re just there to be
like a mentor, supervisor type of role to guide me and help me to improve, then that’s
probably as much as I need, and any other resources that they’ve got, that I could read.
(P10)

DISCUSSION

Although many people and groups are increasingly concerned about the rising

prevalence of self-harm among young people, no group program exists for young people in

the community. While promoting general resilience, the specific focus on self-harm directly

addresses this issue in the population most likely to engage in self-harm or encounter self-

harm among their friends.

This current study shows a need for a feasibility study to be conducted prior to simply

implementing yet another program. The school nurses strongly supported the program,

especially its strengths-based nature. As other studies have found in other contexts, focusing

on strengths and capacities may be more effective than traditional deficit based approaches.

Such an insight could equally apply to school nursing and other prevention-focused services.

A number of key features of the program were identified as positive and perhaps

unique. Since mixed results have so far been achieved in other programs, examining these

factors in future research will be important. In the program there is an acknowledgement of

young people’s preference to talk to friends about their struggles, including self-injury

(Hawton, 2008). The program utilises peer interaction and therefore requires facilitators to

attend to the therapeutic group process as well as to work with the solution-focused material.

The program provides structured reflection for the facilitator. The school nurses identified the
 21 
 

need for and benefits of post-group supervision. This inclusion may be useful in helping them

better relate, and sustain relationships, with the young people in the program. The literature

points to relationships as being central to the success of educational/therapeutic group

working (Hubble, Duncan & Miller, 1999). Several models of supervision are possible: one

to one expert supervision; peer supervision; group supervision, or web-based supervision that

is either real-time or asynchronous.

The participants believed that the program’s content and focus could be applied more

broadly than the issue of self-harm and this suggests that the concept may have broad

applicability within school-based health education. Other solution focused approaches

relevant to this context need to be developed and researched.

All studies have limitations. This was a small scale feasibility study that involved

interviews with school based youth health nurses. The study produced no process or outcome

data to demonstrate the program’s usefulness. However it has clearly shown the program has

merit and more development is worthwhile.

This feasibility study was beneficial because it illuminated several practical obstacles

that can now be addressed. These include: a targeted advertising campaign to different groups

that may win broad-based confidence and support; specific inclusion criteria for the group

participants may assist in recruitment and in ensuring that a broad definition of self-harm is

used (see Table 2); flexibly delivered post-group supervision models may be developed; and

pilot data may be produced from a one-school trial of the program.

We have learned that before the introduction of any program, it must have wide-spread

support from stakeholders within the education system and the whole school community.

There remains, however, an ongoing challenge for programs that target self-harm or other

sensitive topics in schools. This is the fear of contagion - the idea that if self-harm is

discussed it may precipitate self-harming behaviours. While there is evidence to support the
 22 
 

contagion theory in higher-risk and clinical populations (Muehlenkamp, Hoff, Licht, Azure,

& Hasenzahl, 2008) no such evidence exists to support the contagion theory in communities

in general. It seems that the “myth” of talking about self-harm can be a powerful barrier to

the implementation of helpful approaches to meeting young people’s needs. But self-harm is

happening so commonly within the community that we argue that not talking about it is

equally remiss. A similar argument has been used in relation to sex education in schools, and

the evidence clearly shows that the benefits far outweigh the risks (Kirby, 2007).

Education systems and schools are right to be cautious about untested programs, but

they also need to be active in supporting solution-focused research and the systematic

accumulation of evidence. They also need to be accountable to the community by

demonstrating active engagement in the promotion of health and wellbeing in adolescents.

 23 
 

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 27 
 

Figure 1 Empowerment goal

• fun,  friends, learning, 
Context • Awareness  
Empowerment
• Stress, conflict • Change readiness
• Change • Risk Factors • Personal assets • Positive, generative actions 
• Control  • Protective factors • Cultural assets – peers,  for future
• Resources – role models, coaches,  • Family/cultural supports teachers, • Or, Maladaptation and 
mates • School culture conservation

Life at school  Facilitators or 
and home Barriers
 28 
 

Table 1: Session Themes

Session Themes Session Activities

1. Developing rapport; focusing; gaining • A story of resilience – discussed
baseline information • Poetry analysis about changing
habits
2. Skeleton keys • Symbols of strength
• Who am I?
• What will we do if?
3. Obstacle courses • Cycle, representations of stress
4. Media Messages • View film clips and search for skeleton
keys and their effects
5. Peace Making: to learn the difference • Film analysis
between conflict reaction • Web-quest
6. New Beginnings • Pay it forward activities

Table 2: Inclusion Criteria

Any young person who meets the following criteria could be invited to

participate:

1. Meets the program’s broad definition of self harm : any risky

behaviour that could lead to ongoing issues for the young person.

2. One who demonstrates concern about the issue of self harm. They

may be personally demonstrating or considering risky behaviour or

associating with or supporting friends who are

3. Interested in or motivated to participate in a group

4. Looking for psycho-social resources

5. Despite poor school attendance may be contactable and encouraged

to participate by friends or family 

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