Participants

Parents of adolescents referred to a community child and adolescent mental health service (CAMHS) in Croydon, south London, for treatment of self-harm were approached for the study over a period of 11 months. One parent was recruited from a connected CAMHS.

Interviews

The semi-structured interviews lasted approximately 1 h. Topic guides were developed in collaboration with the CAMHS clinicians who devised and ran the parents' groups. In order to check that questions were sufficiently open and wide ranging, once the initial guides had been drawn up they were reviewed by colleagues with experience of qualitative research in fields outside of CAMHS and by a parent of an adolescent who self-harms unconnected to the study. The topic guides were divided into four sections: history of self-harm; personal experience; making sense of self-harm and self-help; and improvements and hopes for the future. Questions posed were broad and open-ended such as ‘Describe how and when you first found out about your son/daughter's self-harm behaviour’. All interviews were conducted face to face at the CAMHS centre by one researcher (A.O.) who had no previous relationship with participants. They were transcribed verbatim and pseudonyms given to protect participant identities. Individual summaries were sent to participants to allow them to reflect on key points, give feedback or expand. Only two parents (Mrs E and Mr J) responded to acknowledge that they had received their summary and both stated they were satisfied with the conclusions drawn.

Analysis

The data were imported into QSR NVivo 7 Software for Windows and analysed using interpretative phenomenological analysis. ^{Reference Smith9} Interpretative phenomenological analysis is concerned with gaining insight into a person's subjective account of their experiences, rather than trying to objectively determine the facts, and is therefore useful for research seeking to explore participants' experiences, understanding and views. ^{Reference Brocki and Wearden10} This inductive form of analysis recognises that the personal preconceptions and individual reflections of a researcher lead to an ‘interpretative’ account of the data.

Triangulation of data, achieved by two independent researchers (A.O. and C.R.) approaching the same sources and independently coding interviews, reduced the potential for researcher bias. The researchers began coding interviews while data collection was ongoing to ensure that data saturation was achieved before recruitment terminated.

Initially, four interviews were independently coded and an open coding session between the two researchers was used to confer on and list themes. Theme descriptions were drawn from the language of participants and all themes were included regardless of degree of prevalence. The remaining eight interviews were analysed using the index of prior themes to ensure consistency of labels and descriptions. Any new emerging themes were added to the index.

Interviews were constantly re-read and re-analysed to verify presence of new themes and validate relevance of original theme items, thus refining thematic categories. The systematic process of ‘constant comparison’ ^{Reference Pope, Ziebland and May11} continued throughout the coding procedure and in a second session between the two researchers each theme's coded items were checked for consistency, interrater agreement and relevance. As part of this process, themes were further honed by grouping into hierarchies or subdividing as necessary.

The process of discovery

The process of discovery was gradual, with waxing and waning levels of concern and a delicate interplay between parent and child as they negotiated the subject of self-harm. In the months leading up to self-harm disclosure, many parents had a suspicion about their child's behaviour, often spotting injuries. However, when directly confronted, all of the young people denied that they were harming themselves and made excuses about the cause (Appendix 1). Although the young person's explanations did not always fully allay parents' suspicion, most took a ‘wait and see’ approach, deciding not to push the issue but watch how the situation developed, hopeful that it might resolve itself.

For parents in this study, formal confirmation of their child's self-harm was often mediated by an outside agency, usually school. This disclosure happened both in partnership with the young person and with the agency making the disclosure on the child's behalf.

Despite the initial desire to know, and outside agencies such as schools or primary services expressing their concern, the majority of parents reacted to suspicion or confirmation of self-harm by trying to ‘brush it under the carpet’. They shared their child's ambivalence towards seeking treatment; they felt that the situation would resolve itself and saying little would be the best approach (Appendix 1).

Given this approach and attitudes towards self-harm, it is not surprising that most parents delayed instigation or acceptance of help and did not push their child to consider gaining professional advice. This process was generally only triggered after deterioration or ‘accumulation’ of problems, commonly trouble at school such as bullying or non-attendance.

The behaviour of outside agencies, namely schools or general practitioners (GPs), was suggested by parents to be a key factor in the timing of accessing help (Appendix 1). Parents discussed how the degree to which staff at school meetings or GP appointments advised or helped manage feelings about self-harm encouraged or curbed their help-seeking. For example, Mrs S accepted an immediate referral to CAMHS and reflected on the importance of the school's initial input in making this, apparently rare, choice (most parents interviewed refused the initial offer, accepting only the second or third). In contrast, poor support after initial disclosure hindered the help-seeking process (Mrs E). Although initially Mrs E's daughter had been willing to see the GP to discuss her self-harm, after his negative response, she tried to deny its existence. Consequently, parent and child began to sidestep the issue once more and it was not discussed again until problems deteriorated several months later.

Making sense of self-harm

Upon discovery of a child's self-harm, an instinctive response was for parents to question the motives and reasons behind it.

There were usually no instant answers, and understanding and acceptance of self-harm was an ongoing gradual process. Even those with significant prior knowledge of self-harm struggled to understand and manage these behaviours in their own child.

In a reflection of earlier poor communication regarding disclosure, almost all parents said that their child would give them little or no explanation for their self-harm. However, when asked if they had any personal opinions on the causes, all identified problems they felt their child currently faced, usually citing several different potential causal factors. Identified causal factors fell into three categories: emotional difficulties, situational difficulties and personality factors.

1. (a) Emotional: ‘Like any other person, if you're worried about something you look for a way to ease off your pain or whatever you're worried about.’ (Mrs H)

2. (b) Situational: ‘The whole thing underlying the self-harm was bullying.’ (Mrs S)

3. (c) Personality: ‘I think a sort of quite profound lack of self-esteem.’ (Mr J); ‘She's also a bit of a perfectionist as well, so you could almost say… she's a high achiever.’ (Mrs S)

Within the context of these problems, parents recognised that self-harm served a purpose in their child's life. The function that it served depended on the core problem. For example:

1. (a) to cope with negative emotion: ‘I did feel very very sad that she'd kind of was using this as a way of coping with her depression and low mood and unhappiness.’ (Mrs B)

2. (b) for emotional expression: ‘I think I've just realised that it's another way of letting go.’ (Mrs H)

3. (c) to provide control: ‘I can understand that it's some way of you having some sort of control over your pain, over your life, because you feel totally out of control when you're feeling so depressed or vulnerable or whatever.’ (Mrs M)

Yet beyond an intellectual understanding, many parents felt they could not come to terms with their child's self-harming behaviour and understated its significance (Appendix 2). For example, the majority saw self-harm as a time-limited ‘phase’, and described their child's use of self-harm as influenced by peers or as a ‘fashion’. Most parents struggled to accept self-harm and recognised the numerous ‘typical’ teenage behaviours that their child could alternatively have engaged in (e.g. drug or alcohol misuse) and felt regret that their child had ‘opted’ to self-harm. Ultimately, all parents felt that they could not fully understand or empathise with self-harm.

Psychological impact of self-harm on parents

Parents described strong and lasting emotional reactions to their child's behaviour. Although several different emotions were recalled, including shock, disappointment, guilt and fear, a persistent feeling of sadness and a sense of loss or bereavement were prominent (Appendix 3).

The psychological impact of self-harm was acute at the time of interview, irrespective of duration since disclosure, and several parents became tearful when discussing this topic. Parents described a sense of feeling helpless, lost, out of control and ‘at sea’ with their situation (Appendix 3).

Following referral to a CAMHS, parents had continued to struggle with the emotional impact of the self-harm and services were powerful in alleviating or heightening their distress. Parents who had accepted the offer of specific support felt that this was very beneficial. In contrast, the one participant without access to support (Mrs K) felt that this lack of specialist advice added to her distress (Appendix 3).

Effect of self-harm on parenting and family

Participants found that knowledge of their child's self-harm had influenced their behaviour as a parent and their experience of family life. They described ‘walking on eggshells’ around the adolescent, nervous of triggering an episode of self-harm. This affected their parenting style and ability to set limits and maintain boundaries (Appendix 4). Several parents found they were now constantly aware of what the young person was doing, both discreetly watching them from a distance, and providing increased overt attention and care-giving.

Many parents felt that they had to deny their own needs and make changes to or limit their lifestyle as a direct result of the self-harm. They found difficulties in balancing parenting and meeting the needs of other children, which heightened the psychological impact of self-harm by increasing parental burden, pressure and stress. However, parents did feel that the self-harm had resulted in some positive changes to family life by strengthening the parent–child relationship (Appendix 4).

Previous research

This study fits with previous research on the burden felt by parents when caring for someone with mental health problems ^{Reference Perkins, Winn, Murray, Murphy and Schmidt12} and the strong emotional response aroused in parents who are carers. ^{Reference Whitney, Murray, Gavan, Todd, Whitaker and Treasure13} It suggests that the previously reported immediate emotional response felt by parents of children who self-harm ^{Reference Raphael, Clarke and Kumar8} is enduring. However, the limited expression of anger in our participants conflicts and may indicate that this emotion does reduce following recurrent episodes. The difficulties described by our participants reflect the communication problems previously shown to exist between children who self-harm and their parents. ^{Reference Tulloch, Buzzard and Pinkus14}

Strengths and limitations

This study included only parents from two CAMHS teams in south London and the opinions and experiences therefore reflect those of parents of adolescents referred to specialist services. Furthermore, as only half the parents approached agreed to participate and all were interviewed in a CAMHS setting, it is not clear how far the findings can be generalised, as results may be subject to sampling or response bias. However, the diversity of accounts was increased by using parents at different stages in the treatment process and, although the small number of participants may limit the study, data saturation was achieved and it is argued that smaller participant numbers are valued in interpretative phenomenological analysis for identification of subtle themes and meanings. ^{Reference Collins and Nicholson15} This paper benefits from participant validation of themes using individual summaries. The reliability of themes is strengthened by the use of researcher triangulation.

Future research could aim to include parents who range more diversely, include other family members, and adolescents themselves, in order to gain a wider perspective on the impact of self-harm on family life and the reciprocal impact of family life on self-harm.

Implications

Teachers and primary healthcare practitioners should be aware of the needs of parents of adolescents who self-harm, in particular, of their feelings of helplessness and desire for advice. Parents may benefit if the time from discovery to referral is reduced and this reduction may be facilitated by improved personal understanding and appropriate guidance from schools and GPs. More research is needed to establish the exact nature of information that would most benefit parents and how this could be efficiently and effectively distributed. However, these parents felt that basic information in the first instance, from schools or GPs, would be useful.

Although individual needs of parents of young people attending CAMHSs should be recognised and continued support offered, it is interesting to note that less than half of the parents accepted CAMHS support, despite almost all parents stating that they needed this input. Thus, the mere offer of support may be more important than its content or provision. More research addressing the reasons why such resources are not utilised by parents and what can be done to redress this is required.

Parents' comments on the process of discovery

Parents' comments on making sense of self-harm

Parents' comments on the psychological impact of self-harm

Parents' comments on the effect of self-harm on family life