Transcript working with young people at risk in an emergency department

working with young people at risk of deliberate self
harm and suicide
in an emergency department
trish flanagan
youth self harm social worker
Royal Perth Hospital Emergency Department
November 2010
Overview
Role of the Youth Self Harm Social
Worker (YSHSW) at RPH
Case study
Statistics relating to suicide/deliberate
self harm (DSH) and hospital
presentations
Define and explore suicidal behaviour &
deliberate self harm
Challenges unique to the YSHSW role –
the environment; the young person; the
clinician
Summary
Resources
Overview of YSHSW Role
Hospital Deliberate Self Harm Social Work positions were developed
and introduced in 1989, funded by the Youth Suicide Advisory Council,
as an example of best practice, based on the principles of early
intervention and prevention. The aim was to reduce representation
rates to hospital for young people with primary presentations of
deliberate self harm.
Primary responsibilities of the role include:
1.Provide assertive intervention while in the hospital environment;
2.Co-ordinate follow up arrangements for ongoing community-based
treatment;
3.Provide support and short term counselling as required until care is
taken over by a community service (up to 3 months);
4.Keep up-to-date a database of deliberate self harm patients for
outcome monitoring and epidemiological research;
5.Provide an annual report to the DOH that includes details on patient
demographics, methods of self harm, admission and follow up
statistics.
In 2001, the Auditor General of Western Australia reviewed the
management of cases of DSH in Emergency Departments identifying a need
to implement a variety of strategies to improve the care of young people
presenting with DSH – assertive assessment and early intervention services
within the community, appropriate follow up and discharge plans upon
discharge from hospital, improve links with, referrals to, and timely
transmission of details to CAMHS in an attempt to reduce wait times to
community based services.
Auditor General Western Australia, Life Matters – Management of
Deliberate Self Harm in Young People 2001, (Online) Available:
http://www.audit.wa.gov.au/reports/pdfreports/report2001_11.pdf (2010,
Sept 2)
YSHSW - Member of the EDMHLT (Emergency Department Mental
Health Liaison Team) accepting referrals for patients aged between 14-25
who present with deliberate self harm/suicidal ideation or behaviour:
The role offers:
• Provision of initial psycho-social assessment including suicide risk
assessment and mental state examination;
•Liaison with family; significant others; external agencies-collateral;
discharge planning;
• Consultation with EDMHLT/ ED clinicians re patient management
and discharge planning/admission;
•Intensive social work input for inpatients and their families
utilising– crisis intervention, problem solving, short term
counselling, Psycho-education;
•Post discharge follow up- monitoring of safety, interim
support/counselling for both the young person and family;
referrals and linkage to community services – youth specific and
generic;
•Follow up for after hours presentations.
Case Study
Lily is a 16 year old female who was brought to the Emergency
Department by ambulance following a premeditated episode of
deliberate self poisoning (12 Panadol & 4 glasses of Passion Pop) whilst
intoxicated with suicidal intent. Superficial lacerations were noted on
both her forearms and lower abdomen. Lily was at home in her bedroom
at the time of the overdose. She alerted her friend via text message
saying goodbye. Her friend advised her parents who phoned Lily’s
mother. Lily denied taking the overdose when confronted by her
mother however upon seeing the empty Panadol packet an ambulance
was called. This is her second suicide attempt in 3 weeks. Lily cites the
relationship breakup with her boyfriend of 12 months and escalating
conflict with her mother as primary precipitants. She reports sleep
disturbances, loss of appetite and weight and poor concentration over
recent weeks. She is unwilling to return home to live with her mother
and has no alternative accommodation options available to her. She is
not currently active with any youth or mental health services and does
not have a regular GP.
Lily was resistant to further interview by medical staff.
She also refused to see her mother who had been escorted into the
distressed relatives room to be supported by nursing staff.
Lily lay motionless on a hospital bed with the covers over her head.
Nursing staff overheard her crying but were unable to engage her
further despite several attempts.
Primary Issues for Lily
Distressed, emotionally overwhelmed; confused,
misunderstood
Feelings of guilt, shame, embarrassment
Loss of relationship with boyfriend – abandonment/rejection
Feelings of hopelessness; helplessness with regard to her
situation
Ongoing conflict with mother
Potential homelessness
Depressive symptoms
Limited support system
Current risk of further dsh/suicidal behaviour
Recent suicidal behaviour resulting in hospitalisation
Self harm behaviours as primary coping strategies
Absence of adaptive distress tolerance/coping strategies –
limited ability to tolerate negative states
Poor help seeking behaviours
Absence of formal counselling/community supports
Issues for the clinician
Lily’s reluctance to engage
Uncertainty around current level of risk – deliberate
self harm/suicidal behaviours
Current refusal for parental involvement
Gathering collateral from parent/guardian whilst
developing a relationship with the young person
Second suicide attempt – elevates short term risk;
premeditated; goodbye text; absence of active help
seeking
Possible homelessness
Potential activation of the Mental Health Act ‘96 if
poor compliance with assessment process
Prevalence of Suicide &
Deliberate self harm
Suicide claims on average the lives of seven Australians a day.
There are approximately 65,000 suicide attempts each year –
and more than 2,200 loved ones will die by suicide in Australia
annually.
Department of Health, Western Australian Suicide Prevention Strategy 2009-2013 ,
Everybody's Business.
Between 1986-2006 there were 925 reported suicides for
young people aged 15-25yrs.
Miller, K. & Robertson, D. Completed Suicides of Western Australians – A Psychological
Autopsy Study, TICHR, WA Coroner’s Database 2009.
Western Australian hospitalisation data indicates that in
2006, 3,182 people were admitted to public and private
hospitals following self-inflicted injury (2,014 females and 1,168
males) . The highest admissions for both men and women
occurred in people aged 15-24 years.
Department of Health, Western Australian Suicide Prevention Strategy 2009-2013 ,
Everybody's Business (Online),
Available:www.mcsp.org.au/files/mcsp_user3/WA_Suicide_Prev_Strat.pdf (2010, Nov 1)
Kids Help Line
In 2009, 438,474 attempts to reach KHL; 53,111 Counselling
contacts (phone, web, email)
Mental Health Concerns – 12% (triple the rate of 2008)
1 in 5 young people presented with a suicidal issue or self
injurous behaviour
5,067 presented with a suicidal related issue – more than 13
counselling sessions per day. An 82% increase since 2005
Deliberate self harm accounted for 15% of counselling
sessions including OD’s considered non-lethal by the young
person. Gender split: 80% female / 20% male
Top 3 concerns for young people aged 15-25yrs
Mental health and suicide related issues
Managing emotional and behavioural responses
Partner relationships
Kids Helpline 2009 Overview (Online), Available:
http://www.kidshelp.com.au/upload/22862.pdf(2010,Oct1)
Royal Perth Hospital DATA
May 2010: 263 presentations identified to be
mental health related
72 of these were young people aged 25yrs and
under (27.5%)
38 female; 34 male
26 (36%) presented post overdose
16 (22%) presented with dsh ideation and/or
suicidal ideation
7 (10) related to deliberate lacerations
Hirsch, N. 2010, ‘Review of the Nature and Number of Mental Health
Related Presentations to the Royal Perth Hospital’s Emergency
Department over 3 months in 2009-2010’.
YSHSW Presentations to the RPH ED 2009/2010
194 young people referred to the YSHSW in 2009/2010 compared with 129 in
2008/2009.
Data below based on 189 referrals
More females presented than males; females - 121 (64%); males - 68 (36%.)
Aboriginal patients accounted for 7% of the overall population referred to
the YSHSW
Poisoning by a solid or liquid substance (including paracetamol overdoses)
represented the predominant method of dsh/attempted suicide accounting
for 46% of referrals. 22% of all referrals were those presenting with Wrist
slashing, stabbing or other laceration; suicidal ideation accounted for 22% of
referrals
Relationship problems remained the primary precipitant accounting for 34%
of all presentations followed by Adjustment to psychiatric disorder at 23%,
Family Difficulties at 21% and Education/School stress at 8%
In 17% of all cases alcohol was involved; with 10% of presentations
involving/suspecting other substances. For 68% of presentations neither
alcohol nor drugs were involved
Flanagan, P. 2010, ‘Youth Self Harm Social Worker Annual Report 2009/2010’.
Unreported
Research suggests that most cases of deliberate self
harm are invisible to health professionals. Both method
(i.e.: one requiring emergency medical assistance) and
evidence of help seeking behaviours indicate a likelihood
of hospital presentations.
Hawton, K & Rodham, K & Evans E. 2006, By Their Own Young Hand,
Jessica Kingsley Publishers, London
Definitions
Suicide : Suicide is a conscious act of self-induced annihilation, best
understood as a multi-dimensional malaise in a needful individual who
defines an issue for which suicide is perceived as the best solution.
Suicidal Behaviour: Suicidal behaviour consists of thoughts, and actions
which, if carried out, may lead to serious injury or death. This behaviour
can be defined as involving the intent to die or the acceptance of death as
a likely consequence.
NSW Health. 2004, Framework for Suicide Risk Assessment and Management for NSW
Health
Staff.
(Online),
Available:http://www.health.nsw.gov.au/pubs/2005/pdf/suicide_risk.pdf (2010, Sept 2).
Self Harm: Self harm is a direct and deliberate physically damaging form
of bodily harm which is intentionally not life-threatening, often repetitive
in nature and socially unacceptable.
Walsh, B.W., & Rosen, P.M. 1988, Self-Mutilation: Theory Research and Treatment.
Guildford Press, New York.
Self harm is a maladaptive behaviour that reflects severe
internal distress (which may not always be evident in the
external demeanor) and a limited ability to develop effective
coping strategies to deal with difficulties. Distinguishing
between ‘self-harm without suicidal intent’ and attempted
suicide can at times be difficult. Regardless of motivation or
intention both are dangerous behaviours with a heightened risk
of dying.
Self harming behaviour usually occurs in one of two contexts:
the person with a vulnerable personality who is acting out inner
distress or the person who is psychotic. A person who is acting
out inner distress in this manner often feels he/she is not able
to communicate distress in less harmful ways. Although the
vulnerable person’s self harming is frequently acting out inner
turmoil or an act of self-soothing rather than an attempt to die,
people who self mutilate do sometimes attempt suicide.
NSW Health. 2004, Framework for Suicide Risk Assessment and Management
for NSW Health Staff. (Online),
Available:http://www.health.nsw.gov.au/pubs/2005/pdf/suicide_risk.pdf (2010,
Sept 2).
Deliberate Self Harm
How and Why
Behaviours: Cutting/stabbing; burning
(physically/chemically), overdosing,
over/under medicating (e.g.: misuse of
insulin); hanging, self strangulation, walking
in front of traffic, jumping from a height;
ingesting hazardous materials/substances;
biting, punching, hitting or bruising the
body, head banging, hair pulling,
picking/scratching at sores or the skin,
episodes of alcohol/drug abuse or
over/under eating.
Risk taking behaviours that may cause personal
harm include: alcohol/drug misuse, train
surfing; reckless driving; repetitive unsafe
sexual practices.
Adapted from: Hawton, K & Rodham, K & Evans E. 2006, By
Their Own Young Hand, Jessica Kingsley Publishers,
London)
Reasons
to soothe uncomfortable emotional states that underlie
the behaviour;
to provide a way to relieve, control or express difficult
or painful feelings;
to cope with emotional pain;
to communicate helplessness, despair and low self
esteem, anger, loneliness, shame and guilt (nonverbally);
to punish oneself;
to distract from problems,
to feel connected to something (even pain);
to prove to yourself that you are not invisible;
provide you with a feeling of control;
to feel real;
to connect with peers;
a form of escape;
an outlet for anger/rage;
to relay to others the need for some support;
care eliciting behaviour;
suicidal act.
Risk Factors for DSH
Individual – depression/anxiety,
poor communication skills, low self
esteem, poor problem solving,
hopelessness, impulsivity, drug or
alcohol abuse.
Family – unreasonable
expectations, neglect or abuse
(physical, sexual or emotional), poor
parental relationships and
arguments, depression, deliberate
self harm or suicide in the family.
Social- difficulty in making
relationships/loneliness, persistent
bullying or peer rejection, easy
availability of drugs, medication or
other methods of dsh.
Triggers for deliberate self harm
Family relationship difficulties
Difficulties with peer relationships e.g.: breakup of a
relationship
Bullying (including cyber bullying)
Significant trauma e.g.: bereavement; abuse
Self harm behaviour in others (Contagion)
Self harm portrayed or reported in the media
Difficult times of the year
Trouble in school or with police
Feeling under pressure from families, school or peers to
conform/achieve
Exam pressure
Times of change e.g.: parental separation/divorce.
Relocation
Adapted from: Hawton, K & Rodham, K & Evans E. 2006, By Their Own Young
Hand, Jessica Kingsley Publishers, London
Cycle of Self Harm
Young people and Depression
Depression is a broad term that can
encompass normal mood states,
clinical syndromes and actual mood
states (eg: melancholia).
At the clinical level, it involves body,
mood and thoughts and affects a
persons view of themselves.
Symptoms include loss of interest and
pleasure; loss of appetite; with weight
gain or loss ; loss of emotional
expression; a persistently sad,
anxious or empty mood; feelings of
hopelessness, pessimism, guilt,
worthlessness or helplessness; social
withdrawal and unusual fatigue and
low energy.
Parker G & Eyers, K. 2009, ‘Glossary’ in Navigating Teenage Depression, Allen
& Unwin, NSW.
Depression and Anxiety are among the
most common mental health problems
experienced by young people in Australia.
Around 160,000 young people aged 1624yrs live with depression.
2008, ABS, 2007 National Survey of Mental Health
& Wellbeing: Summary of Results (4326.0), Canberra
ABS.
These conditions can be serious, debilitating and life
threatening however less than half of those young people
experiencing depression seek help.
Confusion related to diagnosing depression in young people given
normal developmental issues – both emotional and behavioural.
Symptoms of depression often go unrecognised or are attributed
to being “just a part of growing up”.
Long term effects associated with child and adolescent depression
– substance misuse, academic problems, high risk sexual behaviour,
impaired social relations and increased risk of suicide. Untreated
depression is a major risk factor for suicide.
Psychological therapies are the recommended first line
options for the treatment of depression in children and
young people.
Limited clinical trials examining the use of
antidepressants in young people under 18yrs. Uncertainty
about their efficacy and safety for this population.
Reviews have found evidence of an increased risk of
suicidal ideation and behaviour in young people taking
antidepressants however there are no government
restrictions placed on the prescription of antidepressants
for this age group and doctors are not prevented from
prescribing them.
Youth beyondblue, Factsheets and Info (Online), Available:
http://www.youthbeyondblue.com/factsheets-and-info/(2010,Nov2)
Paracetamol MisUsE
“I’m not coping very well... I have taken my 10th Panadol
about 5 minutes ago and am hoping not to live much
longer, even though I know 10 Panadol won’t be enough”.
(Kids help line Caller, Age 15)
Increasing prevalence of Paracetamol and Ibuprofen
Overdoses amongst young people.
Frequently used as a means of dsh (with or without suicidal
intent) by young people either on its own or with other
medications.
Ease of availability and accessibility. Financially viable for
young people.
Overdosing on Paracetamol can be lethal or cause
irreversible liver damage. Ibuprofen is harmful to kidneys.
Perception amongst many young people and parents that it
is not harmful/lethal; often linked with attention seeking
behaviours ‘she can’t be serious, it’s only panadol’.
Often used as a form of repetitive deliberate self harm –
minor overdoses – without help seeking – in an attempt to
regulate emotions.
Research indicates lack of knowledge amongst young people of
the long term effects of chronic toxicity on internal organs.
Chronic intoxication of the liver with Paracetamol can result in
more pronounced liver damage than acute overdoses, often
accompanied by severe renal dysfunction.
Abuse of Paracetamol in Young People, 2005 Kids Help Line Newsletter, October
2005.
Importance of seeking prompt medical assistance to enable
treatment to reverse the effects of the Paracetamol.
In the UK Paracetamol is the most widely used means for dsh and is
responsible for approximately 70,000 cases per year. It is the most
common cause of acute liver failure.
Legislation passed in the UK in 1998 to limit the amount of Paracetamol
bought in one purchase – 16 @ supermarket; 32 @ pharmacy; supplied in
blister packs to make obtaining tablets more difficult.
Initial success of these measures has waned and hospital admissions and
deaths are on the increase.
Paracetamol Poisoning. (Online), Available:
http://www.patient.co.uk/doctor/Paracetamol-Poisoning.htm (2010, Nov1)
Chronic Suicidality
Darkling I listen; and, for many a time
I have been half in love with easeful Death,
Call’d him soft names in many a mused rhyme
To take into the air my quiet breath.
- “Ode to a Nightingale” by John Keats
Chronically suicidal patients have only a faint hope that
their lives will ever be happy or that they can do anything
to change their situation.
Patients comforted by suicidal ideas – options to escape
enables tolerance of distress “half in love with easeful
death”.
This population poses significant challenges for clinicians
Concepts outlined by Joel Paris:
Inner world of the chronically suicidal patient – pain,
emptiness and hopelessness. Suicidality is an attempt to cope
with these states of mind.
Chronic suicidality more associated with personality
disorders, than depression. It requires a diagnostic concept
that reflects continuous dysfunction over time (includes
patients with bipolar disorder, melancholic depression,
substance abuse and schizophrenia).
Methods generally recommended for management of the
chronically suicidal are usually ineffective and
counterproductive i.e. hospitalisation.
Effective therapy requires clinicians tolerating chronic
suicidality whilst working toward healthy ways of coping to
relieve psychological pain.
Paris, J. 2007, Half in Love with Death, Managing the Chronically Suicidal
Patient, Lawrence Erlbaum Associates, Publishers, New Jersey.
Challenges – unique to yshsw
Environmental
The Emergency Department – primarily adult
environment; foreign – often a young persons first
hospital experience; stimulating – bright, loud, devoid of
privacy, confronting, unpredictable; Agenda attached.
Source of anxiety– can result in withdrawal and/or
acting out behaviours – hostility, violence.
Environment can be viewed as threatening; workers
viewed as authority figures. Pressure to conform with
expectations of staff i.e.: participate in the assessment.
Interviews - conducted bedside, cubicles, corridor on a
chair, seated on the floor, interview rooms. Information
gathered inside and outside of the hospital i.e.: sitting
with a young person on the footpath.
Impact of other patients – absence of privacy;
intrusiveness, unpredictable behaviours/violence,
predatory element; psychiatrically or critically unwell
patients.
Use of security – present at interviews if necessary;
observation within the ED; used for their presence to
assist in the management and control of
difficult/obstructive behaviours.
Competing agendas - Pressure to arrive at a decision –
discharge or admit; when the outcome is not clear.
Requirements for extended assessment and gaining
collateral. Ongoing consultation with staff.
Importance of involvement at the commencement of the
assessment process – to establish rapport and trust; to
enable successful, ongoing community involvement/follow
up.
Judgments – staff perception around dsh/suicidal
behaviour – often viewed as “attention seekers”; can be
time consuming for other ED staff; attempts to dispel the
myths and subjective views to maximize appropriate
patient care and management via education.
Organisational constraints - Bed shortage/blockages; 4
hour rule.
Young Person
Engagement & Rapport Building
Rapport is defined as “a warm, relaxed relationship that promotes mutual
acceptance e.g.: between therapist and patient. Rapport implies that the
confidence inspired by the former produces trust and willing cooperation in
the latter”. (1984, Longman Dictionary of Psychology and Psychiatry).
Factors that complicate the development of rapport include:
1. absence of willing participant – young people are not always self referring
2. time limitations with regard to building rapport – important to dedicate
time to listening to the young person’s story; validate experiences, provide
empathy, support and reassurance.
Factors impacting on rapport building with young people in an ED:
1.Acute situation – high levels of distress; possible embarrassment, guilt,
shame associated with presentation
2.Medical status – young people often unwell post dsh attempt
3.Resistance to being in hospital – foreign and frightening; refusing
assessment in an attempt to expediate discharge.
4.Large medical presence at interviews – reluctance to engage or be
transparent when interviewed by a team of clinicians over 1:1.
Confidentiality
•Important in establishing and maintaining a relationship of trust between
health workers and patients.
•Research has consistently found that confidentiality is highly valued among
children. Fear of breach of confidentiality often prevents children accessing
health services.
•Importance of explaining the parameters around confidentiality – i.e.: in the
event of risk of harm to self or others, risk of physical/sexual abuse - along
with who the information is to be shared.
•Dedicating time to exploring reasons behind the request for confidentiality –
negotiating where possible with the young person.
•Communicating limits around information flow i.e.: to parents, verbally and via
documentation with other team members to ensure consistency in practice and
reduce likelihood of unauthorised disclosures.
•Educating parents/guardians with regard to patient confidentiality and risks in
relation to breach i.e.: dissolution of the therapeutic relationship.
•Clinical supervision is imperative when dilemmas arise with regard to
confidentiality.
Department of Health. 2007, Working with Youth, a legal resource for community based
health workers.
Mature Minor Status
• ‘Parental responsibility’ in relation to a child means
all the duties, powers, responsibilities and authority
that, by law, parents have in relation to their child.
• It is usually in the best interests of the
child/adolescent to have a parent or guardian involved
in health care decisions.
• Children/adolescents may seek professional
assistance without their parent or guardians
knowledge. They may also request/insist that
parents/guardians not be informed about health care
being sought or demand confidentiality with regard to
their contact with a health professional.
• The law in Australia recognises the concept of
Mature Minor (founded in common law).
• Philosophy and legal precedent utilised by DCP - the
Gillick Principle - used to determine a child’s
competence.
• The assessment of a child as a ‘mature minor’ is
based on age; experience, emotional maturity and
intellectual capacity.
• Professional judgement (on the maturity of the
child/adolescent) to be made on a case by case basis.
•Consultation with supervisor; DCP/Crisis Care.
Adapted from: Department of Health. 2007, Working with
Youth, a legal resource for community based health workers.
Clinician
Behavioural issues – young people unwilling to engage; manipulative;
obstructive; non-compliant; aggressive; violent whilst in hospital. OR
alternatively those seeking admission where it is not warranted.
Team approach – consistent response to the young person; firm adherence
to boundaries; clear and open communication with colleagues – to avoid
‘splitting’; ‘negotiables’ – exploring ways to foster cooperation.
Frequent presenters – young people with chronic dsh/suicidal behaviours.
Adherence to management plans where possible; liaison with community
treating teams; consistent response by medical and psychiatric staff.
Time constraints – working efficiently and effectively within a specific
timeframe. Prioritising – what is most useful for the patient.
Supporting and Educating families/significant others – anxiety and fear
associated with taking a young person home post dsh/suicide attempt.
Safety – endeavour to be well informed prior to patient contact –
medical notes, collateral (past presentations, history of involvement
with other services) discussions with nursing staff; interview space;
awareness of your environment, other patients and potential risk issues
i.e. unchecked bags.
Staff education - Attempts to dispel judgments that may impact
negatively upon young people and the service they receive whilst in
hospital.
Burnout - area of high stress; workload pressure; highly emotive issues;
collaborative interviews and decision making; importance of self care.
Supervision – importance of clinical supervision around complex cases –
mature minor; child protection and domestic violence; advocating for
admission/discharge – when clinicians opinions differ; barriers to
discharge i.e. lack of safe and appropriate accommodation.
Young people referred under the Mental Health Act ‘96 – unwilling to agree
to voluntary admission; risk of absconding; fear and distress associated
with being formed; educating young person and family.
First psychiatric admission – emotional support/reassurance and education
for both the young person and family.
Homelessness – limited accommodation options for young people at risk;
history of bans at YSAAP services; consultation with DCP.
Obstacles to discharge:
• Risk of harm from others i.e.: family/partners
• Significant precipitants to dsh unresolved – vulnerability of young person
in the community.
• Absence of appropriate accommodation
• Non compliance with recommendations by medical staff
• Unsatisfactory discharge plan i.e.: proposed by the young person
• When a family feels an admission is warranted
• Supporting youth agencies and relaying their concerns/opinions to staff
Feedback
Anecdotal
Positive feedback from patients and families highlighting the
value of the YSHSW role and the EDMHLT.
Support and acknowledgement from youth services confirming
the usefulness of the position in assisting them when requiring
emergency services.
Future positive contacts from young people; subsequent crisis;
seeking advice/guidance and support; requesting referrals.
Summary
YSHSW role focuses on assertive intervention and
follow up post discharge for young people presenting to
the ED with deliberate self harm.
Research continues to highlight the prevalence of
deliberate self harm amongst many young people in the
community struggling to cope with life stressors.
Early intervention and prevention of future dsh
behaviours remains pivotal.
Intensive support and linkage to appropriate youth
community services to assist with the development and
utilisation of healthy adaptive coping strategies is
imperative for young people at risk of dsh/suicidal
behaviours.
Resources
WEBSITES
Ministerial Council for Suicide Prevention – www.mcsp.org.au
Kids Help Line – www.kidshelp.com
ReachOut – www.reachout.com.au
Headspace – www.headspace.org.au
Youth beyondblue – www.youthbeyondblue.com/
Orygen Youth Health – Victoria www.oyh.org.au/
TEXT
Keith Hawton and Karen Rodham with Emma Evans - By their
own young hand
Steven Levenkron – Cutting – Understanding and Overcoming
Self Mutilation
Joel Paris - Half in love with Death, Managing the Chronically
Suicidal Patient
Gordon Parker & Kerry Eyers – Navigating Teenage Depression –
A guide for parents and professionals
SERVICES
Youthlink & YouthReach South – Referrals and Enquiries:
1300 362 569
Youth Focus – 6266 4333
Fremantle Headspace – 9335 6333
Crisis and Emergency
Mental Health Emergency Response Line (MHERL)
– 1300 555 788
Crisis Care – 9233 2111
Local Mental Health Clinics
Questions?
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