Principles of practice for a whole school approach to self-harm: a qualitative study

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This study aimed to explore the perspectives of young people and school staff about how schools should respond to self-harm and subsequently develop principles of practice. Methods Seven focus groups were carried out with school staff and young people. Qualitative data were thematically analysed using the Framework Method to generate themes ( 1 , 2 ). The findings were translated into actionable items by applying the Implementation in Schools Framework ( 3 ). Results Staff and students had overlapping views about how schools should address self-harm. These were captured in three themes 1) Understanding the nature and scope of self-harm in schools, 2) Building whole school capacity to respond to self-harm, 3) Creating a supportive school environment. Principles of practice were generated to guide schools in their approach to self-harm. Conclusion For many young people, schools are a key setting for early intervention in self-harm; however, staff often feel ill-equipped to respond and clear guidance is lacking. This study has developed evidence-based principles of practice for UK schools, drawing on the perspectives of staff and young people to inform a whole-school approach. Self-harm schools young people school staff guidelines principles of practice Figures Figure 1 Introduction Self-harm is increasingly prevalent among young people and is widely recognised as a significant public health concern ( 4 ). It is defined as ‘intentional self-poisoning or self-injury, irrespective of the apparent purpose’ ( 5 ), and is associated with a range of adverse outcomes, including disrupted education and employment trajectories and an elevated risk of suicide ( 4 , 6 ). Recent national survey data highlighted that 24% of 17-year-olds in the UK had self-harmed in the past year ( 7 ). In England, the lifetime prevalence of self-harm among 15-year-olds rose sharply from 22% in 2014 to 34% in 2021 ( 8 ). Research suggests that the COVID-19 pandemic further exacerbated mental health difficulties among young people, contributing to increased rates and severity of self-harm ( 9 ). These trends are often associated with delays in help-seeking and persistent unmet needs( 10 , 11 ). Early identification and timely intervention are crucial to improving outcomes ( 12 ); however, many young people conceal their self-harm due to fear of stigma, being misunderstood, judged or labelled as ‘attention-seeking’ ( 10 , 13 – 15 ). As a result, only a small proportion of adolescents who self-harm present to hospital services ( 16 ). UK Government policy highlights the role of schools in supporting young people’s mental health, including early intervention and prevention of self-harm and suicide ( 17 ). Teachers and other education professionals are often among the first to notice signs of self-harm and are well-positioned to facilitate early intervention and referral to appropriate services ( 18 ). Trusted relationships with school staff can play a vital role in encouraging help-seeking in adolescents. Research shows that young people are more inclined to seek help from a trusted staff member who listens, demonstrates empathy, and creates a supportive and safe environment ( 19 , 20 ). Additionally, staff have described how schools are increasingly acting as a “one stop shop” for parents seeking advice about their child’s mental health, often before approaching health professionals ( 21 ). However, despite a general willingness to help, many school staff report feeling ill-equipped to respond to a student who is self-harming, citing a gap in training, insufficient knowledge and a lack of confidence in managing self-harm within the school setting ( 22 , 23 ). A recent survey found that only half of school staff received any training on self-harm, with just a fifth (22%) rating the training as highly adequate ( 24 ). Limited staff knowledge can result in negative emotional reactions from staff when faced with a student’s self-harm, including panic, fear, or even repulsion ( 25 ). Such responses may inadvertently discourage young people from seeking further help ( 10 ). School staff have expressed a clear need for training and practical support tools to help them respond to and manage self-harm ( 19 , 21 ). Training programmes, particularly for pastoral staff, have shown promise in fostering more reflective and supportive school environments, by helping staff address their own concerns and challenge unhelpful attitudes towards self-harm ( 26 ). Despite school staff expressing a clear need for improved knowledge and training on adolescent self-harm ( 24 , 27 ), there remains a lack of effective, feasible and acceptable training programmes to support school staff ( 22 , 28 , 29 ). A recent online training programme has been developed to address this gap ( 21 , 30 ). Moreover, although students consistently express a desire for open dialogue around self-harm, the topic remains largely absent from school curricula, and many schools still lack a dedicated policy on how to address self-harm ( 19 , 21 , 31 ). A recent review highlighted the limited availability of school policies on self-harm and identified the need for evidence-informed guidelines to support schools in responding appropriately to instances of student self-harm ( 32 ). In the UK, there is limited research and guidance for addressing self-harm in schools. A recent update of NICE guidance provides key advice on the practical steps educational professionals should take e.g. seek advice from a health professional, have a designated lead, make the young person aware of sources of support ( 5 ). In New Zealand, Meinhardt et al (2022) developed guidelines to provide a structured framework for consistent and effective school-based responses to self-harm. Using a Delphi approach, drawing on input from mental health and education experts, the study produced a set of endorsed statements across key domains including staff training, responding to disclosures, post-incident support, and whole-school responsibilities ( 33 ). More recently, Bowden et al (2025) explored key barriers and facilitators to the implementation of self-harm best practice and confirmed that access to guidance is a key facilitator ( 34 ). Guidance should be up to date, easily accessible, locally developed and support a whole-school approach. Whole school approaches involve collaborative efforts between all staff, teachers, families and students. They view the whole school as the unit of change and involve action across the curriculum, school ethos and family and community partnerships ( 35 ). The current study aimed to (i) explore the perspectives of young people and school staff about how schools can address self-harm and (ii) use the findings to develop UK-specific guidelines on how schools can support students who self-harm. Methods Design This study was part of a broader programme of work that developed an online self-harm awareness training programme for secondary schools (19, 21, 29, 30). We analysed qualitative data collected through focus groups with young people and school staff. Reporting has followed the Consolidated Criteria for Reporting Qualitative Studies (COREQ) guidelines (supplemental file 1). Ethics approval Ethical approval was granted by the University of Cambridge Department of Psychology Ethics Committee (ref: PRE.2024.006). Participants and sampling We conducted seven focus groups with 38 participants: five with secondary school staff (n=27) and two with young people (n=11). Staff were recruited from four state-maintained schools and represented a range of roles, including senior leadership (n=5), teaching staff (n=8), administrative and support staff (n=3), and mental health and pastoral teams (n=11). All schools had above-average rates of free school meal eligibility (>19%) and higher numbers of students with Special Educational Needs or Disabilities, both associated with poorer mental health. Three schools were mixed-sex and located in high-need areas of the East of England (36), while the fourth was a boys’ school in an inner-city London borough with above-average poverty levels. Young people were recruited through one participating school and via social media. They were aged 14-21 years (median = 16) and had experience of self-harm and/or supporting a peer or sibling. Most (n=9) were in secondary school, while one was attending university and another was in full-time employment. Procedure Topic guides for each participant group were developed in collaboration with the study’s public advisory groups. At the beginning of the young people’s sessions, we introduced short vignettes depicting scenarios of school staff responding to a student who was self-harming (37). These served as a valuable tool to facilitate discussion of a sensitive topic, allowing participants to reflect without drawing directly on their own personal experiences. Topic guide questions for school staff explored their views on how schools should address self-harm, their own feelings (e.g. confidence and concerns about managing such situations), and their perspectives on staff training (topic guide questions are provided in supplementary file 2). All participants were fully informed about the study and provided electronic consent before taking part; parental consent was obtained for those under 16. Focus groups were facilitated by AMB, an experienced qualitative researcher, with support from HG and PH. Staff groups were conducted in schools during the school day. One young people’s group took place in school, while the other was conducted online to accommodate an evening time slot. Focus groups lasted 1-2 hours, were audio recorded, and transcribed by a university-approved transcription service. Transcripts were checked, anonymised and stored securely in password-protected folders accessible only to the research team. All participants received an online shopping voucher as a thank you for their time. Analysis Qualitative data were analysed using the six stages of the Framework Method (1, 2), a pragmatic approach to analysis. Two researchers (AMB, HG) began by immersing themselves in the transcripts, coding deductively with reference to the topic guide and inductively to capture meanings arising from the data. This informed the development of a preliminary coding framework, which was applied to the remaining transcripts and refined iteratively to incorporate new codes. An Excel matrix was then created, with rows representing focus groups and columns representing subthemes. Data were charted into this framework by AMB, HG and XS, with summaries supported by illustrative quotations to preserve the richness of participants’ accounts. In the final stage, the team reviewed the data to identify cross-cutting patterns and generate higher-level themes. To translate findings into practical recommendations, we mapped them onto the Education Endowment Foundation’s Implementation in Schools Framework (3). Using a structured statement format (specifying what should be done, by whom, when, and how), we developed a set of evidence-based principles of practice to enhance the likelihood of effective implementation in schools. Results In this section, we present the main themes generated from the analysis, integrating the overlapping views of staff and young people: 1) Understanding the nature and scope of self-harm in schools, 2) Building whole school capacity to respond to self-harm, and 3) Creating a supportive school environment. The themes are summarised in the section below (see Figure 1) together with illustrative quotes from staff and young people. This section also presents the guidelines developed from the themes. Theme 1: Understanding the nature and scope of self-harm in schools Recognising hidden and varied forms of self-harm Both staff and young people viewed self-harm as a pressing and increasingly common issue in schools. Staff linked the rise of self-harm to several intersecting factors: high academic expectations, identity-related struggles, peer dynamics, the influence of social media and the lingering effects of the COVID-19 pandemic. Staff noted that self-harm is often “hidden”, particularly among high-achieving students, making it harder to identify those in need. Even though there’s no sign academically that that kid is struggling, they’re actually buckling under the worry and the weight of it all. (Staff) Mental health and pastoral staff emphasised that self-harm can take varied and often non-visible forms, highlighting the importance of recognising behaviours beyond cutting, such as ingestion of harmful substances, and of understanding the underlying emotional distress that drives these behaviours. There was broad consensus that improving staff awareness in this area is essential to ensure they are equipped to identify and support students who might otherwise remain unnoticed. “…digesting different types of toxic materials can be a form of self-harm. Recognising that you’re not always looking out for someone who’s got long sleeves. It’s different types of harm.” (Staff) Breaking down stigma and stereotypes Stigma was viewed as deeply rooted in generational and cultural attitudes, where mental health is not openly discussed and often perceived as “silly” or “shameful”. Staff expressed concern that some colleagues and parents hold judgemental attitudes about self-harm, and such beliefs could undermine relationships and deter young people from seeking help. They emphasised the need to challenge these attitudes, improve colleagues’ understanding, and adapt approaches to work sensitively with families from diverse backgrounds. …there’s generations where mental health wasn’t spoken about…And then it’s that element of they don’t know how to deal with it because their parents just shut it down. And so there needs to be more of a society training to deal with – not an epidemic, but there’s a lot more mental health issues now. (Staff) I’ve been brought up in a culture that self-harm was this kind of an attention-seeking tactic…that culture very much still exists and I think it’s really important that we stamp that out. (Staff) Young people also noted that stigma, particularly the perception of self-harm as “attention-seeking” can discourage young people from seeking help. They felt schools should actively challenge these misconceptions by promoting education and open discussion to raising awareness. And the stigma behind it that some people might think that you're only doing it for attention-seeking, and you don't really want people to think that about you. (Young person) I think the stigma with people our age is very much like they're attention-seeking and that definitely is something that I think schools need to address more because the stigma around things really, really can make an impact on whether a student tells a teacher what's going on or not. (Young person) Both young people and staff highlighted the need to challenge stereotypes. Staff working in a single-sex boys’ school pointed out that self-harm remains an issue among male students, despite the stereotype that it is predominantly a female problem. They noted that prevailing gender norms may contribute to the under-recognition of self-harm among boys and deter them from seeking support. …there's some kind of gender divide, I mean, I think groups of boys in school, it's not something that is spoken about (Young person) Because obviously this is a boys’ school, I don’t know if it’s more common in a girls’ school, like I think boys would try and hide it more. (Staff) Theme 2: Building whole school capacity to respond to self-harm Gaps in staff preparedness and confidence Staff described the evolving role of teachers, noting that schools are increasingly functioning as “frontline services for students”. They reported being expected to manage complex mental health needs with limited guidance, fragmented support and inconsistent training. Several recalled having to respond to self-harm incidents in the classroom without any formal training or preparation, relying instead on instincts to remain calm and avoid escalation. I’ve had one girl who just did it with anything. I had to literally just go over and taking the object out of her hand and saying, “Right, we need to focus on our work now. But it was literally shocking just to think what she did. I’ve had no training. (Staff) Confidence in managing a self-harm disclosure varied widely across staff. Some described self-harm as a “scary” subject, primarily because of its close association with suicide. They reported feelings of guilt or denial after discovering a young person’s self-harm, as well as anxiety about “saying the wrong thing” and potentially triggering further harm. I thought it was a lot of pressure. You don’t want to do something wrong, you don’t know the wrong and right thing to do. Like you don’t want to make a situation worse, but then you don’t want to not help. So it’s like, for me, I just didn’t know the right or wrong way to go about things. (Staff) Teachers who felt unprepared described how limited training exacerbated anxiety and undermined their confidence in responding appropriately. I think mental health in general, school staff find it difficult if they've had no training or not thought about it or if they think that speaking about it is likely to make it worse and therefore, don't ask the kind of direct questions you need to be able to make a risk assessment. …it is very shocking when a kid discloses it to you... I would like to know how to react to that information so that I don't do any more damage... I would like to be able to communicate better to pupils about these issues. Staff confidence was often linked to previous mental health training. Those with relevant training felt more able to engage in conversations with students, while others reported feeling unprepared and uncomfortable, sometimes avoiding the topic altogether. This lack of confidence was closely associated with limited knowledge, training and a lack of clear practical guidance. Because you might just freeze and your mind just goes blank and you don’t know what to actually say. You don’t want to say the wrong thing. So that would be good, just to have some guideline of what to say and questions. (Staff) Safeguarding provision was widely described as generic, with self-harm addressed only superficially and without practical strategies, leaving staff feeling under-prepared. Common concern was the absence of specific dedicated self-harm policies, with the issue typically subsumed under broader safeguarding procedures, as one staff member noted: Most schools don’t have a specific policy on self-harm...it kind of falls under the safeguarding procedures. (Staff) A lack of targeted guidance, combined with minimal training, was seen to undermine staff confidence and contribute to variable practice. Need for whole-school training, education and guidance Staff emphasised the importance of a whole school approach to responding to self-harm, with training accessible to all staff, not just teachers or mental health teams. Non-teaching staff such as catering assistants, caretakers, and librarians were often described as having informal, trusting relationships with students, and are therefore well placed to notice early signs of distress. I think for something like self-harm, it should be an all-staff thing… they’re going to go to the person they feel most comfortable talking to. (Staff) I work in the school library…I would like to be able to spot the warning signs. (Staff) Staff advocated for guidance on what to say and how to say it when a student discloses self-harm, going beyond procedural reporting. A whole school approach was viewed as essential for fostering shared understanding, consistency in responses and a culture where safeguarding is a collective responsibility. I would feel really good about other people having the same knowledge…and that we have a shared knowledge base at a minimum. (Staff) Staff also emphasised the need for practical, accessible provision that could be integrated into existing safeguarding or Continuing Professional Development (CPD) sessions. Preferred formats included short, flexible modules delivered online or holding small, face-to-face groups, which would encourage discussion, reflection and sharing of good practice. It was good to be able to talk to other people… you got ideas from them or lived experiences from them, or how they deal with it. (Staff) Young people felt strongly that self-harm should be included in the curriculum and discussed more openly within schools to raise awareness and reduce stigma, which they saw as a barrier to help-seeking. They preferred that it be addressed directly rather than incorporated under general mental health education. Mental health is spoken about in a very generalised way. It would be beneficial to speak more openly and specifically about self-harm. (Young person) Young people also stressed the importance of being informed about relevant school policies and the support available to them, with several noting that uncertainty about where to seek help could delay or prevent disclosure. I think a lot of it is people don't know where to get that kind of support. So I think it's really important for schools to really put it out there and let students know where they should go to get that help. (Young person) They felt that while assemblies are helpful for sharing information about support, small group discussions were preferable for sensitive topics, as these provide a more comfortable space for conversations. Assemblies can be awkward…especially for more sensitive topics… you’re just sitting there awkwardly uncomfortable with it, then you’re not going to take in that information you need. It needs to be a comfortable environment. (Young person) Both staff and students emphasised the importance of clear, step-by-step guidance for what happens after a disclosure, with young people particularly highlighting the need to be actively involved in decisions about next steps to ensure that support is responsive and collaborative. Theme 3: Creating a supportive school environment Co-design safe, accessible, and youth-friendly spaces for support Participants emphasised that support for students who self-harm should be readily accessible, flexible and embedded in the school day. Both young people and staff felt it was important to provide quiet, private spaces where students could go for help without fear of being overheard or judged, particularly in moments of acute distress. Providing students with choice over how and where support takes place was seen as a way to increase their sense of control and reduce anxiety. ‘Well, where would you like to have a chat?’ It gives them a bit of control over probably what is quite a scary situation. (Staff) Staff highlighted the importance of creating informal, youth-friendly spaces in which students feel safe to talk, as a way to build trust, reduce stigma around self-harm, and encourage early intervention. Young people echoed this, describing the need for spaces that feel confidential and safe. However, some felt that designated ‘support rooms’ or ‘wellbeing hubs’ could sometimes be intimidating or stigmatising, as other students might notice and make assumptions about their mental health. Flexible, student-informed approaches were therefore seen as essential for encouraging help-seeking while minimising the risk of judgement or labelling. It’s got to be in their terms, that they feel comfortable that they have somewhere to go to talk particularly about whatever is on their mind at the time. (Staff) Sometimes having a designated room can be more daunting…people assume they’re going there for a specific reason. (Young person) Across all participants, ‘trust’ emerged as central to encouraging help-seeking. While young people recognised the role of designated mental health staff, they stressed that familiarity and comfort would determine who they approached. Informal, everyday interactions - such as a chat with a form tutor during form time or lunchtime – were preferred over more formal sessions after school which could draw unwanted attention. Small gestures, like asking “How are you today?” were seen as important for building rapport and making support seem more accessible. …even just asking if the student is OK, just to let them know that someone cares…even if you don't already have that trust, you can build on that. (young person) Navigating confidentiality and parental involvement Transparency about confidentiality was a priority for young people, who wanted clear information on when and how parents would be involved. Uncertainty about these processes was seen as a source of anxiety that could deter disclosures. Young people felt that parents could struggle to accept or believe their child is self-harming. Some people can keep things from their parents and it can be hard for them to accept that their child is self-harming…having a lot of information for parents is just so helpful.” (Young person) The fear of the unknown is so much bigger than what’s actually going to happen. (Young person) Staff described the most challenging situations as those where students disclosed self-harm but do not want their parents informed. Safeguarding policies meant that staff had to act when a student’s safety was at risk, but explaining this to a student can be difficult and could undermine trust. I think the trickiest area for me when I've had those conversations is when students don't want their parents to know…my concern when you're sat having that conversation with a child and they do this and then they go, "Are you going to tell my parents?" and you have to then navigate your way around explaining why that has to happen. That's the tough bit. (Staff) Both staff and young people highlighted the importance of engaging parents constructively and sensitively. However, young people were particularly concerned that some home environments may not be supportive or may be the source of the young person’s distress. …we're assuming that the student has a good home life where they'll be supported through it, but that might not be the case, and it might be because of things at home. (Young person) Supporting wider school community Participants highlighted the need to extend support beyond the young person who is self-harming. For example, peers sometimes learn about a friend who is self-harming and disclose to staff. Both staff and students emphasised the importance of reassuring peers that they had acted appropriately by asking for help, while managing confidentiality carefully. Staff voiced that they would like clear protocols for handling of peer-reported self-harm, as they were aware that insensitive responses could damage trust and potentially make the situation worse. Young people felt that giving peers general information about the support their friend would receive could reduce uncertainty and worry and make them more likely to approach staff with concerns in the future. I would want to know how I could help my friend in that situation, because I think I'd feel quite lost. (Young person) Participants highlighted the importance of engaging parents constructively, providing accessible information and guidance on how to respond. This was seen as crucial given that self-harm is often hidden from parents, and first reactions may be angry, dismissive or disbelieving. Staff described the range of emotional responses they encounter and highlighted the need for greater parental support. We deal with a lot of parents who are naturally angry about what their child's done; they're disappointed, upset, angry, all of those kind of emotions, because they don't want their child to be doing that to themselves. I think that there's a certain degree of education for parents in supporting those young people, around what it is (Staff) Young people also noted that some parents might struggle to accept their child is self-harming, highlighting the need for awareness-raising and clear guidance to help parents recognise warning signs and respond constructively. I think with parents and figures of authority, I think the worry is a bad reaction because if they react badly, then you can't do anything about it and you've just got to deal with whatever the result of that may be. (Young person) Participants further emphasised the need of schools to be mindful of home circumstances. Not all families are supportive, and breaking confidentiality could have unintended consequences. As one young person explained: Telling one person such a big thing… if they go and tell loads of other people/tell your parents, it’s like all this information at once… at first it’s good to only tell one person and they keep that private. (Young person) To address these challenges, general education on self-harm for parents was considered essential, particularly during the early years of secondary school. Suggested approaches included parent workshops, written guides, and opportunities to speak with designated staff, enabling parents to feel more confident in having open, supportive conversations with their children about mental health. Staff discussed the emotional toll of responding to self-harm disclosures, particularly for those staff members with personal or family experience of self-harm. Such experiences could increase the emotional impact but also shape professional practice. Senior leaders emphasised the importance of signposting staff to appropriate support and resources to help them manage these demands: There is that fear from me as a leader… this could be really tough for someone to take on board. (Staff) Translating qualitative findings into actionable school guidelines From our analysis, we have developed behaviour-focused principles of practice for schools to create a whole school approach to self-harm. We aligned the principle of practice with the Education Endowment Foundation’s Implementation in Schools Framework (3), which describes implementation as an iterative process that broadly follows four stages (explore, prepare, deliver, sustain). For effective implementation, schools are encouraged to adopt three behaviours (engage, unite, reflect). Engaging people involves meaningful consultation to shape overall direction, uniting people around what is being implemented helps to build buy-in and remind the school community why the new initiative is important, and finally reflection is used to monitor, adapt and improve implementation. Table 1: Principles of practice for schools Theme What Who When How Understanding the nature and scope of self-harm Whole-school training for all school staff Senior leadership Prepare / Deliver Unite staff around a shared understanding of self-harm. Train all staff (teaching & non-teaching) to recognise varied self-harm behaviours, risk factors, and how to respond appropriately and where to signpost. Develop school-wide self-harm policy Senior leadership with whole-school community input Explore / Prepare Self-harm policy tailored to school. Step-by-step post-disclosure guidance Co-produce policy with students, staff and parents to promote shared understanding and consistency of response. Ensure the policy reflects the values of the whole school community. Raise awareness with staff, students, and parents to address misconceptions and stigma (e.g., “attention-seeking”, gender bias) Wellbeing staff* & Mental Health Lead Deliver / Sustain Assemblies for general information on where to find support. Form time, posters, peer-led initiatives, parent workshops to provide information, support and anti-stigma messaging Integrate self-harm awareness in curriculum Senior leadership, teachers & students Deliver / Sustain Curriculum materials co-produced with students to be presented in small-group PSHE or equivalent sessions; avoid large assemblies for sensitive topics Building whole school capacity to respond to self-harm Induction & CPD ** training and briefings for all staff Senior leadership Wellbeing team & Mental Health Lead Sustain Scenario-based training for all school staff; quick-reference guides; reflection group discussions; access to follow-up support and resources provided. Ensure students know support options & policies All school staff Deliver / Sustain Posters in visible locations, raise awareness of designated contacts, and methods to speak to staff. Engage with students to understand their ongoing level of awareness. Creating a supportive school environment Visible, accessible self-harm support within daily school routines All school staff Deliver / Sustain Co-design confidential, stigma-free spaces with students. Engage with students to understand any barriers to help-seeking. Guidance for staff on managing confidentiality Senior leadership Prepare / Deliver / Sustain Clear protocols on limits of confidentiality Support for peers following disclosures All staff Deliver / Sustain Selected staff provide informal check-ins with peers. Reassure them that they acted appropriately Maintain confidentiality for peers to protect trust. Discuss with students how they would like the school to support them to give them a sense of choice and autonomy. Monitor staff wellbeing and confidence Senior leadership Prepare/ Deliver/ Sustain Access to reflective supervision, wellbeing resources, emotional support to manage the personal impact of disclosures. Engage parents with the school’s self-harm strategy and encourage positive, trusting relationships between staff and parents All staff Deliver Sustain Offer parents clear, practical information & resources on recognising signs of self-harm and responding constructively especially at key transitions; workshops. *e.g. Counsellors, Safeguarding Leads, Mental Health Support Teams (MHST) **Continuing Professional Development [Insert Table 1] Discussion The current study explored the views and experiences of young people and school staff on how schools can address self-harm. Framework analysis generated three themes which represent overlapping views of staff and young people, including the need to understand the nature and scope of self-harm in schools, building a whole-school approach, and creating a supportive school environment. Findings highlight several ways schools can support students and have directly informed the development of whole-school guidelines on self-harm. Staff and students perceived self-harm as a pressing and increasingly common issue, consistent with recent evidence of rising prevalence in the UK ( 38 ). Staff attributed this to multiple, interacting factors, such as high academic demands, identity related struggles, peer dynamics, social media and the effects of the COVID-19 pandemic. This suggests that many staff in our study were aware of the potentially complex and varied risk factors that can contribute to self-harm. Staff who had completed prior mental health training noted that self-harm behaviours are diverse, often hidden, and not readily recognised, supporting evidence that limited awareness of this range of behaviours may contribute to self-harm being frequently over-looked ( 39 ). Our findings also suggest that disclosure of self-harm and responses from others are influenced by broader cultural and social factors, such as stigma, stereotypes, and generational or cultural attitudes. Consistent with a previous study, young people described facing stigma and being labelled as attention-seeking ( 15 ), while wider cultural perceptions and societal norms across religion, media, and ethnicity can exacerbate feelings of guilt, shame or acceptance ( 40 ). Participants in our study consistently endorsed implementing a whole-school approach to self-harm that offers readily accessible and flexible support to all students who need it. Both staff and young people valued the availability of safe, quiet spaces within schools to speak with staff and receive support. However, they were cautious about designated areas, which could make young people feel exposed and stigmatised when support is too visible. Similarly, other studies have shown that young people often feel uncomfortable sharing private thoughts and feelings in the presence of peers, as this makes them feel more vulnerable ( 19 , 41 ). Moreover, being seen speaking with designated pastoral staff can carry negative labels such as ‘troublemakers’ and ‘difficult’, creating concerns around stigma ( 42 ). In our study, trust and existing relationships were seen as key. Findings highlighted that young people prefer to speak with a familiar staff member they trust, rather than a formal ‘point person’, reflecting broader concerns around confidentiality and privacy when speaking about mental health to a staff member they do not know well ( 43 ). School staff in other studies have emphasised the ongoing need to build and maintain trusting relationships so that students feel comfortable seeking support at school when problems arise ( 44 ). Our findings highlight the need to involve young people in decisions around parental involvement, ensuring a balance between safeguarding responsibilities and student preferences. Consistent with prior studies, staff supported a student-led approach in which students are consulted on the timing, content and extent of how much information is disclosed ( 45 , 46 ). Participants described responding ‘on their feet’ to disclosures without training or specific guidelines, with self-harm most often treated solely as a safeguarding issue. These accounts reflect wider evidence that school staff feel underprepared, lacking in knowledge and confidence to respond to self-harm, and call for targeted training and consistent school-level policies ( 22 , 28 , 29 ). Staff in our study advocated for a unified approach, shared guidelines, and training accessible to all members of the school community. This is consistent with evidence that staff members who do not have mental health support role are the ones who first spot signs of self-harm ( 47 ) and that equipping all staff with basic skills to recognise mental health difficulties and to provide appropriate support is essential ( 45 ). Recent work also highlights the importance of implementing best practice guidelines consistently across schools ( 34 ). Young people in our study emphasised the value of including self-harm within the curriculum to raise awareness, reduce stigma and encourage help-seeking, echoing calls for structured education on self-harm in schools ( 19 ). However, the development of education materials and how they are delivered should be informed by students. Our study also draws attention to the need for schools to support the wider school community following incidents of self-harm. Staff sought clearer guidance on responding to peer-reported self-harm and for supporting students who confide about a friend’s behaviour. This aligns with an earlier study that young people want education on recognising signs of self-harm and how to respond to a disclosure from peers ( 19 ). Both staff and young people highlighted that peers disclose another student’s self-harm also require support and reassurance that they have done the right thing. Parents were also identified as needing tailored information and guidance in how to recognise signs of self-harm and constructively respond to their child, reflecting previous research that parents value support around communication, psychoeducation, emotional regulation and parenting strategies ( 48 ). Finally, staff in our study raised the personal and emotional impact of managing student self-harm, particularly for those with lived experience. Staff in leadership roles stressed the need for resources to support staff wellbeing, echoing findings that staff often experience lasting emotional strain and find it difficult to ‘switch off’ outside of work, highlight the importance of access to external support ( 47 ). Limitations A strength of this study is that participants were drawn from areas with high levels of mental health need, including schools with above average rates of free school meal eligibility in both urban and rural settings. However, recruitment was limited to of the East of England and London and may not reflect the perspectives of staff and young people in other parts of the UK. Nonetheless, the themes of stigma, staff confidence and the importance of whole school approaches, are consistent with international literature and may therefore have wider relevance. We also acknowledge the imbalance in sample sizes between staff and young people, meaning themes may be more reflective of staff perspectives. Future research with young people is needed to inform the development of student-centred spaces and policies for responding to self-harm within schools, ensuring that practices are acceptable and appropriate Conclusions This study makes an important contribution by developing evidence-based principles of practice for UK schools, grounded in the perspectives of staff and young people. While schools are a key setting for early intervention and prevention of self-harm, staff often feel underprepared due to limited training, knowledge and guidance. By highlighting these gaps and proposing whole-school principles of practice, this study provides a foundation for improving staff confidence, fostering supportive environments and ensuring that school responses to self-harm are both effective and acceptable to young people. Abbreviations CPD: Continuing Professional Development MHST: Mental Health Support Teams Declarations Ethics approval and consent to participate Ethical approval was granted by the University of Cambridge Department of Psychology Ethics Committee (ref: PRE.2024.006). Informed consent was obtained from each participant before taking part. Consent for publication All participants provided consent for publication. Availability of data and materials The datasets generated and/or analysed during the current study are not publicly available due to risk of identifying participants but are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This project was funded by the National Institute for Health and Care Research (NIHR) under its Research for Patient Benefit program (grant reference NIHR NIHR202720), and by the UK Research and Innovation Medical Research Council (Public Health Intervention Development (MR/Y503277/1). Author contributions AMB and JKA conceived the study design and wrote the protocol. AMB and HG recruited participants, conducted the focus groups and analysis. AMB wrote the first draft of the manuscript. All authors contributed to the manuscript and approved its content. Acknowledgments The authors would like to express their gratitude to all the participating schools, especially the senior staff members who assisted with recruitment. They also wish to acknowledge the advisory group members for their valuable advice in the research. Thank you to Poppy Hall (PH) with assisting with the young person’s focus groups and Xueying Sun (XS) for assisting with some of the analysis. All research at the Department of Psychiatry in the University of Cambridge is supported by the NIHR Cambridge Biomedical Research Centre (NIHR203312) and the NIHR Applied Research Collaboration East of England. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. References Ritchie J, Lewis J, McNaughton Nicholls C, Ormston R. Qualitative research practice : a guide for social science students and researchers2013. 430- p. Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Medical Research Methodology. 2013;13(1):117-. Sharples J, Eaton, J., & Boughelaf, J. . A School's Guide to Implementation. Guidance Report. . 2024. Hawton K, Saunders KEA, Connor RCO. Self-harm and suicide in adolescents. The Lancet 2012;379:2373-82. NICE. Self-harm: assessment, management and preventing recurrence. 2022. 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Deliberate self harm in adolescents: Self report survey in schools in England. British Medical Journal. 2002;325(7374):1207-11. Department for Health, Education Df. Transforming children and young people's mental health provision: a green paper Impact Assessment Summary. United Kingdom Government; 2017. p. 1-32. Newlove-Delgado T, Moore D, Ukoumunne OC, Stein K, Ford T. Mental health related contact with education professionals in the British Child and Adolescent Mental Health Survey 2004. Journal of Mental Health Training, Education and Practice. 2015;10(3):159-69. Colville L, Anderson JK, Burn A-M. How schools can respond to pupils who self-harm: a qualitative study with young people and school staff. Emotional and Behavioural Difficulties. 2024;29(3-4):123-37. O'Reilly M, Svirydzenka N, Adams S, Dogra N. Review of mental health promotion interventions in schools. Soc Psychiatry Psychiatr Epidemiol. 2018;53(7):647-62. Burn A-M, Hall P, Anderson J. A Web-Based Training Program for School Staff to Respond to Self-Harm: Design and Development of the Supportive Response to Self-Harm Program. JMIR Formative Research. 2024;8:e50024-e. Berger E, Hasking P, Reupert A. 'We’re working in the dark here': Education needs of teachers and school staff regarding student self-injury. School Mental Health: A Multidisciplinary Research and Practice Journal. 2014;6(3):201-12. Heath NL, Toste JR, Sornberger MJ, Wagner C. Teachers' Perceptions of Non-Suicidal Self-Injury in the Schools. School Mental Health. 2011;3(1):35-43. Evans R, Parker R, Russell AE, Mathews F, Ford T, Hewitt G, et al. Adolescent self-harm prevention and intervention in secondary schools: a survey of staff in England and Wales. Child and Adolescent Mental Health. 2019;24(3):230-8. Best R. Deliberate Self-Harm in Adolescence: A Challenge for Schools. British Journal of Guidance & Counselling. 2006;34(2):161-75. Lee F. Self-harm training in secondary schools: An educational psychology intervention using interpretative phenomenological analysis. Educational & Child Psychology. 2016;33(2):105-16. Timson D, Priest H, Clark-Carter D. Adolescents Who Self-Harm: Professional Staff Knowledge, Attitudes and Training Needs. Journal of Adolescence. 2012;35(5):1307-14. Berger E, Hasking P, Reupert A. Response and training needs of school staff towards student self-injury. Teaching & Teacher Education. 2014;44:25-34. Pierret ACS, Anderson JK, Ford TJ, Burn A-M. Review : Education and training interventions , and support tools for school staff to adequately respond to young people who disclose self-harm – a systematic literature review of effectiveness , feasibility and acceptability. 2020. Burn AM, Gains H, Anderson JK. A Self-Harm Awareness Training Module for School Staff: Co-Design and User Testing Study. JMIR Form Res. 2025;9:e69309. Evans R, Hurrell C. The role of schools in children and young people's self-harm and suicide: Systematic review and meta-ethnography of qualitative research. BMC Public Health. 2016;16(1):1-3. Matthews EL, Townsend ML, Gray AS, Grenyer BFS. Ideal standards for policy on student self-harm: What research and practice tells us. School Psychology International. 2021;42(2):187-209. Meinhardt I, Cargo T, Te Maro B, Bowden L, Fortune S, Cuthbert S, et al. Development of guidelines for school staff on supporting students who self-harm: a Delphi study. BMC Psychiatry. 2022;22(1):1-14. Bowden L, Hetrick, S.E., Cargo, T., Woodfield, M., Meinhardt, I., Clark, T.C. and Fortune, S., . Maximising the management of self-harm in schools: A collaborative, implementation science approach by secondary schools and child and adolescent mental health services Mental Health & Prevention. 2025;37:200391. Goldberg JM, Sklad M, Elfrink TR, Schreurs KMG, Bohlmeijer ET, Clarke AM. Effectiveness of interventions adopting a whole school approach to enhancing social and emotional development: a meta-analysis. European Journal of Psychology of Education. 2019;34:755-82. Porter BW, W. Understanding the Barriers and Enablers of the Applied Research Collaboration (East of England) Population-in-Focus Approach. A Qualitative Review. 2023. Barter C, Renold E. The Use of Vignettes in Qualitative Research 1999 [Available from: http://sru.soc.surrey.ac.uk/SRU25.html. Hawton K, Bale L, Brand F, Townsend E, Ness J, Waters K, et al. Mortality in children and adolescents following presentation to hospital after non-fatal self-harm in the Multicentre Study of Self-harm: a prospective observational cohort study. The Lancet Child and Adolescent Health. 2020;4(2):111-20. Parker R. A small-scale study investigating staff and student perceptions of the barriers to a preventative approach for adolescent self-harm in secondary schools in Wales-a grounded theory model of stigma. Public Health. 2018;159:8-13. Venkatesan S. Exploring self-harm: A narrative review of socio-cultural factors. . World Journal of Advanced Research and Reviews. 2024;23:605–15. Foulkes L, Stapley E. Want to improve school mental health interventions? Ask young people what they actually think. Journal of Philosophy of Education. 2022;56(1):41-50. Spratt J, Shucksmith J, Philip K, Watson C. ‘The bad people go and speak to her’: young people’s choice and agency when accessing mental health support in school. . Children & Society 2010;24(6):483-94. Patte KA, Battista K, Goddard J, Ferrob J, Leatherdale ST. Students’ reasons for being reluctant to seek help for mental health concerns in secondary schools. . Cogent Mental Health. 2024;31:1-7. Dimitropoulos G, Cullen E, Cullen O, Pawluk C, McLuckie A, Patten S, et al. “Teachers often see the red flags first”: perceptions of school staff regarding their roles in supporting students with mental health concerns. . School mental health. 2022;14(2):402-15. Meinhardt I, Cuthbert S, Gibson K, Fortune S, Hetrick SE. Young people and adult stakeholders' reflections on how school staff should support students who self-harm: A qualitative study. Journal of Adolescence. 2022;94(7):969-80. Fox KR, Bettis AH, Burke TA, Hart EA, Wang SB. Exploring adolescent experiences with disclosing self-injurious thoughts and behaviors across settings. . Research on child and adolescent psychopathology 2022;50(5):669-81. Dowling S, Doyle L. Responding to self-harm in the school setting: the experience of guidance counsellors and teachers in Ireland. British Journal of Guidance & Counselling. 2017;45(5):583-92. French Á GK, Nearchou F, Raftery S, O’Dwyer B, Hennessy E. . Parents’ information needs in relation to adolescent self-harm: perspectives of parents and professionals. Archives of suicide research. 2024;28(4):1131-46. Additional Declarations No competing interests reported. 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It is defined as \u0026lsquo;intentional self-poisoning or self-injury, irrespective of the apparent purpose\u0026rsquo; (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), and is associated with a range of adverse outcomes, including disrupted education and employment trajectories and an elevated risk of suicide (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Recent national survey data highlighted that 24% of 17-year-olds in the UK had self-harmed in the past year (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). In England, the lifetime prevalence of self-harm among 15-year-olds rose sharply from 22% in 2014 to 34% in 2021 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Research suggests that the COVID-19 pandemic further exacerbated mental health difficulties among young people, contributing to increased rates and severity of self-harm (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). These trends are often associated with delays in help-seeking and persistent unmet needs(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Early identification and timely intervention are crucial to improving outcomes (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e); however, many young people conceal their self-harm due to fear of stigma, being misunderstood, judged or labelled as \u0026lsquo;attention-seeking\u0026rsquo; (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). As a result, only a small proportion of adolescents who self-harm present to hospital services (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eUK Government policy highlights the role of schools in supporting young people\u0026rsquo;s mental health, including early intervention and prevention of self-harm and suicide (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Teachers and other education professionals are often among the first to notice signs of self-harm and are well-positioned to facilitate early intervention and referral to appropriate services (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Trusted relationships with school staff can play a vital role in encouraging help-seeking in adolescents. Research shows that young people are more inclined to seek help from a trusted staff member who listens, demonstrates empathy, and creates a supportive and safe environment (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Additionally, staff have described how schools are increasingly acting as a \u0026ldquo;one stop shop\u0026rdquo; for parents seeking advice about their child\u0026rsquo;s mental health, often before approaching health professionals (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eHowever, despite a general willingness to help, many school staff report feeling ill-equipped to respond to a student who is self-harming, citing a gap in training, insufficient knowledge and a lack of confidence in managing self-harm within the school setting (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). A recent survey found that only half of school staff received any training on self-harm, with just a fifth (22%) rating the training as highly adequate (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Limited staff knowledge can result in negative emotional reactions from staff when faced with a student\u0026rsquo;s self-harm, including panic, fear, or even repulsion (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Such responses may inadvertently discourage young people from seeking further help (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). School staff have expressed a clear need for training and practical support tools to help them respond to and manage self-harm (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Training programmes, particularly for pastoral staff, have shown promise in fostering more reflective and supportive school environments, by helping staff address their own concerns and challenge unhelpful attitudes towards self-harm (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDespite school staff expressing a clear need for improved knowledge and training on adolescent self-harm (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), there remains a lack of effective, feasible and acceptable training programmes to support school staff (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). A recent online training programme has been developed to address this gap (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Moreover, although students consistently express a desire for open dialogue around self-harm, the topic remains largely absent from school curricula, and many schools still lack a dedicated policy on how to address self-harm (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). A recent review highlighted the limited availability of school policies on self-harm and identified the need for evidence-informed guidelines to support schools in responding appropriately to instances of student self-harm (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn the UK, there is limited research and guidance for addressing self-harm in schools. A recent update of NICE guidance provides key advice on the practical steps educational professionals should take e.g. seek advice from a health professional, have a designated lead, make the young person aware of sources of support (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). In New Zealand, Meinhardt et al (2022) developed guidelines to provide a structured framework for consistent and effective school-based responses to self-harm. Using a Delphi approach, drawing on input from mental health and education experts, the study produced a set of endorsed statements across key domains including staff training, responding to disclosures, post-incident support, and whole-school responsibilities (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). More recently, Bowden et al (2025) explored key barriers and facilitators to the implementation of self-harm best practice and confirmed that access to guidance is a key facilitator (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Guidance should be up to date, easily accessible, locally developed and support a whole-school approach. Whole school approaches involve collaborative efforts between all staff, teachers, families and students. They view the whole school as the unit of change and involve action across the curriculum, school ethos and family and community partnerships (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe current study aimed to (i) explore the perspectives of young people and school staff about how schools can address self-harm and (ii) use the findings to develop UK-specific guidelines on how schools can support students who self-harm.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eDesign\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was part of a broader programme of work that developed an online self-harm awareness training programme for secondary schools (19, 21, 29, 30). We analysed qualitative data collected through focus groups with young people and school staff. Reporting has followed the Consolidated Criteria for Reporting Qualitative Studies (COREQ) guidelines (supplemental file 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was granted by the University of Cambridge Department of Psychology Ethics Committee (ref: PRE.2024.006).\u003c/p\u003e\n\u003ch2\u003eParticipants and sampling\u003c/h2\u003e\n\u003cp\u003eWe conducted seven focus groups with 38 participants: five with secondary school staff (n=27) and two with young people (n=11). Staff were recruited from four state-maintained schools and represented a range of roles, including senior leadership (n=5), teaching staff (n=8), administrative and support staff (n=3), and mental health and pastoral teams (n=11). All schools had above-average rates of free school meal eligibility (\u0026gt;19%) and higher numbers of students with Special Educational Needs or Disabilities, both associated with poorer mental health. Three schools were mixed-sex and located in high-need areas of the East of England (36), while the fourth was a boys\u0026rsquo; school in an inner-city London borough with above-average poverty levels. \u003c/p\u003e\n\u003cp\u003eYoung people were recruited through one participating school and via social media. They were aged 14-21 years (median = 16) and had experience of self-harm and/or supporting a peer or sibling. Most (n=9) were in secondary school, while one was attending university and another was in full-time employment. \u003c/p\u003e\n\u003ch2\u003eProcedure\u003c/h2\u003e\n\u003cp\u003eTopic guides for each participant group were developed in collaboration with the study\u0026rsquo;s public advisory groups. At the beginning of the young people\u0026rsquo;s sessions, we introduced short vignettes depicting scenarios of school staff responding to a student who was self-harming (37). These served as a valuable tool to facilitate discussion of a sensitive topic, allowing participants to reflect without drawing directly on their own personal experiences. Topic guide questions for school staff explored their views on how schools should address self-harm, their own feelings (e.g. confidence and concerns about managing such situations), and their perspectives on staff training (topic guide questions are provided in supplementary file 2). \u003c/p\u003e\n\u003cp\u003eAll participants were fully informed about the study and provided electronic consent before taking part; parental consent was obtained for those under 16. Focus groups were facilitated by AMB, an experienced qualitative researcher, with support from HG and PH. Staff groups were conducted in schools during the school day. One young people\u0026rsquo;s group took place in school, while the other was conducted online to accommodate an evening time slot. Focus groups lasted 1-2 hours, were audio recorded, and transcribed by a university-approved transcription service. Transcripts were checked, anonymised and stored securely in password-protected folders accessible only to the research team. All participants received an online shopping voucher as a thank you for their time.\u003c/p\u003e\n\u003ch2\u003eAnalysis\u003c/h2\u003e\n\u003cp\u003eQualitative data were analysed using the six stages of the Framework Method (1, 2), a pragmatic approach to analysis. Two researchers (AMB, HG) began by immersing themselves in the transcripts, coding deductively with reference to the topic guide and inductively to capture meanings arising from the data. This informed the development of a preliminary coding framework, which was applied to the remaining transcripts and refined iteratively to incorporate new codes. \u003c/p\u003e\n\u003cp\u003eAn Excel matrix was then created, with rows representing focus groups and columns representing subthemes. Data were charted into this framework by AMB, HG and XS, with summaries supported by illustrative quotations to preserve the richness of participants\u0026rsquo; accounts. In the final stage, the team reviewed the data to identify cross-cutting patterns and generate higher-level themes. \u003c/p\u003e\n\u003cp\u003eTo translate findings into practical recommendations, we mapped them onto the Education Endowment Foundation\u0026rsquo;s \u003cem\u003eImplementation in Schools Framework\u003c/em\u003e (3). Using a structured statement format (specifying what should be done, by whom, when, and how), we developed a set of evidence-based principles of practice to enhance the likelihood of effective implementation in schools.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eIn this section, we present the main themes generated from the analysis, integrating the overlapping views of staff and young people: 1) Understanding the nature and scope of self-harm in schools, 2) Building whole school capacity to respond to self-harm, and 3) Creating a supportive school environment. The themes are summarised in the section below (see Figure 1) together with illustrative quotes from staff and young people. This section also presents the guidelines developed from the themes.\u003c/p\u003e\n\u003ch2\u003eTheme 1: Understanding the nature and scope of self-harm in schools\u003c/h2\u003e\n\u003ch3\u003eRecognising hidden and varied forms of self-harm\u003c/h3\u003e\n\u003cp\u003eBoth staff and young people viewed self-harm as a pressing and increasingly common issue in schools. Staff linked the rise of self-harm to several intersecting factors: high academic expectations, identity-related struggles, peer dynamics, the influence of social media and the lingering effects of the COVID-19 pandemic. Staff noted that self-harm is often \u0026ldquo;hidden\u0026rdquo;, particularly among high-achieving students, making it harder to identify those in need.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEven though there\u0026rsquo;s no sign academically that that kid is struggling, they\u0026rsquo;re actually buckling under the worry and the weight of it all. (Staff)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMental health and pastoral staff emphasised that self-harm can take varied and often non-visible forms, highlighting the importance of recognising behaviours beyond cutting, such as ingestion of harmful substances, and of understanding the underlying emotional distress that drives these behaviours. There was broad consensus that improving staff awareness in this area is essential to ensure they are equipped to identify and support students who might otherwise remain unnoticed.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;digesting different types of toxic materials can be a form of self-harm. Recognising that you\u0026rsquo;re not always looking out for someone who\u0026rsquo;s got long sleeves. It\u0026rsquo;s different types of harm.\u0026rdquo; (Staff)\u003cbr\u003e\u003c/em\u003e\u003c/p\u003e\n\u003ch3\u003eBreaking down stigma and stereotypes\u003c/h3\u003e\n\u003cp\u003eStigma was viewed as deeply rooted in generational and cultural attitudes, where mental health is not openly discussed and often perceived as \u0026ldquo;silly\u0026rdquo; or \u0026ldquo;shameful\u0026rdquo;. Staff expressed concern that some colleagues and parents hold judgemental attitudes about self-harm, and such beliefs could undermine relationships and deter young people from seeking help. They emphasised the need to challenge these attitudes, improve colleagues\u0026rsquo; understanding, and adapt approaches to work sensitively with families from diverse backgrounds.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026hellip;there\u0026rsquo;s generations where mental health wasn\u0026rsquo;t spoken about\u0026hellip;And then it\u0026rsquo;s that element of they don\u0026rsquo;t know how to deal with it because their parents just shut it down. And so there needs to be more of a society training to deal with \u0026ndash; not an epidemic, but there\u0026rsquo;s a lot more mental health issues now. (Staff)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI\u0026rsquo;ve been brought up in a culture that self-harm was this kind of an attention-seeking tactic\u0026hellip;that culture very much still exists and I think it\u0026rsquo;s really important that we stamp that out. (Staff)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eYoung people also noted that stigma, particularly the perception of self-harm as \u0026ldquo;attention-seeking\u0026rdquo; can discourage young people from seeking help. They felt schools should actively challenge these misconceptions by promoting education and open discussion to raising awareness.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAnd the stigma behind it that some people might think that you\u0026apos;re only doing it for attention-seeking, and you don\u0026apos;t really want people to think that about you. (Young person)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI think the stigma with people our age is very much like they\u0026apos;re attention-seeking and that definitely is something that I think schools need to address more because the stigma around things really, really can make an impact on whether a student tells a teacher what\u0026apos;s going on or not. (Young person)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBoth young people and staff highlighted the need to challenge stereotypes. Staff working in a single-sex boys\u0026rsquo; school pointed out that self-harm remains an issue among male students, despite the stereotype that it is predominantly a female problem. They noted that prevailing gender norms may contribute to the under-recognition of self-harm among boys and deter them from seeking support.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026hellip;there\u0026apos;s some kind of gender divide, I mean, I think groups of boys in school, it\u0026apos;s not something that is spoken about (Young person)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBecause obviously this is a boys\u0026rsquo; school, I don\u0026rsquo;t know if it\u0026rsquo;s more common in a girls\u0026rsquo; school, like I think boys would try and hide it more. (Staff)\u003c/em\u003e\u003c/p\u003e\n\u003ch2\u003eTheme 2: Building whole school capacity to respond to self-harm\u003c/h2\u003e\n\u003ch3\u003eGaps in staff preparedness and confidence\u003c/h3\u003e\n\u003cp\u003eStaff described the evolving role of teachers, noting that schools are increasingly functioning as \u0026ldquo;frontline services for students\u0026rdquo;. They reported being expected to manage complex mental health needs with limited guidance, fragmented support and inconsistent training. Several recalled having to respond to self-harm incidents in the classroom without any formal training or preparation, relying instead on instincts to remain calm and avoid escalation.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI\u0026rsquo;ve had one girl who just did it with anything. I had to literally just go over and taking the object out of her hand and saying, \u0026ldquo;Right, we need to focus on our work now.\u003c/em\u003e \u003cem\u003eBut it was literally shocking just to think what she did. I\u0026rsquo;ve had no training. (Staff)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eConfidence in managing a self-harm disclosure varied widely across staff. Some described self-harm as a \u0026ldquo;scary\u0026rdquo; subject, primarily because of its close association with suicide. They reported feelings of guilt or denial after discovering a young person\u0026rsquo;s self-harm, as well as anxiety about \u0026ldquo;saying the wrong thing\u0026rdquo; and potentially triggering further harm.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI thought it was a lot of pressure. You don\u0026rsquo;t want to do something wrong, you don\u0026rsquo;t know the wrong and right thing to do. Like you don\u0026rsquo;t want to make a situation worse, but then you don\u0026rsquo;t want to not help. So it\u0026rsquo;s like, for me, I just didn\u0026rsquo;t know the right or wrong way to go about things. (Staff)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTeachers who felt unprepared described how limited training exacerbated anxiety and undermined their confidence in responding appropriately.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI think mental health in general, school staff find it difficult if they\u0026apos;ve had no training or not thought about it or if they think that speaking about it is likely to make it worse and therefore, don\u0026apos;t ask the kind of direct questions you need to be able to make a risk assessment.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026hellip;it is very shocking when a kid discloses it to you... I would like to know how to react to that information so that I don\u0026apos;t do any more damage... I would like to be able to communicate better to pupils about these issues.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eStaff confidence was often linked to previous mental health training. Those with relevant training felt more able to engage in conversations with students, while others reported feeling unprepared and uncomfortable, sometimes avoiding the topic altogether. This lack of confidence was closely associated with limited knowledge, training and a lack of clear practical guidance.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBecause you might just freeze and your mind just goes blank and you don\u0026rsquo;t know what to actually say. You don\u0026rsquo;t want to say the wrong thing. So that would be good, just to have some guideline of what to say and questions. (Staff)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSafeguarding provision was widely described as generic, with self-harm addressed only superficially and without practical strategies, leaving staff feeling under-prepared. Common concern was the absence of specific dedicated self-harm policies, with the issue typically subsumed under broader safeguarding procedures, as one staff member noted:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMost schools don\u0026rsquo;t have a specific policy on self-harm...it kind of falls under the safeguarding procedures. (Staff)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA lack of targeted guidance, combined with minimal training, was seen to undermine staff confidence and contribute to variable practice.\u003c/p\u003e\n\u003ch3\u003eNeed for whole-school training, education and guidance\u003c/h3\u003e\n\u003cp\u003eStaff emphasised the importance of a whole school approach to responding to self-harm, with training accessible to all staff, not just teachers or mental health teams. Non-teaching staff such as catering assistants, caretakers, and librarians were often described as having informal, trusting relationships with students, and are therefore well placed to notice early signs of distress.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI think for something like self-harm, it should be an all-staff thing\u0026hellip; they\u0026rsquo;re going to go to the person they feel most comfortable talking to. (Staff)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI work in the school library\u0026hellip;I would like to be able to spot the warning signs. (Staff)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eStaff advocated for guidance on what to say and how to say it when a student discloses self-harm, going beyond procedural reporting. A whole school approach was viewed as essential for fostering shared understanding, consistency in responses and a culture where safeguarding is a collective responsibility.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI would feel really good about other people having the same knowledge\u0026hellip;and that we have a shared knowledge base at a minimum. (Staff)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eStaff also emphasised the need for practical, accessible provision that could be integrated into existing safeguarding or Continuing Professional Development (CPD) sessions. Preferred formats included short, flexible modules delivered online or holding small, face-to-face groups, which would encourage discussion, reflection and sharing of good practice.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIt was good to be able to talk to other people\u0026hellip; you got ideas from them or lived experiences from them, or how they deal with it. (Staff)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eYoung people felt strongly that self-harm should be included in the curriculum and discussed more openly within schools to raise awareness and reduce stigma, which they saw as a barrier to help-seeking. They preferred that it be addressed directly rather than incorporated under general mental health education.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMental health is spoken about in a very generalised way. It would be beneficial to speak more openly and specifically about self-harm. (Young person)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eYoung people also stressed the importance of being informed about relevant school policies and the support available to them, with several noting that uncertainty about where to seek help could delay or prevent disclosure.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI think a lot of it is people don\u0026apos;t know where to get that kind of support. So I think it\u0026apos;s really important for schools to really put it out there and let students know where they should go to get that help. (Young person)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThey felt that while assemblies are helpful for sharing information about support, small group discussions were preferable for sensitive topics, as these provide a more comfortable space for conversations.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAssemblies can be awkward\u0026hellip;especially for more sensitive topics\u0026hellip; you\u0026rsquo;re just sitting there awkwardly uncomfortable with it, then you\u0026rsquo;re not going to take in that information you need. It needs to be a comfortable environment. (Young person)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBoth staff and students emphasised the importance of clear, step-by-step guidance for what happens after a disclosure, with young people particularly highlighting the need to be actively involved in decisions about next steps to ensure that support is responsive and collaborative.\u003c/p\u003e\n\u003ch2\u003eTheme 3: Creating a supportive school environment\u003c/h2\u003e\n\u003ch3\u003eCo-design safe, accessible, and youth-friendly spaces for support\u003c/h3\u003e\n\u003cp\u003eParticipants emphasised that support for students who self-harm should be readily accessible, flexible and embedded in the school day. Both young people and staff felt it was important to provide quiet, private spaces where students could go for help without fear of being overheard or judged, particularly in moments of acute distress. Providing students with choice over \u003cem\u003ehow\u003c/em\u003e and \u003cem\u003ewhere\u003c/em\u003e support takes place was seen as a way to increase their sense of control and reduce anxiety.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026lsquo;Well, where would you like to have a chat?\u0026rsquo; It gives them a bit of control over probably what is quite a scary situation. (Staff)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eStaff highlighted the importance of creating informal, youth-friendly spaces in which students feel safe to talk, as a way to build trust, reduce stigma around self-harm, and encourage early intervention. Young people echoed this, describing the need for spaces that feel confidential and safe. However, some felt that designated \u0026lsquo;support rooms\u0026rsquo; or \u0026lsquo;wellbeing hubs\u0026rsquo; could sometimes be intimidating or stigmatising, as other students might notice and make assumptions about their mental health. Flexible, student-informed approaches were therefore seen as essential for encouraging help-seeking while minimising the risk of judgement or labelling.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIt\u0026rsquo;s got to be in their terms, that they feel comfortable that they have somewhere to go to talk particularly about whatever is on their mind at the time. (Staff)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSometimes having a designated room can be more daunting\u0026hellip;people assume they\u0026rsquo;re going there for a specific reason. (Young person)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAcross all participants, \u0026lsquo;trust\u0026rsquo; emerged as central to encouraging help-seeking. While young people recognised the role of designated mental health staff, they stressed that familiarity and comfort would determine who they approached. Informal, everyday interactions - such as a chat with a form tutor during form time or lunchtime \u0026ndash; were preferred over more formal sessions after school which could draw unwanted attention. Small gestures, like asking \u0026ldquo;How are you today?\u0026rdquo; were seen as important for building rapport and making support seem more accessible.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026hellip;even just asking if the student is OK, just to let them know that someone cares\u0026hellip;even if you don\u0026apos;t already have that trust, you can build on that. (young person)\u003c/em\u003e\u003c/p\u003e\n\u003ch3\u003eNavigating confidentiality and parental involvement\u003c/h3\u003e\n\u003cp\u003eTransparency about confidentiality was a priority for young people, who wanted clear information on when and how parents would be involved. Uncertainty about these processes was seen as a source of anxiety that could deter disclosures. Young people felt that parents could struggle to accept or believe their child is self-harming.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSome people can keep things from their parents and it can be hard for them to accept that their child is self-harming\u0026hellip;having a lot of information for parents is just so helpful.\u0026rdquo; (Young person)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe fear of\u003c/em\u003e\u003cem\u003e\u0026nbsp;the unknown is so much bigger than what\u0026rsquo;s actually going to happen. (Young person)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eStaff described the most challenging situations as those where students disclosed self-harm but do not want their parents informed. Safeguarding policies meant that staff had to act when a student\u0026rsquo;s safety was at risk, but explaining this to a student can be difficult and could undermine trust.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI think the trickiest area for me when I\u0026apos;ve had those conversations is when students don\u0026apos;t want their parents to know\u0026hellip;my concern when you\u0026apos;re sat having that conversation with a child and they do this and then they go, \u0026quot;Are you going to tell my parents?\u0026quot; and you have to then navigate your way around explaining why that has to happen. That\u0026apos;s the tough bit. (Staff)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBoth staff and young people highlighted the importance of engaging parents constructively and sensitively. However, young people were particularly concerned that some home environments may not be supportive or may be the source of the young person\u0026rsquo;s distress.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026hellip;we\u0026apos;re assuming that the student has a good home life where they\u0026apos;ll be supported through it, but that might not be the case, and it might be because of things at home. (Young person)\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003ch3\u003eSupporting wider school community\u003c/h3\u003e\n\u003cp\u003eParticipants highlighted the need to extend support beyond the young person who is self-harming. For example, peers sometimes learn about a friend who is self-harming and disclose to staff. Both staff and students emphasised the importance of reassuring peers that they had acted appropriately by asking for help, while managing confidentiality carefully. Staff voiced that they would like clear protocols for handling of peer-reported self-harm, as they were aware that insensitive responses could damage trust and potentially make the situation worse. Young people felt that giving peers general information about the support their friend would receive could reduce uncertainty and worry and make them more likely to approach staff with concerns in the future.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI would want to know how I could help my friend in that situation, because I think I\u0026apos;d feel quite lost. (Young person)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants highlighted the importance of engaging parents constructively, providing accessible information and guidance on how to respond. This was seen as crucial given that self-harm is often hidden from parents, and first reactions may be angry, dismissive or disbelieving. Staff described the range of emotional responses they encounter and highlighted the need for greater parental support.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWe deal with a lot of parents who are naturally angry about what their child\u0026apos;s done; they\u0026apos;re disappointed, upset, angry, all of those kind of emotions, because they don\u0026apos;t want their child to be doing that to themselves. I think that there\u0026apos;s a certain degree of education for parents in supporting those young people, around what it is (Staff)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eYoung people also noted that some parents might struggle to accept their child is self-harming, highlighting the need for awareness-raising and clear guidance to help parents recognise warning signs and respond constructively.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI think with parents and figures of authority, I think the worry is a bad reaction because if they react badly, then you can\u0026apos;t do anything about it and you\u0026apos;ve just got to deal with whatever the result of that may be. (Young person)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants further emphasised the need of schools to be mindful of home circumstances. Not all families are supportive, and breaking confidentiality could have unintended consequences. As one young person explained:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTelling one person such a big thing\u0026hellip; if they go and tell loads of other people/tell your parents, it\u0026rsquo;s like all this information at once\u0026hellip; at first it\u0026rsquo;s good to only tell one person and they keep that private. (Young person)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTo address these challenges, general education on self-harm for parents was considered essential, particularly during the early years of secondary school. Suggested approaches included parent workshops, written guides, and opportunities to speak with designated staff, enabling parents to feel more confident in having open, supportive conversations with their children about mental health.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eStaff discussed the emotional toll of responding to self-harm disclosures, particularly for those staff members with personal or family experience of self-harm. Such experiences could increase the emotional impact but also shape professional practice. Senior leaders emphasised the importance of signposting staff to appropriate support and resources to help them manage these demands:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThere is that fear from me as a leader\u0026hellip; this could be really tough for someone to take on board. (Staff)\u003c/em\u003e\u003c/p\u003e\n\u003ch2\u003eTranslating qualitative findings into actionable school guidelines\u003c/h2\u003e\n\u003cp\u003eFrom our analysis, we have developed behaviour-focused principles of practice for schools to create a whole school approach to self-harm. We aligned the principle of practice with the Education Endowment Foundation\u0026rsquo;s Implementation in Schools Framework (3), which describes implementation as an iterative process that broadly follows four stages (explore, prepare, deliver, sustain). For effective implementation, schools are encouraged to adopt three behaviours (engage, unite, reflect). Engaging people involves meaningful consultation to shape overall direction, uniting people around what is being implemented helps to build buy-in and remind the school community why the new initiative is important, and finally reflection is used to monitor, adapt and improve implementation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Principles of practice for schools\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme\u003c/strong\u003e \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWhat\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWho\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWhen\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHow\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003eUnderstanding the nature and scope of self-harm\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWhole-school training for \u003cu\u003eall\u003c/u\u003e school staff\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003eSenior leadership\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003ePrepare / Deliver\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003eUnite staff around a shared understanding of self-harm.\u003c/p\u003e\n \u003cp\u003eTrain all staff (teaching \u0026amp; non-teaching) to recognise varied self-harm behaviours, risk factors, and how to respond appropriately and where to signpost.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDevelop school-wide self-harm policy\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003eSenior leadership with whole-school community input\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eExplore / Prepare \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003eSelf-harm policy tailored to school.\u003c/p\u003e\n \u003cp\u003eStep-by-step post-disclosure guidance\u003c/p\u003e\n \u003cp\u003eCo-produce policy with students, staff and parents to promote shared understanding and consistency of response.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eEnsure the policy reflects the values of the whole school community.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRaise awareness with staff, students, and parents to address misconceptions and stigma (e.g., \u0026ldquo;attention-seeking\u0026rdquo;, gender bias)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003eWellbeing staff* \u0026amp; Mental Health Lead\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eDeliver / Sustain\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003eAssemblies for general information on where to find support.\u003c/p\u003e\n \u003cp\u003eForm time, posters, peer-led initiatives, parent workshops to provide information, support and anti-stigma messaging\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntegrate self-harm awareness in curriculum \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003eSenior leadership, teachers \u0026amp; students\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eDeliver / Sustain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003eCurriculum materials co-produced with students to be presented in small-group PSHE or equivalent sessions; avoid large assemblies for sensitive topics\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003eBuilding whole school capacity to respond to self-harm\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInduction \u0026amp; CPD\u003c/strong\u003e**\u003cstrong\u003e\u0026nbsp;training and briefings for all staff\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003eSenior leadership\u003c/p\u003e\n \u003cp\u003eWellbeing team \u0026amp; Mental Health Lead\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eSustain\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003eScenario-based training for all school staff; quick-reference guides; reflection group discussions; access to follow-up support and resources provided.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEnsure students know support options \u0026amp; policies\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003eAll school staff \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eDeliver / Sustain\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003ePosters in visible locations, raise awareness of designated contacts, and methods to speak to staff.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eEngage with students to understand their ongoing level of awareness.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003eCreating a supportive school environment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVisible, accessible self-harm support within daily school routines \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003eAll school staff\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eDeliver / Sustain\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003eCo-design confidential, stigma-free spaces with students.\u003c/p\u003e\n \u003cp\u003eEngage with students to understand any barriers to help-seeking.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGuidance for staff on managing confidentiality\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003eSenior leadership\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003ePrepare / Deliver / Sustain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003eClear protocols on limits of confidentiality\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSupport for peers following disclosures\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003eAll staff\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eDeliver / Sustain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003eSelected staff provide informal check-ins with peers. Reassure them that they acted appropriately\u003c/p\u003e\n \u003cp\u003eMaintain confidentiality for peers to protect trust.\u003c/p\u003e\n \u003cp\u003eDiscuss with students how they would like the school to support them to give them a sense of choice and autonomy.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMonitor staff wellbeing and confidence \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003eSenior leadership\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003ePrepare/ Deliver/ Sustain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003eAccess to reflective supervision, wellbeing resources, emotional support to manage the personal impact of disclosures.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEngage parents with the school\u0026rsquo;s self-harm strategy and encourage positive, trusting relationships between staff and parents\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003eAll staff\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eDeliver\u003c/p\u003e\n \u003cp\u003eSustain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003eOffer parents clear, practical information \u0026amp; resources on recognising signs of self-harm and responding constructively especially at key transitions; workshops.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*e.g. Counsellors, Safeguarding Leads, Mental Health Support Teams (MHST)\u003c/p\u003e\n\u003cp\u003e**Continuing Professional Development\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e[Insert Table 1]\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe current study explored the views and experiences of young people and school staff on how schools can address self-harm. Framework analysis generated three themes which represent overlapping views of staff and young people, including the need to understand the nature and scope of self-harm in schools, building a whole-school approach, and creating a supportive school environment. Findings highlight several ways schools can support students and have directly informed the development of whole-school guidelines on self-harm.\u003c/p\u003e\u003cp\u003eStaff and students perceived self-harm as a pressing and increasingly common issue, consistent with recent evidence of rising prevalence in the UK (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Staff attributed this to multiple, interacting factors, such as high academic demands, identity related struggles, peer dynamics, social media and the effects of the COVID-19 pandemic. This suggests that many staff in our study were aware of the potentially complex and varied risk factors that can contribute to self-harm. Staff who had completed prior mental health training noted that self-harm behaviours are diverse, often hidden, and not readily recognised, supporting evidence that limited awareness of this range of behaviours may contribute to self-harm being frequently over-looked (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOur findings also suggest that disclosure of self-harm and responses from others are influenced by broader cultural and social factors, such as stigma, stereotypes, and generational or cultural attitudes. Consistent with a previous study, young people described facing stigma and being labelled as attention-seeking (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), while wider cultural perceptions and societal norms across religion, media, and ethnicity can exacerbate feelings of guilt, shame or acceptance (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eParticipants in our study consistently endorsed implementing a whole-school approach to self-harm that offers readily accessible and flexible support to all students who need it. Both staff and young people valued the availability of safe, quiet spaces within schools to speak with staff and receive support. However, they were cautious about designated areas, which could make young people feel exposed and stigmatised when support is too visible. Similarly, other studies have shown that young people often feel uncomfortable sharing private thoughts and feelings in the presence of peers, as this makes them feel more vulnerable (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Moreover, being seen speaking with designated pastoral staff can carry negative labels such as \u0026lsquo;troublemakers\u0026rsquo; and \u0026lsquo;difficult\u0026rsquo;, creating concerns around stigma (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn our study, trust and existing relationships were seen as key. Findings highlighted that young people prefer to speak with a familiar staff member they trust, rather than a formal \u0026lsquo;point person\u0026rsquo;, reflecting broader concerns around confidentiality and privacy when speaking about mental health to a staff member they do not know well (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). School staff in other studies have emphasised the ongoing need to build and maintain trusting relationships so that students feel comfortable seeking support at school when problems arise (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). Our findings highlight the need to involve young people in decisions around parental involvement, ensuring a balance between safeguarding responsibilities and student preferences. Consistent with prior studies, staff supported a student-led approach in which students are consulted on the timing, content and extent of how much information is disclosed (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eParticipants described responding \u0026lsquo;on their feet\u0026rsquo; to disclosures without training or specific guidelines, with self-harm most often treated solely as a safeguarding issue. These accounts reflect wider evidence that school staff feel underprepared, lacking in knowledge and confidence to respond to self-harm, and call for targeted training and consistent school-level policies (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Staff in our study advocated for a unified approach, shared guidelines, and training accessible to all members of the school community. This is consistent with evidence that staff members who do not have mental health support role are the ones who first spot signs of self-harm (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e) and that equipping all staff with basic skills to recognise mental health difficulties and to provide appropriate support is essential (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). Recent work also highlights the importance of implementing best practice guidelines consistently across schools (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Young people in our study emphasised the value of including self-harm within the curriculum to raise awareness, reduce stigma and encourage help-seeking, echoing calls for structured education on self-harm in schools (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). However, the development of education materials and how they are delivered should be informed by students.\u003c/p\u003e\u003cp\u003eOur study also draws attention to the need for schools to support the wider school community following incidents of self-harm. Staff sought clearer guidance on responding to peer-reported self-harm and for supporting students who confide about a friend\u0026rsquo;s behaviour. This aligns with an earlier study that young people want education on recognising signs of self-harm and how to respond to a disclosure from peers (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Both staff and young people highlighted that peers disclose another student\u0026rsquo;s self-harm also require support and reassurance that they have done the right thing. Parents were also identified as needing tailored information and guidance in how to recognise signs of self-harm and constructively respond to their child, reflecting previous research that parents value support around communication, psychoeducation, emotional regulation and parenting strategies (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). Finally, staff in our study raised the personal and emotional impact of managing student self-harm, particularly for those with lived experience. Staff in leadership roles stressed the need for resources to support staff wellbeing, echoing findings that staff often experience lasting emotional strain and find it difficult to \u0026lsquo;switch off\u0026rsquo; outside of work, highlight the importance of access to external support (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e).\u003c/p\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eA strength of this study is that participants were drawn from areas with high levels of mental health need, including schools with above average rates of free school meal eligibility in both urban and rural settings. However, recruitment was limited to of the East of England and London and may not reflect the perspectives of staff and young people in other parts of the UK. Nonetheless, the themes of stigma, staff confidence and the importance of whole school approaches, are consistent with international literature and may therefore have wider relevance. We also acknowledge the imbalance in sample sizes between staff and young people, meaning themes may be more reflective of staff perspectives. Future research with young people is needed to inform the development of student-centred spaces and policies for responding to self-harm within schools, ensuring that practices are acceptable and appropriate\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study makes an important contribution by developing evidence-based principles of practice for UK schools, grounded in the perspectives of staff and young people. While schools are a key setting for early intervention and prevention of self-harm, staff often feel underprepared due to limited training, knowledge and guidance. By highlighting these gaps and proposing whole-school principles of practice, this study provides a foundation for improving staff confidence, fostering supportive environments and ensuring that school responses to self-harm are both effective and acceptable to young people.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCPD: Continuing Professional Development\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMHST: Mental Health Support Teams\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eEthical approval was granted by the University of Cambridge Department of Psychology Ethics Committee (ref: PRE.2024.006).\u0026nbsp;Informed consent was obtained from each participant before taking part.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eAll participants provided consent for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available due to risk of identifying participants but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis project was funded by the National Institute for Health and Care Research (NIHR) under its Research for Patient Benefit program (grant reference NIHR NIHR202720), and by the UK Research and Innovation Medical Research Council (Public Health Intervention Development (MR/Y503277/1).\u003c/p\u003e\n\u003ch2\u003eAuthor contributions\u003c/h2\u003e\n\u003cp\u003eAMB and JKA conceived the study design and wrote the protocol. AMB and HG recruited participants, conducted the focus groups and analysis. AMB wrote the first draft of the manuscript. All authors contributed to the manuscript and approved its content.\u003c/p\u003e\n\u003ch2\u003eAcknowledgments\u003c/h2\u003e\n\u003cp\u003eThe authors would like to express their gratitude to all the participating schools, especially the senior staff members who assisted with recruitment. They also wish to acknowledge the advisory group members for their valuable advice in the research. Thank you to Poppy Hall (PH) with assisting with the young person\u0026rsquo;s focus groups and Xueying Sun (XS) for assisting with some of the analysis. All research at the Department of Psychiatry in the University of Cambridge is supported by the NIHR Cambridge Biomedical Research Centre (NIHR203312) and the NIHR Applied Research Collaboration East of England. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRitchie J, Lewis J, McNaughton Nicholls C, Ormston R. Qualitative research practice : a guide for social science students and researchers2013. 430- p.\u003c/li\u003e\n\u003cli\u003eGale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Medical Research Methodology. 2013;13(1):117-.\u003c/li\u003e\n\u003cli\u003eSharples J, Eaton, J., \u0026amp; Boughelaf, J. . A School\u0026apos;s Guide to Implementation. Guidance Report. . 2024.\u003c/li\u003e\n\u003cli\u003eHawton K, Saunders KEA, Connor RCO. Self-harm and suicide in adolescents. The Lancet 2012;379:2373-82.\u003c/li\u003e\n\u003cli\u003eNICE. Self-harm: assessment, management and preventing recurrence. 2022.\u003c/li\u003e\n\u003cli\u003eBorschmann R, Becker D, Coffey C, Spry E, Moreno-Betancur M, Moran P, Patton GC. 20-Year Outcomes in Adolescents Who Self-Harm: a Population-Based Cohort Study. The Lancet Child and Adolescent Health. 2017;1(3):195-202.\u003c/li\u003e\n\u003cli\u003ePatalay P. Psychological distress, self-harm and attempted suicide in UK 17-year olds: prevalence and sociodemographic inequalities Br J Psychiatry. 2021 219(2):437-9.\u003c/li\u003e\n\u003cli\u003eHulbert SE, T; Ferris, E; Hrytsenko, V; Kendall, S. HBSC England National Report: Findings from the 2001-2022 HBSC study for England. University of Kent; 2023.\u003c/li\u003e\n\u003cli\u003eTrafford AM, Carr MJ, Ashcroft DM, Chew-Graham CA, Cockcroft E, Cybulski L, et al. Temporal trends in eating disorder and self-harm incidence rates among adolescents and young adults in the UK in the 2 years since onset of the COVID-19 pandemic: a population-based study. The Lancet Child \u0026amp; Adolescent Health. 2023;0(0).\u003c/li\u003e\n\u003cli\u003eRowe SL, French RS, Henderson C, Ougrin D, Slade M, Moran P. Help-seeking behaviour and adolescent self-harm: A systematic review. Australian and New Zealand Journal of Psychiatry. 2014;48(12):1083-95.\u003c/li\u003e\n\u003cli\u003eGunnell D, Appleby L, Arensman E, Hawton K, John A, Kapur N, et al. Suicide risk and prevention during the COVID-19 pandemic. The lancet Psychiatry. 2020;7(6):468-71.\u003c/li\u003e\n\u003cli\u003eNurkhodjaev SB, S; Abdullaeva, V. Early Detection and Prevention of Suicidal Behavior in Adolescents. Indian Journal of Forensic Medicine \u0026amp; Toxicology. 2020; 14(4):7258-63.\u003c/li\u003e\n\u003cli\u003eNada-raja S, Morrison D, Skegg K. A population-based study of help-seeking for self-harm in young adults. 2003.\u003c/li\u003e\n\u003cli\u003eCurtis S, Thorn P, McRoberts A, Hetrick S, Rice S, Robinson J. Caring for Young People Who Self-Harm: A Review of Perspectives from Families and Young People. International journal of environmental research and public health. 2018;15(5).\u003c/li\u003e\n\u003cli\u003eLloyd B, Blazely A, Phillips L. Stigma towards individuals who self harm: impact of gender and disclosure. Journal of Public Mental Health. 2018;17(4):184-94.\u003c/li\u003e\n\u003cli\u003eHawton K, Rodham K, Evans E, Weatherall R. Deliberate self harm in adolescents: Self report survey in schools in England. British Medical Journal. 2002;325(7374):1207-11.\u003c/li\u003e\n\u003cli\u003eDepartment for Health, Education Df. Transforming children and young people\u0026apos;s mental health provision: a green paper Impact Assessment Summary. United Kingdom Government; 2017. p. 1-32.\u003c/li\u003e\n\u003cli\u003eNewlove-Delgado T, Moore D, Ukoumunne OC, Stein K, Ford T. Mental health related contact with education professionals in the British Child and Adolescent Mental Health Survey 2004. Journal of Mental Health Training, Education and Practice. 2015;10(3):159-69.\u003c/li\u003e\n\u003cli\u003eColville L, Anderson JK, Burn A-M. How schools can respond to pupils who self-harm: a qualitative study with young people and school staff. Emotional and Behavioural Difficulties. 2024;29(3-4):123-37.\u003c/li\u003e\n\u003cli\u003eO\u0026apos;Reilly M, Svirydzenka N, Adams S, Dogra N. Review of mental health promotion interventions in schools. Soc Psychiatry Psychiatr Epidemiol. 2018;53(7):647-62.\u003c/li\u003e\n\u003cli\u003eBurn A-M, Hall P, Anderson J. A Web-Based Training Program for School Staff to Respond to Self-Harm: Design and Development of the Supportive Response to Self-Harm Program. JMIR Formative Research. 2024;8:e50024-e.\u003c/li\u003e\n\u003cli\u003eBerger E, Hasking P, Reupert A. \u0026apos;We\u0026rsquo;re working in the dark here\u0026apos;: Education needs of teachers and school staff regarding student self-injury. School Mental Health: A Multidisciplinary Research and Practice Journal. 2014;6(3):201-12.\u003c/li\u003e\n\u003cli\u003eHeath NL, Toste JR, Sornberger MJ, Wagner C. Teachers\u0026apos; Perceptions of Non-Suicidal Self-Injury in the Schools. School Mental Health. 2011;3(1):35-43.\u003c/li\u003e\n\u003cli\u003eEvans R, Parker R, Russell AE, Mathews F, Ford T, Hewitt G, et al. Adolescent self-harm prevention and intervention in secondary schools: a survey of staff in England and Wales. Child and Adolescent Mental Health. 2019;24(3):230-8.\u003c/li\u003e\n\u003cli\u003eBest R. Deliberate Self-Harm in Adolescence: A Challenge for Schools. British Journal of Guidance \u0026amp; Counselling. 2006;34(2):161-75.\u003c/li\u003e\n\u003cli\u003eLee F. Self-harm training in secondary schools: An educational psychology intervention using interpretative phenomenological analysis. Educational \u0026amp; Child Psychology. 2016;33(2):105-16.\u003c/li\u003e\n\u003cli\u003eTimson D, Priest H, Clark-Carter D. Adolescents Who Self-Harm: Professional Staff Knowledge, Attitudes and Training Needs. Journal of Adolescence. 2012;35(5):1307-14.\u003c/li\u003e\n\u003cli\u003eBerger E, Hasking P, Reupert A. Response and training needs of school staff towards student self-injury. Teaching \u0026amp; Teacher Education. 2014;44:25-34.\u003c/li\u003e\n\u003cli\u003ePierret ACS, Anderson JK, Ford TJ, Burn A-M. Review : Education and training interventions , and support tools for school staff to adequately respond to young people who disclose self-harm \u0026ndash; a systematic literature review of effectiveness , feasibility and acceptability. 2020.\u003c/li\u003e\n\u003cli\u003eBurn AM, Gains H, Anderson JK. A Self-Harm Awareness Training Module for School Staff: Co-Design and User Testing Study. JMIR Form Res. 2025;9:e69309.\u003c/li\u003e\n\u003cli\u003eEvans R, Hurrell C. The role of schools in children and young people\u0026apos;s self-harm and suicide: Systematic review and meta-ethnography of qualitative research. BMC Public Health. 2016;16(1):1-3.\u003c/li\u003e\n\u003cli\u003eMatthews EL, Townsend ML, Gray AS, Grenyer BFS. Ideal standards for policy on student self-harm: What research and practice tells us. School Psychology International. 2021;42(2):187-209.\u003c/li\u003e\n\u003cli\u003eMeinhardt I, Cargo T, Te Maro B, Bowden L, Fortune S, Cuthbert S, et al. Development of guidelines for school staff on supporting students who self-harm: a Delphi study. BMC Psychiatry. 2022;22(1):1-14.\u003c/li\u003e\n\u003cli\u003eBowden L, Hetrick, S.E., Cargo, T., Woodfield, M., Meinhardt, I., Clark, T.C. and Fortune, S., . Maximising the management of self-harm in schools: A collaborative, implementation science approach by secondary schools and child and adolescent mental health services Mental Health \u0026amp; Prevention. 2025;37:200391.\u003c/li\u003e\n\u003cli\u003eGoldberg JM, Sklad M, Elfrink TR, Schreurs KMG, Bohlmeijer ET, Clarke AM. Effectiveness of interventions adopting a whole school approach to enhancing social and emotional development: a meta-analysis. European Journal of Psychology of Education. 2019;34:755-82.\u003c/li\u003e\n\u003cli\u003ePorter BW, W. Understanding the Barriers and Enablers of the Applied Research Collaboration (East of England) Population-in-Focus Approach. A Qualitative Review. 2023.\u003c/li\u003e\n\u003cli\u003eBarter C, Renold E. The Use of Vignettes in Qualitative Research 1999 [Available from: http://sru.soc.surrey.ac.uk/SRU25.html.\u003c/li\u003e\n\u003cli\u003eHawton K, Bale L, Brand F, Townsend E, Ness J, Waters K, et al. Mortality in children and adolescents following presentation to hospital after non-fatal self-harm in the Multicentre Study of Self-harm: a prospective observational cohort study. The Lancet Child and Adolescent Health. 2020;4(2):111-20.\u003c/li\u003e\n\u003cli\u003eParker R. A small-scale study investigating staff and student perceptions of the barriers to a preventative approach for adolescent self-harm in secondary schools in Wales-a grounded theory model of stigma. Public Health. 2018;159:8-13.\u003c/li\u003e\n\u003cli\u003eVenkatesan S. Exploring self-harm: A narrative review of socio-cultural factors. . World Journal of Advanced Research and Reviews. 2024;23:605\u0026ndash;15.\u003c/li\u003e\n\u003cli\u003eFoulkes L, Stapley E. Want to improve school mental health interventions? Ask young people what they actually think. Journal of Philosophy of Education. 2022;56(1):41-50.\u003c/li\u003e\n\u003cli\u003eSpratt J, Shucksmith J, Philip K, Watson C. \u0026lsquo;The bad people go and speak to her\u0026rsquo;: young people\u0026rsquo;s choice and agency when accessing mental health support in school. . Children \u0026amp; Society 2010;24(6):483-94.\u003c/li\u003e\n\u003cli\u003ePatte KA, Battista K, Goddard J, Ferrob J, Leatherdale ST. Students\u0026rsquo; reasons for being reluctant to seek help for mental health concerns in secondary schools. . Cogent Mental Health. 2024;31:1-7.\u003c/li\u003e\n\u003cli\u003eDimitropoulos G, Cullen E, Cullen O, Pawluk C, McLuckie A, Patten S, et al. \u0026ldquo;Teachers often see the red flags first\u0026rdquo;: perceptions of school staff regarding their roles in supporting students with mental health concerns. . School mental health. 2022;14(2):402-15.\u003c/li\u003e\n\u003cli\u003eMeinhardt I, Cuthbert S, Gibson K, Fortune S, Hetrick SE. Young people and adult stakeholders\u0026apos; reflections on how school staff should support students who self-harm: A qualitative study. Journal of Adolescence. 2022;94(7):969-80.\u003c/li\u003e\n\u003cli\u003eFox KR, Bettis AH, Burke TA, Hart EA, Wang SB. Exploring adolescent experiences with disclosing self-injurious thoughts and behaviors across settings. . Research on child and adolescent psychopathology 2022;50(5):669-81.\u003c/li\u003e\n\u003cli\u003eDowling S, Doyle L. Responding to self-harm in the school setting: the experience of guidance counsellors and teachers in Ireland. British Journal of Guidance \u0026amp; Counselling. 2017;45(5):583-92.\u003c/li\u003e\n\u003cli\u003eFrench \u0026Aacute; GK, Nearchou F, Raftery S, O\u0026rsquo;Dwyer B, Hennessy E. . Parents\u0026rsquo; information needs in relation to adolescent self-harm: perspectives of parents and professionals. Archives of suicide research. 2024;28(4):1131-46.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Self-harm, schools, young people, school staff, guidelines, principles of practice","lastPublishedDoi":"10.21203/rs.3.rs-7529401/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7529401/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eSelf-harm is common among adolescents and recognised as a significant public health issue. This study aimed to explore the perspectives of young people and school staff about how schools should respond to self-harm and subsequently develop principles of practice.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eSeven focus groups were carried out with school staff and young people. Qualitative data were thematically analysed using the Framework Method to generate themes (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The findings were translated into actionable items by applying the Implementation in Schools Framework (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eStaff and students had overlapping views about how schools should address self-harm. These were captured in three themes 1) Understanding the nature and scope of self-harm in schools, 2) Building whole school capacity to respond to self-harm, 3) Creating a supportive school environment. Principles of practice were generated to guide schools in their approach to self-harm.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eFor many young people, schools are a key setting for early intervention in self-harm; however, staff often feel ill-equipped to respond and clear guidance is lacking. This study has developed evidence-based principles of practice for UK schools, drawing on the perspectives of staff and young people to inform a whole-school approach.\u003c/p\u003e","manuscriptTitle":"Principles of practice for a whole school approach to self-harm: a qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-19 14:33:53","doi":"10.21203/rs.3.rs-7529401/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-21T09:33:28+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-12T19:09:27+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-02T05:13:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"192186688138759771653836248239143316178","date":"2025-09-16T19:40:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"155220473747854552450479795047514045749","date":"2025-09-16T07:11:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"336006601057290082545466402299324671023","date":"2025-09-14T05:38:05+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-12T04:58:38+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-10T10:04:15+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-09T03:28:29+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-09T03:28:13+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-09-03T17:23:08+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ff0e2812-70e5-4ba8-a159-6951bd9aa43c","owner":[],"postedDate":"September 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-22T15:59:31+00:00","versionOfRecord":{"articleIdentity":"rs-7529401","link":"https://doi.org/10.1186/s12889-025-25538-3","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2025-12-17 15:57:10","publishedOnDateReadable":"December 17th, 2025"},"versionCreatedAt":"2025-09-19 14:33:53","video":"","vorDoi":"10.1186/s12889-025-25538-3","vorDoiUrl":"https://doi.org/10.1186/s12889-025-25538-3","workflowStages":[]},"version":"v1","identity":"rs-7529401","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7529401","identity":"rs-7529401","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}