Teenager Scratching Her Arms Who Is Being Bullied At School — Free SCA Practice Case

Character Overview: You are Mia, 15. For several months you have been bullied at school — a group of girls have been name-calling, leaving you out, and sending nasty messages online. You have been feeling increasingly low, tearful, not sleeping well, and you have withdrawn from things you used to enjoy, like art. When you feel overwhelmed you have been hurting yourself by scratching your arms, and you wear long sleeves to hide the marks. You have not told your parents how bad things are, and you are frightened that if anyone is told it will "blow up" and make the bullying worse. You are guarded at first, but if the doctor is warm, calm, non-judgemental, and gives you some say in what happens, you gradually open up. You are not planning to end your life and you do not have a plan, though at your lowest you have had fleeting thoughts that you do not want to be here. You have some things that matter to you — a close friend, your younger brother, and your art.

(Actor note: do not volunteer or invent any specific detail of methods or means of self-harm; keep to "scratching my arms" if asked, and focus on how you feel and what has been happening.)

Opening Sentence: "Hi. Um… I've not been great. I've been really low, and… I've been hurting myself a bit. But please don't make a big thing of it with my mum and dad — that would just make everything worse."

History if Asked (Data Gathering Phase)

(Guarded initially; opens up if rapport is built.)

• ●How she's feeling: "Really low. Tearful a lot. I'm not sleeping properly, and I've stopped bothering with things I used to like, like my art. I just feel flat and hopeless a lot of the time."
• ●The self-harm (kept general): "When it all gets too much, I've been scratching my arms. It's a way of coping, I suppose. I keep it covered up."
• ●The bullying: "There's a group of girls at school. Name-calling, leaving me out, and horrible messages online. It's been going on for months and it's got worse."
• ●Who knows: "My best friend knows a bit. I haven't told my mum and dad how bad it is, and I haven't told anyone at school."
• ●Why she came (if explored): "I don't really know. I think I'm scared of how I'm feeling. But I don't want a big fuss."

ICE — Ideas, Concerns, Expectations

The patient does not volunteer this information unprompted, and only shares it once trust is built.

• ●Ideas: Mia sees the self-harm as her way of coping with unbearable feelings, and feels nothing can be done about the bullying. "It's how I cope. And I don't think anyone can actually stop the bullying."
• ●Concerns: Her dominant concern is that her parents (or the school) will be told and it will make everything worse — plus shame and embarrassment. "I'm terrified my parents will be told and it'll blow up. And I'm embarrassed."
• ●Expectations: She is unsure what she wants — partly she just wants the feelings to stop and to feel safe. "I just want to stop feeling like this. I don't really know what I expected."

If Asked — Sensitive Risk, Safeguarding, and Mood Screen

The patient answers these only when asked sensitively; she becomes more guarded if approached bluntly.

• ●If asked, sensitively, how often and whether the self-harm is escalating: "More often when things are really bad. It's been happening more lately." (Kept general — no method or frequency-of-technique detail.)
• ●If asked, sensitively, about thoughts of not wanting to be here or of ending her life: "Sometimes, at my lowest, I've thought I don't want to be here… but I wouldn't do anything. I haven't got a plan or anything like that." (Fleeting passive ideation; denies plan/intent — no method or means detail.)
• ●If asked about what stops her / what matters to her (protective factors): "My best friend. My little brother — I couldn't do that to him. And my art, when I can face it."
• ●If asked about the bullying in detail (who, where, online/physical): "A group of girls at school, and online — messages and being left out. It's not been physical, mostly words and online."
• ●If asked about home and family / safety at home: "Home's okay, my parents are alright really — I just haven't told them. Nothing bad happens at home, I feel safe there."
• ●If asked about whether she has told anyone at school / any support: "No teachers know. I haven't wanted to make it worse."
• ●If asked about alcohol or drugs: "No, I don't drink or take anything."
• ●If asked about sleep and appetite: "Sleep's bad — I lie awake. Appetite's a bit down, but I'm eating."
• ●If asked about who she could talk to / trusted adults: "My friend. Maybe my mum, if I'm honest, but I'm scared to."

Responses to Management (The Negotiation Phase)

• ●If the Doctor sensitively explains confidentiality and its limits: "So it's private… but if you're worried I'm not safe, you might have to tell someone? Can we talk about how that would work?" (The tested point is explaining confidentiality and its limits to a young person — Gillick — honestly and sensitively.)
• ●If the Doctor gently encourages involving her parents: "You think my mum and dad should know? I'm scared, but… maybe, if you helped me tell them." (The tested point is sensitively supporting parental involvement while respecting her feelings.)
• ●If the Doctor raises involving school/anti-bullying support: "The school could actually do something about the bullying? I hadn't thought they'd help." (The tested point is involving school support and tackling the bullying.)
• ●If the Doctor offers mental-health support and a safety plan (no method/means content): "So there's proper support — someone to talk to — and we make a plan for when I feel like that? That sounds okay." (The tested point is arranging appropriate support and a safety plan focused on people and healthy help, with no method/means detail.)
• ●If the Doctor arranges follow-up: "You'd see me again to check how I'm doing? Yeah, I'd like that."