Bullying

What is bullying?

Bullying is about belittling and humiliating other people to give satisfaction to the abuser.

We tend to think of bullying as being something from school and probably it is more prevalent in the immature environment of school but it can occur in the workplace, in the home, with the official who likes to wield power and anywhere where there is interaction between people.

A problem does not have to be recognised to exist and many victims of bullying suffer in silence, afraid even to complain. Hence, it is impossible to tell if it is really more prevalent or just more recognised than before.

The advent of the internet and social media added cyberbullying to the potential for bullying, further contributing to the problem. With ever increasingly young children using social media, and with increasing evidence of the potential harm cyberbullying can have, this has been an important issue to address in recent years.

Bullying in the workplace is a significant problem, with lives that are a misery and days lost from work by people who cannot face another day of victimisation being just part of the price that is paid. Even healthcare is not immune, with bullying of inexperienced staff by more senior staff and intimidation of staff by patients or their families.

The nature of bullying

Bullying is often seen as physical oppression but does not have to be physical. Girls are less likely than boys to be physical but they can be extremely vicious and spiteful in the things that they do. Cyberbullying adds another level. All this can be just as traumatic as physical attacks and it has driven some children to suicide.

Types of bullying

Bullying can take many forms.

At school
Examples of bullying include:¹

• Teasing.

• Physical assault.

• Threats.

• Name calling.

• Social bullying - social exclusion, spreading rumours about a person.

• Damage to property or school work.

Cyberbullying
This is harmful behaviour to others online or via tablets and smartphones. The bully may use social media networks, messaging apps or gaming sites. Children, adolescents or adults may be bullied in this way. It may involve:²

• Sending/posting of offensive or insulting messages.

• Posting false information about a person.

• Posting pictures to ridicule a person.

• Distributing pictures or videos of someone being attacked or humiliated.

• Impersonating another person.

• Excluding a person from a group.

• Cyberstalking - using the internet to stalk or harass an individual.

• Trolling. This is posting offensive or inflammatory messages to provoke people or cause disruption. Trolling is not always bullying but may be in some instances.

In the workplace
Bullying may involve:³

• Aggression - verbal or electronic.

• Persistent humiliation, ridicule or criticism in front of others.

• Picking on one individual.

• Malicious rumours.

• Unjustifiably changing areas of responsibility and relegating people to demeaning or inappropriate tasks. Undermining a competent individual.

• Deliberate exclusion of an individual from discussions or decisions.

• Denying training or promotion opportunities without justification.

How common is bullying? (epidemiology)

There are wide ranges in reports as to the incidence of bullying, which may be more indicative of differing criteria than differing patterns. Around one in three children report that they have been bullied at some point, with 10-14% experiencing bullying which goes on for six months or more.⁴

The UK Department of Education advises that most young people have been involved in cyberbullying in some way, as a perpetrator, victim or bystander.⁵

A report from the Advisory, Conciliation and Arbitration Service (ACAS) states:⁶

• The ACAS helpline gets 20,000 calls per year related to bullying or harassment.

• The impact on the economy of absenteeism and lost productivity due to bullying or harassment is estimated at £13.75 billion per year.

• Prevalence is rising. Managers reported bullying or harassment issues in 11% of workplaces in 2011, compared to 7% in 1998.

Symptoms of bullying (presentation)⁷

Bullying can lead to adverse physical and mental health effects for both the victim and bully. The primary health care team has a role in identifying the signs of bullying, and providing support for those affected and their families.

• Bullying can result in emotional distress, depression, anxiety, social isolation, low self-esteem, school avoidance/refusal, and substance abuse.

• In addition, victims of bullying often present with multiple physical symptoms, including insomnia, headaches, abdominal pain, digestive issues, disordered eating habits, dizziness, skin problems, and localised pain.

• There is a direct association between bullying and low academic performance in victims because bullying leads to increased school absenteeism.

• There is also a significant association between bullying and incidents of self-harm and increased rates of suicide risk (suicidal thoughts and attempts).

Differential diagnosis

There are other reasons for school phobia and school refusal.

• The child may simply be struggling academically. These children usually say that they find the lessons boring, as if they are too simple for their superior brain. They may also be disruptive in class. They tend not to have the air of oppression that is more typical of those who are bullied.

• Sometimes children are reluctant to go to school because they are worried about the one they leave at home. For example, a physically or mentally unwell parent, or one who has problems with misuse of alcohol or drugs.

• Sometimes it is not their peers who are constantly belittling and humiliating children but their teachers.

• The child may be the victim of abuse by someone rather older, and possibly the victim of sexual abuse. The perpetrators do not wait in the woods wearing dirty raincoats but are usually previously known to the child and trusted by the family. The child who is bullied may also be more susceptible to grooming because of low self-esteem. 'My little princess' and 'This is our special secret' are some of the phrases used to make the child feel special. See the separate Safeguarding Children - How to Recognise Abuse or a Child at Risk article for more information.

Treatment and management

A GP's role is to help support and empower the victim (or perpetrator) to resolve the situation. This involves listening, empathy, giving advice and information and treating any physical or psychological sequelae.

Children and adolescents

Having made the diagnosis, the more difficult problem is how to manage it. This must be done in consultation with the child, who may well be afraid that a 'bull in a china shop' approach will only make the bullies more vicious.

Reassure the child that the right thing is to share the information. Denial will not make it go away but is the bully's best friend. These fears must be explained to the parents too, who may be governed more by emotion than by reason.

If the parents confront the bully directly this will be counterproductive and could get them into trouble. A rational approach is required and, where the bullying is taking place in or around school, the school must be involved.

Where non-school-related cyberbullying has taken place, it may be appropriate to notify the police. In less serious cases, parents may be able to take control by changing the child's mobile number and re-educating on safe use of social media.

There has been much publicity about bullying in recent years and, nowadays, by law, all state (not private) schools must have a behaviour policy in place that includes measures to prevent all forms of bullying among pupils.¹

Schools must also follow anti-discrimination law. This means staff must act to prevent discrimination, harassment and victimisation within the school.

The child may be relieved that at last something is being done and it will all be better tomorrow. The reality is that it will take rather longer. It is not the role of the doctor to sort out the bullying but the doctor does have a responsibility to ascertain that the child and parents are made aware of the direction that they should take.

A follow-up appointment, probably in about a month, should be offered to ascertain that all is going according to plan and, it is hoped, that "medical" problems which led to the consultation will be significantly improved or entirely gone.

Most schools will be able to offer appropriate counselling if there are ongoing psychological problems. In some cases a referral to the local Children and Adolescent Mental Health Services (CAMHS) may be needed, or advice about local youth counselling options.

There have been cases of children and teenagers committing suicide following bullying or cyberbullying, so this is an issue which must be taken seriously.^{8 9}

Adults¹⁰

Again, the GP can offer advice and support.

For victims of workplace bullying, advise discussion with their manager or Human Resources (HR) department. If neither is possible, they could also discuss matters with their trade union representative, or with ACAS, who have a helpline.

Discuss their long-term plans and wishes with regard to ongoing employment; encourage them to find a way to achieve these. Sometimes a fit note or sick note may be appropriate, either to alert the workplace to the impact on health of the situation, or to achieve a change in working environment.

People may be too affected by stress to continue working and a sick note may be necessary while the situation is resolved. For those who are victims of domestic violence, see the separate article Domestic Violence for further information about the resources available.

Ideally, if the situation is resolved there may be no need for further medical involvement. However, often it is not as simple as this. Referral may be needed for psychological therapy, such as counselling or cognitive behavioural therapy (CBT). Medication may be needed for symptoms of anxiety, depression or insomnia.

The bully

The bully is also someone in need of help. Victim empathy is often employed in prevention of re-offending courses used in the prison and probation services. Getting the bully to appreciate what it must be like to be on the other end may be useful.

The bully may not be the strong, confident person that may initially appear but a frail and insecure individual. In some cases there may be low self-esteem or depression. They are also more likely to be struggling academically.

There is likely to be a reason or background for bullying behaviour. People who have been bullied or mistreated themselves are more likely to bully others. It may be an attention-seeking behaviour, in which case there is probably a reason why attention is needed.

In the workplace, bullying may result from someone being put in a position of authority without training in leadership skills.

Long-term outcome⁴

Victims suffer great misery, underachieve and experience poor health which may continue long after the bullying has ceased.

In childhood and adolescence, a history of having been bullied has been shown to increase the risk of:

• Physical symptoms: abdominal pain, headache, back pain, tiredness, dizziness, insomnia, nightmares.

• Inferior academic achievement.

• School absenteeism.

• Anxiety disorders.

• Depression.

• Borderline personality disorder symptoms.

• Psychotic episodes.

• Self-harm.

• Suicidal ideation and suicide.⁸ Cyberbullying was found to increase the risk of suicidal ideation more than traditional bullying in one meta-analysis.⁹

Into adulthood, long-term effects of being bullied in childhood include an increased risk of:

• Anxiety disorders.

• Depression.

• Psychotic symptoms.

• Suicidal ideation and suicidal behaviour.

• Having lower academic qualifications.

• Having difficulty keeping a job.

• Having lower income.

• Having relationship problems and difficulty making friends or finding a long-term partner.

• Having poor general health.

The offenders are more likely to have delinquent behaviour and this may continue into adult life. They may be more likely to be involved in crime and illicit drug use. However, this has been less extensively studied and other factors may also account for this.

Bullying in the workplace can lead to:

• Stress-related symptoms.

• Anxiety and panic attacks.

• Depression.

• Post-traumatic stress disorder (PTSD).

• Insomnia.

• Loss of self-esteem.

• Physical problems: increased blood pressure, symptoms of irritable bowel syndrome, peptic ulcers, skin disease.

• Lower productivity at work.

• Absenteeism at work with implications for future employability.

• Suicidal ideation and behaviour.

Prevention⁷

An atmosphere of openness and ability to talk about it is essential. Prevention programmes in schools do work.¹¹

Providing anticipatory guidance for children and parents should begin at a young age. Starting a discussion about bullying can draw attention to the problem and empower children and parents to seek support or additional information. Other preventive measures include providing support and encouraging them to find enjoyable activities that promote confidence and self-esteem and to seek positive friendships, and modeling how to treat others with kindness and respect.

Students who feel more connected to their school environments are more likely to do well in school, stay in school, and make healthy choices, and are less likely to engage in high-risk behaviours. The parent-child relationship is a significant predictor of a child's involvement in all roles of bullying at school. Interventions aimed at parents of high-risk young persons that focus on positive parenting skills can lead to decreased bullying and violent behaviour.

Preventing bullying in the workplace is largely a management role. It involves promoting a safe work environment where there is respect between individuals, suitable training for leadership roles, promoting communication and putting in place systems to allow for prompt resolution of bullying issues which arise. Employers are responsible for preventing bullying and harassment within the workplace.¹⁰