Self-harm: assessment, management and preventing recurrence

Provide information and support for people who have self-harmed. Share information with family members or carers (as appropriate). Topics to discuss include:

• what self-harm is

• why people self-harm and, where possible, the specific circumstances of the person

• support and treatments available

• self-care (also see recommendation 1.11.12 in the section on harm minimisation), including when to seek help

• how to deal with injuries

• how to manage scars

• care plans and safety plans, and what they involve

• the impact of encountering stigma around self-harm

• who will be involved in their care and how to get in touch with them

• where appointments will take place

• what to do if they have any concerns

• what do to in an emergency

• local services and how to get in touch with them, including out-of-hours

• local peer support groups, online forums, local and national charities, and how to get in touch with them.

Provide information and support for the family members or carers (as appropriate) of the person who has self-harmed. Topics to discuss include:

• the emotional impact on the person and their family members or carers

• advice on how to cope when supporting someone who self-harms

• what to do if the person self-harms again

• how to seek help for the physical consequences of self-harm

• how to assist and support the person

• how to recognise signs that the person may self-harm

• steps to reduce the likelihood of self-harm in the future

• support for families and carers and how to access it

• the impact of encountering stigma around self-harm

• local services and how to get in touch with them, including out-of-hours

• local peer support groups, online forums, local and national charities, and how to get in touch with them

• their right to a formal assessment of their own needs including their physical and mental health (known as a 'carer's assessment'), and how to access this (see the NICE guideline on supporting adult carers).

Information for people who have self-harmed and their family members or carers should be:

• tailored to their individual needs and circumstances, taking into account, for example, whether this is a first presentation or repeat self‑harm, the severity and type of self-harm, and if the person has any coexisting health conditions, neurodevelopmental conditions or a learning disability

• provided throughout their care

• sensitive and empathetic

• supportive and respectful

• consistent with their care plan, if there is one in place

• conveyed in the spirit of hope and optimism.
  
  For more guidance on communication, providing information (including different formats) and shared decision making, see the NICE guidelines on shared decision making, service user experience in adult mental health, patient experience in adult NHS services and babies, children and young people's experience of healthcare.

Recognise that support and information may need to be adapted for people who may be subject to discrimination, for example, people who are physically disabled, people with neurodevelopmental conditions or a learning disability, people from underserved groups, people from Black, Asian and minority ethnic backgrounds and people who are LGBTQ+.

Healthcare professionals and social care practitioners who have contact with people who self-harm should be able to:

• understand when and how to apply the principles of the Mental Capacity Act 2005 and its Code of Practice, the Mental Health Act 2007 and its Code of Practice, and the Care Act 2014 and the Care Act 2014 statutory guidance

• assess mental capacity

• make decisions about when treatment and care can be given without consent

• understand when and how to seek further guidance about consent to care

• direct people to independent mental capacity advocates (IMCAs).
  
  Also see the NICE guidelines on decision making and mental capacity, service user experience in adult mental health, and babies, children and young people's experience of healthcare, and the Department of Health and Social Care's consensus statement on information sharing and suicide prevention.

Healthcare professionals and social care practitioners who have contact with children and young people who self-harm should also be able to:

• understand how to apply the principles of the Children Act 1989 and the Children and Families Act 2014 in relation to competence, capacity and confidentiality and the scope of parental responsibility

• understand how to apply the principles of the Mental Health Act 2007 to young people

• understand how issues of capacity and competence to consent apply to children and young people of different ages

• assess the young person's capacity to consent (including Gillick competence).

If staff working with people who self-harm need to discuss issues relating to capacity and consent, they should have access to:

• specialist advice (for example, liaison psychiatry) at all times and

• legal advice as needed.

Staff working with people who self-harm should be familiar with the limits of confidentiality with regard to information about a person's treatment and care.

Staff working with people who self-harm should be aware of the benefits of involving the person's family and carers and sharing information, and should recognise the need to seek consent from the person as early as possible. Also see the Department of Health and Social Care's consensus statement on information sharing and suicide prevention.

Staff working with people who self-harm should recognise that if it is necessary to breach confidentiality, they should ensure that the person who has self-harmed is still involved in decisions about their care and, where possible, is informed about the breach of confidentiality.

All staff who have contact with people who self-harm should:

• understand when and how to apply the safeguarding principles of the Care Act 2014, the Children Act 1989, and the Children and Families Act 2014

• ask about safeguarding concerns, for example, domestic abuse, violence or exploitation at the earliest opportunity and, if appropriate, when the person is alone

• explore whether the person's needs should be assessed and documented according to local safeguarding procedures

• be aware of local safeguarding procedures for vulnerable adults and children in their care, and seek advice from the local named lead on safeguarding if needed.
  
  Also see the NICE guidelines on domestic violence and abuse, looked-after children and young people, child abuse and neglect and child maltreatment.

If people who self-harm are referred to local health and social care services under local safeguarding procedures, use a multi-agency approach, including education and/or third sector services, to ensure that different areas of the person's life are taken into account when assessing and planning for their needs.

Ask the person who has self-harmed whether and how they would like their family or carers to be involved in their care, taking into account the factors in recommendation 1.4.2, and review this regularly. If the person agrees, share information with family members or carers (as appropriate), and encourage them to be involved.

When thinking about involving family members or carers in supporting a person who has self-harmed, take into account issues such as:

• whether the person has consented for information to be shared and, if so, if the consent is limited to certain aspects of their care

• any safeguarding concerns

• the person's mental capacity, age and competence to make decisions

• the person's right to confidentiality and autonomy in decision making

• the balance between autonomy (in children and young people, their developing independence and maturity) and the need to involve family members or carers

• the balance between the possible benefits and risks of involving family members or carers and the rights of the person.
  
  Also see the NICE guidelines on decision making and mental capacity, service user experience in adult mental health, and babies, children and young people's experience of healthcare.

When involving family members or carers in supporting a person who has self-harmed:

• encourage a collaborative approach to:

  • empower and support the person who has self-harmed

  • minimise the person's self-harm behaviours and

  • support the person's recovery to prevent recurrence

• give them opportunities to be involved in decision making, care planning and developing safety plans to support the person beyond the initial self-harm episode, and through their care pathway

• ensure that there is ongoing and timely communication with the family or carers

• regularly review whether the person who has self-harmed still wants their family or carers to be involved in their care, and ensure that they know they can withdraw consent to share information at any time.

Be aware that even if the person has not consented to involving their family or carers in their care, family members or carers can still provide information about the person.

If the person who has self-harmed finds it difficult to vocalise their distress when they are in need of care, support the person and their family members or carers (as appropriate) in trying alternative methods of communication (such as non-verbal language, letters, emotional wellbeing passports, and using agreed safe words, phrases or emojis).

At the earliest opportunity after an episode of self-harm, a mental health professional should carry out a psychosocial assessment to:

• develop a collaborative therapeutic relationship with the person

• begin to develop a shared understanding of why the person has self‑harmed

• ensure that the person receives the care they need

• give the person and their family members or carers (as appropriate) information about their condition and diagnosis.

Do not delay the psychosocial assessment until after medical treatment is completed.

If the person who has self-harmed is intoxicated by drugs or alcohol, agree with the person and colleagues what immediate assistance is needed, for example, support and advice about medical assessment and treatment.

Do not use breath or blood alcohol levels to delay the psychosocial assessment.

If the person is not able to participate in the psychosocial assessment, ensure that they have regular reviews, and complete a psychosocial assessment as soon as possible.

If the person who has self-harmed has agreed a care plan, check this with them and follow it as much as possible.

Carry out the psychosocial assessment in a private, designated area where it is possible to speak in confidence without being overheard.

Take into account the needs and preferences of the person who has self‑harmed as much as possible when carrying out the psychosocial assessment, for example, by:

• making appropriate adaptations for any learning disability or physical, mental health or neurodevelopmental condition the person may have and

• providing the option to have a healthcare professional of the same sex carry out the psychosocial assessment when the person has requested this.

During the psychosocial assessment, explore the functions of self-harm for the person. Take into account:

• the person's values, wishes and what matters to them

• the need for psychological interventions, social care and support, or occupational or vocational rehabilitation

• any learning disability, neurodevelopmental conditions or mental health problems

• the person's treatment preferences

• that each person who self-harms does so for their own reasons

• that each episode of self-harm should be treated in its own right, and a person's reasons for self-harm may vary from episode to episode

• whether it is appropriate to involve their family and carers; see the section on involving family members and carers.

During the psychosocial assessment, explore the following to identify the person's strengths, vulnerabilities and needs:

• historic factors

• changeable and current factors

• future factors, including specific upcoming events or circumstances

• protective or mitigating factors.

For children and young people who have self-harmed, ensure that a mental health professional experienced in assessing children and young people who self-harm carries out the psychosocial assessment. They should ask about:

• their social, peer group, education and home situations

• any caring responsibilities

• the use of social media and the internet to connect with others and the effects of these on mental health and wellbeing

• any child protection or safeguarding issues (also see the section on safeguarding).

For older people who have self-harmed, ensure that a mental health professional experienced in assessing older people who self-harm carries out the psychosocial assessment. They should:

• pay particular attention to the potential presence of depression, cognitive impairment, physical ill health and frailty

• include an assessment of the person's social and home situation, including any role they have as a carer

• recognise the increased potential for loneliness and isolation

• recognise that there are higher rates of suicide after an episode of self‑harm for older people.

For people with a learning disability who have self-harmed, ensure that a mental health professional experienced in assessing people with a learning disability who self-harm carries out the psychosocial assessment.

If a person has self-harmed and presents to services but wants to leave before a full psychosocial assessment has taken place, assess the person's safety and any mental health problems before they leave.

Together with the person who self-harms and their family and carers (if appropriate), develop or review a care plan using the key areas of needs and safety considerations identified in the psychosocial assessment (see recommendations 1.5.8 to 1.5.14).

Give the person a copy of their care plan, and share the plan as soon as possible with relevant healthcare professionals and social care practitioners involved in the person's care.

If a person presents with frequent episodes of self-harm or if treatment has not been effective, carry out a multidisciplinary review with the person and those involved in their care and support, and others who may need to be involved, to agree a joint plan and approach. This should involve:

• identifying an appropriately trained professional or practitioner to coordinate the person's care and act as a point of contact

• reviewing the person's existing care and support, and arranging referral to any necessary services

• developing a care plan

• developing a safety plan for future episodes of self-harm, which should be written with and agreed by the person who self-harms.

Do not use risk assessment tools and scales to predict future suicide or repetition of self-harm.

Do not use risk assessment tools and scales to determine who should and should not be offered treatment or who should be discharged.

Do not use global risk stratification into low, medium or high risk to predict future suicide or repetition of self-harm.

Do not use global risk stratification into low, medium or high risk to determine who should be offered treatment or who should be discharged.

Focus the assessment (see the section on principles for assessment and care by healthcare professionals and social care practitioners) on the person's needs and how to support their immediate and long-term psychological and physical safety.

Mental health professionals should undertake a risk formulation as part of every psychosocial assessment.

Consider admission to a general hospital after an episode of self-harm if:

• there are concerns about the safety of the person (for example, the person is at risk of violence, abuse or exploitation) and psychiatric admission is not indicated

• safeguarding planning needs to be completed and psychiatric admission is not indicated

• the person is unable to engage in a psychosocial assessment (for example, because they are too distressed or intoxicated).

If a 16- or 17-year-old is admitted to a general hospital, ensure that it is to a ward that can meet the needs of young people.

For arrangements for initial aftercare for people who have been admitted to a general hospital after they have self-harmed, see the section on initial aftercare after an episode of self-harm.

Do not delay carrying out a psychosocial assessment or offering mental health treatment if the person is admitted to hospital or needs treatment for physical injuries.

If a person self-harms during a hospital admission, follow the local hospital policy for investigating untoward incidents and undertake a full investigation. Local areas should be aware of the NHS Patient Safety Incident Response Framework.

Before discharging a person who has self-harmed from a general hospital, ensure that:

• a psychosocial assessment has taken place

• a plan for further management has been drawn up with all appropriate agencies and people

• a discharge planning meeting with all appropriate agencies and people has taken place and

• arrangements for aftercare have been specified, including clear written communication with the primary care team.

After an episode of self-harm, discuss and agree with the person, and their family members and carers (as appropriate), the purpose, format and frequency of initial aftercare and which services will be involved in their care. Record this in the person's care plan and ensure that the person and their family members and carers have a copy of the plan and contact details for the team providing the aftercare.

If there are ongoing safety concerns for the person after an episode of self-harm, the mental health team, GP, team who carried out the psychosocial assessment or the team responsible for their care should provide initial aftercare within 48 hours of the psychosocial assessment.

When planning treatment following self-harm, take into account any associated coexisting conditions and the psychosocial assessment.

For guidance on how to treat coexisting conditions that may be related to self-harm, also see the NICE guidelines on:

• Alcohol-use disorders

• Autism spectrum disorder in adults

• Autism spectrum disorder in under 19s

• Bipolar disorder

• Borderline personality disorder

• Care and support of people growing older with learning disabilities

• Challenging behaviour and learning disabilities

• Depression in adults

• Depression in children and young people

• Drug misuse in over 16s: opioid detoxification

• Drug misuse in over 16s: psychosocial interventions

• Eating disorders

• Generalised anxiety disorder and panic disorder in adults

• Learning disabilities and behaviour that challenges

• Mental health problems in people with learning disabilities

• Obsessive-compulsive disorder and body dysmorphic disorder

• Psychosis and schizophrenia in adults

• Post-traumatic stress disorder.

Offer a structured, person-centred, cognitive behavioural therapy (CBT)-informed psychological intervention (for example, CBT or problem-solving therapy) that is specifically tailored for adults who self-harm. Ensure that the intervention:

• starts as soon as possible

• is typically between 4 and 10 sessions; more sessions may be needed depending on individual needs

• is tailored to the person's needs and preferences.

For children and young people with significant emotional dysregulation difficulties who have frequent episodes of self-harm, consider dialectical behaviour therapy adapted for adolescents (DBT-A). Take into account the age of the child or young person and any planned transition between services.

Healthcare staff should be appropriately trained and supervised in the therapy they are offering to people who self-harm.

Work collaboratively with the person, using a strengths-based approach to identify solutions to reduce their distress that leads to self-harm.

Consider developing a safety plan in partnership with people who have self-harmed. Safety plans should be used to:

• establish the means of self-harm

• recognise the triggers and warning signs of increased distress, further self-harm or a suicidal crisis

• identify individualised coping strategies, including problem solving any factors that may act as a barrier

• identify social contacts and social settings as a means of distraction from suicidal thoughts or escalating crisis

• identify family members or friends to provide support and/or help resolve the crisis

• include contact details for the mental health service, including out‑of‑hours services and emergency contact details

• keep the environment safe by working collaboratively to remove or restrict lethal means of suicide.

The safety plan should be in an accessible format and:

• be developed collaboratively and compassionately between the person who has self-harmed and the professional involved in their care using shared decision making (see the NICE guideline on shared decision making)

• be developed in collaboration with family and carers, as appropriate

• use a problem-solving approach

• be held by the person

• be shared with the family, carers and relevant professionals and practitioners as decided by the person

• be accessible to the person and the professionals and practitioners involved in their care at times of crisis.

Do not use diagnosis, age, substance misuse or coexisting conditions as reasons to withhold psychological interventions for self-harm.

Do not offer drug treatment as a specific intervention to reduce self-harm.

Ensure continuity of care, wherever possible, in the staff caring for people who have self-harmed by minimising the number of different staff they see.

For guidance on ensuring continuity of care, see the section on continuity of care and relationships in the NICE guideline on patient experience in adult NHS services and the section on continuity and coordination of care in the NICE guideline on babies, children and young people's experience of healthcare.

Do not use staff who are untrained in clinical observation (for example, security staff or trainee health and social care staff) to undertake such observations in a person who has self-harmed.

Ensure that the care plans of people who have self-harmed can be accessed by primary and secondary care plus other professionals and practitioners involved in their care.

Ensure that staff working with people who have self-harmed are visible and accessible to the people they are caring for, to encourage interaction, particularly during handovers and busy periods.

Assess the safety of the environment, balancing respect for the person's autonomy against the need for restrictions. Use the least restrictive measures.

Consider removing items that may be used to self-harm and involve the person who has self-harmed in this decision.

At the earliest opportunity, healthcare staff should help people who have self-harmed to become familiar with the clinical setting in which they are being cared for, and tell them how to get support.

Staff should know how to raise concerns without delay about a person who has self-harmed.

When prescribing medicines to someone who has previously self-harmed or who may self-harm in the future, healthcare professionals should take into account:

• the toxicity of the prescribed medicines for people at risk of overdose (for example, opiate-containing painkillers and tricyclic antidepressants)

• their recreational drug and alcohol consumption, the risk of misuse, and possible interaction with prescribed medicines

• the person's wider access to medicines prescribed for themselves or others

• the need for effective communication where multiple prescribers are involved.
  
  Also see the section on reducing access to methods of suicide in the NICE guideline on preventing suicide in community and custodial settings.

Use shared decision making to discuss limiting the quantity of medicines supplied to people with a history of self-harm (for example, weekly prescriptions), and ask them to return unwanted medicines for safe disposal. Also see the NICE guideline on shared decision making.

Consider carrying out a medicines review after an episode of self-harm. Take into account the pharmacokinetic properties of medicines, for example, half-life, risk of toxicity and the concurrent use of medicines such as benzodiazepines and opiates. If necessary, contact the National Poisons Information Service for further advice. Also see the NICE guideline on medicines optimisation. For people with learning disabilities or autism or both, the NHS England STOMP-STAMP principles may be useful.

Community pharmacy staff should be aware of warning signs relating to self-harm, such as identifying people who are in acute distress, buying large amounts of over-the-counter medicines or who have access to large amounts of medicines.

Healthcare professionals, including GPs and community pharmacy staff, should use consultations and medicines reviews as an opportunity to assess self-harm if appropriate, for example, asking about thoughts of self-harm or suicide, actual self-harm, and access to substances that might be taken in overdose (including prescribed, over-the-counter medicines, herbal remedies and recreational drugs).

Training for all staff who work with people of any age who self-harm should:

• involve people who self-harm and, where appropriate, their families or carers, and staff in the planning, delivery and evaluation of training

• be available in a range of formats, including interactive role play, online, face-to-face and through provision of resources

• explore staff attitudes (including non-healthcare staff), values, beliefs and biases

• be appropriate to the level of responsibility of the staff member

• be provided on a regular and ongoing basis.

All staff who work with people of any age who self-harm should have training specific to their role so that they can provide care and treatment outlined in this guideline. Training should cover:

• the range of different behaviours that can be considered self-harm

• treating and managing episodes of self-harm, including de‑escalation using the least restrictive measures

• discussing self-harm with the person in an open way to explore the reasons for each episode of self-harm

• involving people who self-harm in all discussions and allowing sufficient time for decision making about their treatment and subsequent care

• communicating compassionately and facilitating engagement with people who have self-harmed, including using active listening skills

• being culturally competent through respecting and appreciating the cultural contexts of people's lives

• education about the underlying factors, triggers or motives that may lead people to self-harm

• education about the stigma and discrimination usually associated with self-harm and the need to avoid judgemental attitudes

• recognising the impact of other diagnoses and comorbidities, and how they interact with self-harm

• balancing patient autonomy and safety when providing care for people who have self-harmed

• assessing the needs and safety of the person who has self-harmed (relevant to their role and environment)

• the formal processes involved in treatment after self-harm, including:

  • treatment and referral options

  • relevant care pathways

  • relevant legislation

  • procedures specific to the setting, including layout, policies and protocols.

In addition to the training in recommendation 1.14.2, mental health professionals who work with people of any age who self-harm should have training on conducting psychosocial assessments and risk formulation.

All staff observing people who have self-harmed should also be trained in therapeutic observation methods, including engagement and rapport building.

All staff who work with people of any age who self-harm should have the opportunity for regular, high-quality formal supervision from senior staff with relevant skills, training and experience. Supervision should:

• take into account the emotional impact of self-harm on staff and how best to support them

• promote the delivery of compassionate care

• focus on ongoing skill development

• include reflective practice

• promote confidence and competence in staff working with people who have self-harmed.

Ensure that all staff working with people who self-harm have easily accessible ongoing support from senior staff with relevant skills, training and experience. Support should include:

• clear lines of responsibility around decision making, particularly for situations where there are challenges around the balance between autonomy and safety for a person who has self-harmed

• emotional support or signposting to emotional support services, as preferred by the member of staff.