Key priorities for implementation

Key priorities for implementation

The following recommendations have been identified as priorities for implementation.

Working with people who self-harm

  • Health and social care professionals working with people who self-harm should:

    • aim to develop a trusting, supportive and engaging relationship with them

    • be aware of the stigma and discrimination sometimes associated with self-harm, both in the wider society and the health service, and adopt a non-judgemental approach

    • ensure that people are fully involved in decision-making about their treatment and care

    • aim to foster people's autonomy and independence wherever possible

    • maintain continuity of therapeutic relationships wherever possible

    • ensure that information about episodes of self-harm is communicated sensitively to other team members.

Psychosocial assessment

  • Offer an integrated and comprehensive psychosocial assessment of needs (see recommendations 1.3.2-1.3.5) and risks (see recommendations 1.3.6–1.3.8) to understand and engage people who self-harm and to initiate a therapeutic relationship.

  • Assessment of needs should include:

    • skills, strengths and assets

    • coping strategies

    • mental health problems or disorders

    • physical health problems or disorders

    • social circumstances and problems

    • psychosocial and occupational functioning, and vulnerabilities

    • recent and current life difficulties, including personal and financial problems

    • the need for psychological intervention, social care and support, occupational rehabilitation, and also drug treatment for any associated conditions

    • the needs of any dependent children.

Risk assessment

  • When assessing the risk of repetition of self-harm or risk of suicide, identify and agree with the person who self-harms the specific risks for them, taking into account:

    • methods and frequency of current and past self-harm

    • current and past suicidal intent

    • depressive symptoms and their relationship to self-harm

    • any psychiatric illness and its relationship to self-harm

    • the personal and social context and any other specific factors preceding self-harm, such as specific unpleasant affective states or emotions and changes in relationships

    • specific risk factors and protective factors (social, psychological, pharmacological and motivational) that may increase or decrease the risks associated with self-harm

    • coping strategies that the person has used to either successfully limit or avert self-harm or to contain the impact of personal, social or other factors preceding episodes of self-harm

    • significant relationships that may either be supportive or represent a threat (such as abuse or neglect) and may lead to changes in the level of risk

    • immediate and longer-term risks.

Risk assessment tools and scales

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

Care plans

  • Discuss, agree and document the aims of longer-term treatment in the care plan with the person who self-harms. These aims may be to:

    • prevent escalation of self-harm

    • reduce harm arising from self-harm or reduce or stop self-harm

    • reduce or stop other risk-related behaviour

    • improve social or occupational functioning

    • improve quality of life

    • improve any associated mental health conditions.

Review the person's care plan with them, including the aims of treatment, and revise it at agreed intervals of not more than 1 year.

  • Care plans should be multidisciplinary and developed collaboratively with the person who self-harms and, provided the person agrees, with their family, carers or significant others[2]. Care plans should:

    • identify realistic and optimistic long-term goals, including education, employment and occupation

    • identify short-term treatment goals (linked to the long-term goals) and steps to achieve them

    • identify the roles and responsibilities of any team members and the person who self-harms

    • include a jointly prepared risk management plan (see recommendations 1.4.4 and 1.4.5)

    • be shared with the person's GP.

Risk management plans

  • A risk management plan should be a clearly identifiable part of the care plan and should:

    • address each of the long-term and more immediate risks identified in the risk assessment

    • address the specific factors (psychological, pharmacological, social and relational) identified in the assessment as associated with increased risk, with the agreed aim of reducing the risk of repetition of self-harm and/or the risk of suicide

    • include a crisis plan outlining self-management strategies and how to access services during a crisis when self-management strategies fail

    • ensure that the risk management plan is consistent with the long-term treatment strategy.

Inform the person who self-harms of the limits of confidentiality and that information in the plan may be shared with other professionals.

Interventions for self-harm

  • Consider offering 3 to 12 sessions of a psychological intervention that is specifically structured for people who self-harm, with the aim of reducing self-harm. In addition:

    • The intervention should be tailored to individual need and could include cognitive-behavioural, psychodynamic or problem-solving elements.

    • Therapists should be trained and supervised in the therapy they are offering to people who self-harm.

    • Therapists should also be able to work collaboratively with the person to identify the problems causing distress or leading to self-harm.

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

Treating associated mental health conditions

[2] 'Significant other' refers not just to a partner but also to friends and any person the service user considers to be important to them.

  • National Institute for Health and Care Excellence (NICE)