Guidance
Key priorities for implementation
Key priorities for implementation
The following recommendations have been identified as priorities for implementation.
Working with people who self-harm
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Health and social care professionals working with people who self-harm should:
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aim to develop a trusting, supportive and engaging relationship with them
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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
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ensure that people are fully involved in decision-making about their treatment and care
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aim to foster people's autonomy and independence wherever possible
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maintain continuity of therapeutic relationships wherever possible
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ensure that information about episodes of self-harm is communicated sensitively to other team members.
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Psychosocial assessment
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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.
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Assessment of needs should include:
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skills, strengths and assets
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coping strategies
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mental health problems or disorders
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physical health problems or disorders
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social circumstances and problems
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psychosocial and occupational functioning, and vulnerabilities
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recent and current life difficulties, including personal and financial problems
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the need for psychological intervention, social care and support, occupational rehabilitation, and also drug treatment for any associated conditions
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the needs of any dependent children.
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Risk assessment
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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:
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methods and frequency of current and past self-harm
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current and past suicidal intent
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depressive symptoms and their relationship to self-harm
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any psychiatric illness and its relationship to self-harm
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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
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specific risk factors and protective factors (social, psychological, pharmacological and motivational) that may increase or decrease the risks associated with self-harm
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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
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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
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immediate and longer-term risks.
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Risk assessment tools and scales
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Do not use risk assessment tools and scales to predict future suicide or repetition of self-harm.
Care plans
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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:
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prevent escalation of self-harm
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reduce harm arising from self-harm or reduce or stop self-harm
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reduce or stop other risk-related behaviour
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improve social or occupational functioning
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improve quality of life
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improve any associated mental health conditions.
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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.
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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:
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identify realistic and optimistic long-term goals, including education, employment and occupation
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identify short-term treatment goals (linked to the long-term goals) and steps to achieve them
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identify the roles and responsibilities of any team members and the person who self-harms
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include a jointly prepared risk management plan (see recommendations 1.4.4 and 1.4.5)
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be shared with the person's GP.
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Risk management plans
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A risk management plan should be a clearly identifiable part of the care plan and should:
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address each of the long-term and more immediate risks identified in the risk assessment
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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
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include a crisis plan outlining self-management strategies and how to access services during a crisis when self-management strategies fail
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ensure that the risk management plan is consistent with the long-term treatment strategy.
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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
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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:
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The intervention should be tailored to individual need and could include cognitive-behavioural, psychodynamic or problem-solving elements.
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Therapists should be trained and supervised in the therapy they are offering to people who self-harm.
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Therapists should also be able to work collaboratively with the person to identify the problems causing distress or leading to self-harm.
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Do not offer drug treatment as a specific intervention to reduce self-harm.
Treating associated mental health conditions
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Provide psychological, pharmacological and psychosocial interventions for any associated conditions, for example those described in the following published NICE guidance:
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Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence (NICE clinical guideline 115).
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Depression (NICE clinical guideline 90).
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Psychosis and schizophrenia in adults (NICE clinical guideline 178).
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Borderline personality disorder (NICE clinical guideline 78).
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Drug misuse (psychosocial interventions or opioid detoxification) (NICE clinical guidelines 51 and 52).
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Bipolar disorder (NICE clinical guideline 185).
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[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.