Rationale and impact

These sections briefly explain why the committee made the recommendations and how they might affect practice.

Information and support

Recommendations 1.1.1 to 1.1.4

Why the committee made the recommendations

There was evidence on the information that people who had self-harmed and their family members and carers want to receive, and how they want to receive it. The committee based the recommendations on the evidence, their knowledge and experience, and the NICE guidelines on patient experience in adult NHS mental health services, and patient experience in adult NHS services.

Much of the evidence on the information needs of people who had self-harmed was consistent with that of family and carers, who want information about self-harm to be shared with them. However, there was conflicting evidence about whether people want information to be shared with family members. The committee agreed that information should be available to the person's family and carers where appropriate and in agreement with the person.

There was evidence that family members and carers have additional information and support needs specific to their experience that are often unmet. The committee agreed that further information and support should be provided to family members and carers as appropriate.

There was evidence that people who had self-harmed and their family and carers perceived support (or a lack of it) based on how they had been communicated with, and that they value support from a range of sources. There was also evidence that people who had self-harmed value information that is specific to their circumstances, and the committee agreed that information should be tailored to the individual. The evidence also suggested that people and their family and carers find it difficult to get the information or support they need.

The committee discussed existing NICE guidelines that have important information about how to appropriately provide information and support to people and agreed that the guidelines are relevant for people who have self-harmed.

The recommendation that people from protected groups should have additional support was based on the committee's experience and knowledge that forms of discrimination are often causal factors for self-harm.

How the recommendations might affect practice

The recommendations should make it easier for people who have self-harmed and their family members and carers to get support and information after an episode of self-harm, and reduce the variation in the information provided. It should also lead to a higher quality of care.

The impact for providers will vary according to what information and support they currently offer. The recommendations may mean that providers need to change the information they give, but the cost should be minimal and will result in people who self-harm and their family and carers being better informed about self-harm and their care options. The recommendations may mean that family members seek further care for themselves more frequently than they currently do, but it is difficult to estimate the effect this will have on practice.

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Safeguarding

Recommendations 1.3.1 and 1.3.2

Why the committee made the recommendations

The recommendations are based on the committee's knowledge of current best practice, as well as existing guidance on safeguarding in healthcare. The committee agreed that staff should always consider whether such concerns exist for children and adults who have self-harmed, and be prepared to follow safeguarding procedures when necessary. This will enable staff to intervene in situations where safeguarding is a concern to reduce the risk of further harm to the person.

The committee agree that a multi-agency approach to safeguarding would promote collaborative working between different sectors, allowing for information sharing and therefore improving the service provided to the person.

How the recommendations might affect practice

These recommendations are in line with existing recommended practice, but may also enable better communication and transitions across services through multi‑agency approaches.

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Involving family members and carers

Recommendations 1.4.1 and 1.4.2

Why the committee made the recommendations

There was conflicting evidence on if and how family members and carers should be involved in the support and treatment of people who have self-harmed. The evidence showed both potential harms and benefits, so the committee based the recommendations on the evidence and their own knowledge and experience.

The committee highlighted if the person has not given consent, family and carers can still share information with healthcare professionals, which can provide helpful insights to make a holistic assessment of, and base their professional judgements on, the needs of the person who has self-harmed.

There was evidence that people who had self-harmed and their family and carers value being able to communicate using non-verbal means. The committee agreed that this can encourage positive communication because it can often be difficult for the person to express their needs when they are very distressed. The use of non‑verbal forms of communication can reduce the need for the person to explain how they are feeling, and help to build the initial therapeutic rapport and understanding of the person's needs.

How the recommendations might affect practice

These recommendations should make it easier for healthcare professionals to recognise when it is appropriate to involve family members and carers in the care of people who have self-harmed. They should also enable family members and carers to be involved in care in a way that is collaborative and helpful for the person who has self-harmed.

Providers may need to change how they involve family members and carers, but the costs are expected to be small and will result in a higher quality of care for people who self-harm.

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Psychosocial assessment and care by mental health professionals

Recommendations 1.5.1 to 1.5.17

Why the committee made the recommendations

The recommendations are based on the available evidence, but because of concerns over the quality and scarcity of evidence, most are based on the committee's knowledge and experience.

There was evidence that an assessment model incorporating therapeutic elements such as identification of the target problem has a positive effect on satisfaction. The committee agreed the factors to take into account in the psychosocial assessment, and what it should include.

The committee agreed that delaying a psychosocial assessment could result in the person receiving inappropriate treatment. They discussed that if the person is not able to meaningfully engage in the assessment (for example, if the person is unconscious or has very high levels of intoxication), they should be regularly reviewed so that it can take place as soon as appropriate, and that any care plan should always be followed to optimise the psychosocial assessment.

The committee agreed that breathalysers and blood alcohol tests do not accurately assess the ability of a person to meaningfully engage with an assessment, and could be used to wrongly deny someone an assessment.

The committee agreed that care plans should be followed where possible to ensure a higher standard of care and inform the assessment, including whether certain questions should be prioritised.

There was evidence that people value privacy and having a safe and trusted environment when discussing self-harm.

The committee agreed the self-harm functions and factors to explore. The committee agreed these would allow coexisting conditions to be taken into account and enable staff to provide a higher quality of care. The committee also agreed that using the psychosocial assessment to develop a care plan could have a positive impact on the person's engagement with follow-up. Qualitative evidence was consistent with the committee's agreement that including family and carers in the person's care has a positive impact.

The committee discussed that briefly assessing the person if they chose to leave before a full assessment had taken place could prevent repeat self-harm or attempted suicide.

The committee agreed that providing the person with a copy of their care plan would increase transparency and improve trust. Additionally, the committee agreed that providing any other relevant healthcare professionals and social care practitioners with the care plan would ensure that all staff are up-to-date about the person's preferences, improving the quality of their care and their transition between services.

There was insufficient evidence for the committee to define how frequent attendance for self-harm would have to be to trigger a multidisciplinary review. However, the committee agreed that this recommendation was still important based on their knowledge that the individual circumstances of the person, including whether they are continuing to self-harm, should be assessed to evaluate whether a multidisciplinary review is necessary. The committee agreed that a multidisciplinary review should enable staff to reconsider current care, finding the most suitable care approach for the person and therefore preventing further repeat self-harm.

How the recommendations might affect practice

The recommendations should change how psychosocial assessments are conducted, to reduce the potential for distress during assessment and improve the person's satisfaction and engagement with services. The recommendations should also allow for more involvement of family members and carers when appropriate, which could result in better quality care.

Most of the recommendations are based on existing recommended practice with some additional considerations that should have a minimal effect on costs, depending on how services currently assess people who have self-harmed.

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Risk assessment tools and scales

Recommendations 1.6.1 to 1.6.6

Why the committee made the recommendations

The committee agreed that risk assessment tools and scales cannot accurately predict risk of self-harm or suicide, and that determining access to treatment or hospital admission based on inaccurate risk assessment tools could lead to repeat self-harm, distress and lower patient satisfaction.

The committee agreed that the potential harms of risk stratification, including the implication that risk is static instead of dynamic, outweigh any benefits it has as a clinical communication tool or an adjunct to clinical assessment, so agreed that risk stratification should not be used.

The committee agreed that assessment of a person's needs, vulnerabilities, and safety should be a part of every assessment and that 'risk' should not be used to determine care management in isolation of other factors. They agreed that all staff should use their clinical judgement when assessing someone who has self-harmed and they should refer to the non-specialist assessment recommendations for what to do in the event they are concerned about the person and their safety. Additionally, mental health staff should conduct a risk formulation to place the person's safety considerations in context with their strengths and difficulties.

How the recommendations might affect practice

The recommendations should change how assessments are conducted to take into account the person's needs and safety as standard and reduce reliance on assessment of a person's 'risk' in isolation of other factors. This should result in a reduction in the occurrence of arbitrary thresholds being used to determine access to care.

Risk assessment tools and scales are still used in some settings to determine access to treatment and care. The recommendations might have an initial effect on costs, depending on how services currently assess people who have self-harmed; however, service provision should already be determined by a person's needs rather than risk thresholds. Additionally, the change in practice should result in lower costs over time because people will receive the care they need rather than have it determined by unreliable risk tools and scales, potentially reducing repeat self-harm.

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Assessment and care by healthcare professionals and social care practitioners

Recommendations 1.7.1 to 1.7.27

Why the committee made the recommendations

There was no evidence, so the committee made recommendations mostly based on their knowledge and experience, supplemented by qualitative evidence from the reviews on information and support needs, and staff skills. They agreed it is important to give advice about assessment and care in different settings, but the lack of evidence meant they were unable to be more specific.

The committee made a recommendation for research on the most effective approaches to assessment in non-specialist settings to better inform future guideline development. Because of a lack of evidence, the committee also made a recommendation for research on models of care for children and young people who self-harm.

Principles for assessment and care by healthcare professionals and social care practitioners

Recommendations 1.7.1 to 1.7.5

The committee agreed that assessment for people who have self-harmed should be collaborative and prioritise preserving the person's dignity to minimise distress, while maintaining physical safety. Evidence showed that people who had self-harmed value positive, compassionate support after an episode of self-harm. The committee agreed that the person carrying out the assessment should gather information from other sources, such as professionals, practitioners and family members, in order for the assessment to be as accurate as possible, and ask about potential coping strategies to inform any future safety plan.

The committee agreed that healthcare professionals and social care practitioners should establish a number of specific presenting factors to inform their assessment and care. Healthcare professionals and social care practitioners should also be involved in the care of people who have self-harmed as much as possible but know when to refer them to mental health services (as set out in the sections on assessment and care in different health and social care settings), to ensure that the care is appropriate.

The committee agreed that physical healthcare and mental healthcare should always be delivered concurrently so neither is prioritised at the expense of the other, and to prevent treatment delays. Non-specialist healthcare professionals and social care practitioners should seek appropriate advice about care for people who have self‑poisoned.

The committee agreed that punitive or aversive approaches should not be used, based on their knowledge that such approaches are considered malpractice and often have harmful effects on people who have self-harmed, potentially leading to increased distress and repeat self-harm or suicide.

Assessment and care in primary care

Recommendations 1.7.6 to 1.7.8

The committee agreed that referring people to mental health services would be reassuring and ensure that people are in the most appropriate setting, and that referral should be prioritised in certain situations to prevent further distress.

The committee agreed that if people are being cared for in primary care following an episode of self-harm, there should be continuity of care and regular reviews of factors relating to their self-harm to ensure that the person who has self-harmed feels supported and engaged with services.

Assessment and care by ambulance staff and paramedics

Recommendations 1.7.9 to 1.7.11

The committee agreed that information about the person's situation should be recorded because it is invaluable for mental health staff when they carry out the psychosocial assessment. The committee agreed that collaboration between ambulance staff and the person who has self-harmed about their care would allow these preferences to be accommodated by ambulance staff and in other settings.

The committee agreed that ambulance staff should discuss whether assessment should be carried out by alternative services based on qualitative evidence from the review on skills for non-specialist staff. This showed that ambulance staff often felt that the emergency department was not the preferred place that the person who had self-harmed wanted to be taken. They agreed that referral to alternative services when the situation is appropriate could facilitate the person's engagement with services. The committee also discussed factors that should be considered when deciding whether alternative services should be used, to ensure that the person receives the best possible care without delay.

Assessment and care by non-mental health emergency department professionals

Recommendations 1.7.12 to 1.7.20

The committee agreed that an initial rapid assessment of the person's mental and physical care needs is important to quickly establish the best course of action and accommodate the person's needs and safety considerations.

The recommendations about liaison psychiatry are based on the committee's knowledge that such services have a positive influence on care. The recommendations are also based on evidence from the review on models of care, which showed that specialist psychosocial assessment by mental health staff has an important benefit in terms of self-harm repetition over 12 months.

Evidence from the qualitative review on the information and support needs of people who have self-harmed showed that people value privacy and a safe and trusted environment when discussing self-harm.

The committee agreed that people who have self-harmed may feel neglected when asked to wait in isolated areas of the emergency department, and that people who have self-harmed may need support during a time of potential distress.

The committee based the governance recommendations on the Healthcare Safety Information Branch (HSIB) report on investigation into the provision of mental health care to patients presenting at the emergency department (2018), which found that clarity about service pathways and good communication between teams can result in successful safeguarding, de‑escalation of mental health crises, and prevent immediate repeat self-harm or suicide.

The HSIB report also informed the recommendation that there should be an agreed policy or procedure in place for people who wish to leave before treatment is complete. The committee agreed this would ensure that people who leave and who have ongoing safety concerns are identified so appropriate follow-up contact can be made. The committee also agreed it is important that mechanical restraint is not used on people to prevent them from leaving the emergency department or from self-harming, because in their experience, this results in increased distress and a loss of autonomy and dignity for the person, potentially resulting in a loss of trust in services and an unwillingness to seek help in the future.

The committee agreed that policies and procedures for identifying people who frequently self-harm would allow non-specialist staff in emergency departments to facilitate a multidisciplinary review to ensure that people get the right treatment and support.

Assessment and care in general hospital settings

Recommendations 1.7.21 to 1.7.24

The recommendations about liaison psychiatry are based on the committee's knowledge that such services have a positive influence on care. The recommendations are also based on evidence from the review on models of care, which showed that specialist psychosocial assessment by mental health staff had an important benefit in terms of self-harm repetition over 12 months.

The recommendation about observation was based on the committee's experience that observation can be intimidating and unnecessary, especially when carried out by security guards. The committee agreed that observation should be discussed with people to reduce distress, and carried out by healthcare staff.

The committee agreed that children and young people in hospital have specific needs and should therefore have access to age-appropriate specialist care.

Assessment and care in social care

Recommendations 1.7.25 to 1.7.27

The committee agreed that a shared approach between healthcare professionals and social care practitioners is important to promote holistic care for people who self‑harm to ensure that different areas of the person's life are taken into account. The committee discussed their experience that social care services can be withdrawn from people after an episode of self-harm, and agreed that this practice should be strongly discouraged despite the lack of evidence, based on their knowledge that this often results in people not receiving the care that they need, potentially leading to repeat self-harm and suicide.

The committee agreed that in many circumstances, self-harm is identified by social care practitioners through a safeguarding concern. They agreed that when this occurs, social care practitioners should refer the person to local mental health services to ensure they start on a care pathway and receive appropriate care. The committee agreed that social care services should be provided in conjunction with mental health care, to ensure that the person continues to receive social care support as needed.

How the recommendations might affect practice

The recommendations should change the way in which assessments are conducted in a range of settings, to reduce the potential for distress after self-harm and improve the person's satisfaction and engagement with services.

Most of the recommendations are based on existing best practice with some additional considerations that should have a minimal effect on costs, depending on how services currently assess people who have self-harmed. The recommendation that people who have self-harmed should have access to age-appropriate liaison psychiatry in emergency departments and general hospital settings should not have a cost or resource impact because this should already be standard practice.

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Assessment and care by professionals from other sectors

Recommendations 1.8.1 to 1.8.12

Why the committee made the recommendations

There was no evidence, so the committee based the recommendations on their knowledge and experience. They agreed it is important to give advice about assessment and care in different settings, but the lack of evidence meant they were unable to be more specific.

The committee made a recommendation for research on the most effective approaches to psychosocial assessment in non-specialist settings to better inform future guideline development.

Principles for assessment and care by professionals from other sectors

Recommendations 1.8.1 and 1.8.2

The committee agreed that people who have self-harmed can often initially present to non-health professionals, and agreed principles on compassion and preserving the dignity of the person who has self-harmed, regardless of whether the professional has healthcare training. The committee also agreed that non-health professionals should address immediate physical health needs if necessary to prevent further potential harm, but should also seek appropriate clinical support or refer to healthcare services to ensure that the care is appropriate. There was also qualitative evidence from the review on information and support needs of parents and carers, which showed that carers often urgently seek information from qualified healthcare professionals or social care practitioners on discovery of self-harm.

The committee agreed there were factors of a person's presentation that professionals should establish to inform how they care for the person who has self‑harmed. Non-health professionals should also be involved in the care of people who have self-harmed as much as possible but know when to refer them to mental health services, to ensure that the care is appropriate.

Assessment and care in schools and educational settings

Recommendations 1.8.3 to 1.8.7

The recommendations are based on the committee's knowledge that both non‑specialist staff and specialist mental health staff can work in educational settings with children and young people who have self-harmed, and therefore all staff in educational settings need policies and procedures for how to identify and respond to students who have self-harmed. The recommendations are also based on qualitative evidence from the review on skills for specialist staff, which showed that school mental health staff want policies for how to respond to people who have self-harmed because they often feel unsupported and unsure whether they are acting in the best interest of the student.

The committee agreed that formal policies and procedures and a designated lead on self-harm would ensure educational staff would be equipped with appropriate means to respond to self-harm and be supported in their decision making, boosting staff confidence and competence, and improving the quality of care of children and young adults who have self-harmed.

The committee agreed that collaboration with other mental health staff would support the person's access to services and help prevent repeat self-harm, while taking into account the effect on the person's friends and peers would allow support to be provided.

Assessment and care in the criminal justice system and other secure settings

Recommendations 1.8.8 to 1.8.12

The committee based the recommendations on the NICE guideline on mental health of adults in contact with the criminal justice system and their knowledge and experience. They agreed that staff awareness of the high rates of self-harm would allow them to be better prepared to assess and care for people who self-harm. They also agreed staff should be aware of support services that are available to them to ensure that their own support needs are met.

The committee agreed that people who have self-harmed in secure settings need onsite support or, where that is not possible, transfer to healthcare settings. As a result, the committee agreed that staff in these settings should be aware of the arrangements in place, so they can facilitate appropriate care and support if a person self-harms.

The committee also agreed that the NICE guideline on the mental health of adults in contact with the criminal justice system contained a lot of detail about assessment, especially in prisons, and that staff knowledge of this guideline would ensure staff in these settings followed best practice.

The committee discussed the benefits of providing a safe place to people who had self-harmed and agreed that this could reduce the person's distress and their access to means to self-harm, as well as reducing the risk for people to be subject to punitive measures such as isolation after self-harm.

How the recommendations might affect practice

The recommendations should change the way in which assessments are conducted in a range of settings to reduce the potential for distress after self-harm and improve the person's satisfaction and engagement with services. The recommendations should also allow for better communication between services, including between non-health and healthcare settings.

Most of the recommendations are based on existing best practice with some additional considerations that should have a minimal effect on costs, depending on how services currently assess people who have self-harmed.

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Admission to and discharge from hospital

Recommendations 1.9.1 to 1.9.6

Why the committee made the recommendations

The evidence showed that there were no significant short- or long-term differences in repeat self-harm by poisoning, regardless of whether people were admitted to hospital or discharged home. There was no evidence for other types of self-harm or other outcomes. The recommendations are based on the available evidence and the committee's experience and knowledge that admission to hospital carries a greater risk of distress to people of all ages than any potential benefit.

The committee agreed that despite the lack of evidence for the benefit of admitting people to hospital, in some cases it can be helpful to give the person time to recover or if there are safeguarding concerns.

If it is necessary to admit a young person who has self-harmed into hospital, the committee agreed that it can be distressing for them to be admitted to a ward that is not equipped to meet the needs of young people.

The committee agreed that treatment for physical injuries should never be used as a reason to delay or deny a psychosocial assessment because this would be considered malpractice, potentially resulting in heightened distress or neglect of the person's other healthcare needs.

The committee discussed current practice about what happens when a person self‑harms while in hospital, and agreed that full investigations should continue to be recommended when an incident occurs to consistently improve services and ensure that further incidents are prevented.

The committee also agreed that discharging a person before they had been assessed and a plan for further management drawn up could be detrimental because people who have self-harmed are likely to need further care and support. A lack of a plan could result in repeat self-harm or suicide, and would create a barrier to care for the person.

The committee made a recommendation for research on routine or automatic hospital admission for young people or adults to better inform future guideline development.

How the recommendations might affect practice

The recommendations should reduce variation in practice, and reduce the potential for distress because of any unnecessary admissions.

The recommendations could increase the number of beds available in hospitals and reduce overall costs related to overnight admissions to hospital for people who have self-harmed.

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Initial aftercare after an episode of self-harm

Recommendations 1.10.1 and 1.10.2

Why the committee made the recommendations

There was evidence that discharge protocols with enhanced initial aftercare provide important benefits such as increased engagement with services and treatment, and reduced rates of repeat self-harm compared with usual discharge. The committee based the recommendations on the evidence and their knowledge and experience that prioritising person-centred care and empowering people who have self-harmed to make decisions about their own care could improve service-user satisfaction and reduce distress or hopelessness. The committee agreed that any aftercare arrangements should be shared with the person, based on their knowledge that this is an important facet of collaborative care, and that providing contact details encourages engagement with care.

The committee discussed that people who have self-harmed are most likely to repeat self-harm within 2 to 3 days of their previous episode of self-harm. They discussed current best practice in line with the existing NICE guideline on transition between inpatient mental health settings and community or care home settings, which includes follow‑up within 48 hours of presentation. Quantitative evidence was consistent with this, because it showed that telephone contact within 48 hours after discharge had a positive effect on service engagement. The evidence also found a possible important reduction in the number of suicide attempts for those receiving initial contact 3 days after discharge compared with those receiving initial contact within 7 days of discharge, although the different settings in which follow‑up was conducted may also have affected the outcomes. Qualitative evidence from the review on information and support needs for people who have self-harmed also showed that people value proactive, prompt follow‑up and find long waiting times frustrating. However, there were concerns about resourcing and capacity to provide initial aftercare to all patients within this timeframe. The committee agreed that, although follow-up within 48 hours would be ideal for everyone, not all people who have self-harmed will need immediate aftercare. To ensure priority is given to those who need it most, aftercare within 48 hours should be provided to people with ongoing safety concerns to reduce rates of repeat self-harm.

There was limited evidence that continuity of personnel has a positive effect on service engagement and repeat self-harm. The committee agreed, based on their experience, that continuity of personnel from initial assessment to aftercare allows people to gain familiarity with particular professionals, improving satisfaction and service engagement, and reducing the risk of distress or hopelessness. Evidence from the review on models of care showed that a continuity chain protocol has a possible important benefit in terms of engagement with services compared with usual care. The committee agreed that this is most important for people who have received treatment from a mental health service, based on their knowledge that the person who had self-harmed would have spent more time with mental health staff and may have built up trust with particular staff members, as well as evidence from the review on models of care, which showed that specialist community mental health follow‑up has an important benefit in terms of self-harm repetition over 12 months.

How the recommendations might affect practice

The recommendations are mostly in line with current practice. They should lead to a reduction in people waiting for up to 72 hours for aftercare following presentation for self-harm. Providing initial aftercare within 48 hours for people if there are ongoing safety concerns should reduce repeat self-harm and suicide, and improve satisfaction and engagement with services. Any resource impact associated with this would be a worthwhile use of resources.

The recommendations for continuity of personnel may have a resource impact depending on how often the same staff members who have carried out an assessment or mental healthcare also carry out aftercare. Where this is not the case, there will be an increased workload for these healthcare professionals.

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Interventions for self-harm

Recommendations 1.11.1 to 1.11.14

Why the committee made the recommendations

The committee agreed that the psychosocial assessment should be used to develop a meaningful narrative that would inform the care plan. They agreed this would ensure that treatment for any coexisting conditions that could be linked to self-harm are prioritised, enabling healthcare professionals to provide the most appropriate intervention for the individual, and resulting in more person-centred, higher-quality care. The committee referred to a number of other NICE guidelines for conditions that can be linked to self-harm, and agreed it is important that healthcare professionals plan treatment for people who have self-harmed in line with the guidance for any underlying or coexisting conditions before other interventions are considered.

The evidence showed that psychotherapies informed by cognitive behavioural therapy (CBT) have positive effects on repetition of self-harm at long-term follow‑up and on depression, hopelessness and suicidal ideation over time for adults. However, the evidence did not show an effect on repeat self-harm at other follow-up times. Additionally, the evidence was limited by the wide interpretation of 'CBT-based psychotherapies' as being inclusive of other types of therapies in addition to CBT, and the indistinct categorisation of all interventions throughout the evidence review. The committee agreed other therapies might be effective for adults who have self-harmed as long as they are informed by CBT, as indicated by the evidence.

The evidence also showed that dialectic behavioural therapy for adolescents (DBT‑A) has a positive effect on repetition of self-harm at post-intervention for adolescents. However, the evidence was limited by the fact that participants in studies had all self-harmed more than once, were all older than 12 years and most were female, and there was no evidence of effect of DBT-A on repeat self-harm by 12‑month follow‑up. The committee extrapolated the evidence based on their confidence that DBT-A is likely to be similarly effective in younger children and boys as it is in over-12s and girls; however, the committee agreed they could not be sure that DBT-A would be similarly effective for children and young people who did not frequently self-harm.

The evidence for other therapies was uncertain, and the evidence for the effects of pharmacological interventions was limited. The pharmacological evidence showed an uncertain effect of newer-generation antidepressants or antipsychotics on repetition of self-harm for adults, and no evidence of effect for mood stabilisers or natural products on repetition of self-harm for adults. The recommendations are based on the available evidence and the committee's knowledge and experience of the current practice of offering psychological or psychosocial interventions.

The committee agreed that any therapy offered should be delivered by staff with training in the relevant therapy and who are receiving appropriate supervision. This is to ensure the competence of the professional delivering the training allows for the needs of the person to be met and for the treatment to be tailored for people who self-harm. The committee agreed that further limitations on which staff could deliver therapies were unnecessary and could result in implementation difficulties and delays in treatment provision.

The recommendation that treatment should be offered without delay was based on the committee's knowledge that delaying treatment could lead to further self-harm or suicide, and on evidence from the review on involving families and carers in the management of self-harm, which showed that long waiting times for treatment is often a barrier to seeking help.

The safety planning recommendations were based on the committee's knowledge and experience that safety plans equip people who have self-harmed with the ability to identify and use their strengths and sources of support to overcome crisis moments and prevent repeat self-harm. This was supplemented by qualitative evidence from both staff skills reviews, which showed that individualised coping strategies are important to people who have self-harmed, and that specialist staff identified safety planning as an important technique to help manage self-harm. The committee considered the components of safety planning interventions from 3 studies included in the Cochrane review on psychosocial interventions, and used this evidence to recommend important aspects of safety plans that the committee agreed would prevent further self-harm.

The recommendations about how the safety plan should be implemented were based on the committee's knowledge and experience that collaborative decision making improves engagement with services, and that ensuring a copy is available to the person emphasises this collaborative aspect. The committee agreed that sharing the care plan with family and friends when appropriate could provide the benefit of social connectedness between the person and their sources of support, which is a protective factor against self-harm. The committee agreed that safety plans should always be accessible to ensure that people receive the most appropriate care, especially if they are too distressed to remember their plan.

The committee agreed that psychological or psychosocial interventions should always be available for those who may need them, based on their knowledge and experience that exclusion from these services even when they are appropriate for the individual increases the potential for repeat self-harm or suicide.

The committee agreed, based on the uncertain evidence on pharmacological interventions and their knowledge and experience, that drug treatment is usually offered for other comorbidities such as depression, and should not be offered specifically for self-harm.

The committee made a recommendation for research on specific psychological interventions (digital and/or face-to-face) to better inform future guideline development.

Harm minimisation

Recommendations 1.11.11 to 1.11.13

There was no evidence, so the recommendations are based on the committee's knowledge and experience. They agreed there are benefits to providing advice on coping strategies. However, the lack of evidence meant they were unable to make any recommendations about the use of safer self-harm strategies, or to be more specific in the recommendations.

The committee agreed that harm minimisation strategies can be helpful when a person is working towards stopping self-harm but has not yet managed to do so. In these circumstances, it may be possible to discuss harm minimisation strategies with the person who has self-harmed; however, this should only be done as part of a therapeutic partnership where treatment is ongoing. The aim of these strategies should be to work towards stopping the self-harm, while minimising the harm before this is possible for the person. The committee also agreed that some harm minimisation strategies are not appropriate for all people who self-harm, depending on the person's care and support needs.

The committee made a recommendation for research on the experience, feasibility, acceptability and effectiveness of harm minimisation strategies for people who self-harm to better inform future guideline development.

Therapeutic risk taking

Recommendation 1.11.14

There was no evidence, so the committee based the recommendation on their knowledge and experience. They agreed that there are benefits to taking therapeutic risks when working with people who have self-harmed. However, the lack of evidence meant they were unable to be more specific about when therapeutic risk taking should be considered. The committee agreed that therapeutic risk taking could promote autonomy, problem-solving skills and positive thinking, leading to improved patient satisfaction and reduced rates of self-harm. However, the committee discussed the fact that a misunderstanding of therapeutic risk taking resulting in assessment or care being withheld could potentially lead to significant increased rates of repeat self-harm or suicide, and agreed it is important to recommend that risk-taking strategies should only follow a psychosocial assessment and be used concurrently with any other psychiatric care. They also agreed that risk‑taking strategies should be a part of ongoing assessments to determine the efficacy of the approach for the person. The committee also agreed that other relevant professionals and practitioners would need to be involved to help with implementing the therapeutic risk-taking approach and to ensure that the approach has been communicated to the relevant teams.

How the recommendations might affect practice

The recommendations should increase the number of people receiving psychological interventions after an episode of self-harm, and reduce the number of people denied appropriate interventions because of limited or no availability. In turn, this should reduce repeat self-harm and suicide, and improve satisfaction and engagement with services. The recommendations should also ensure that a therapeutic risk-taking approach will not lead to the withholding of assessment or treatment for people who have self-harmed, potentially improving the quality of care provided, service user satisfaction, and reducing the rates of repeat self-harm or suicide.

The recommendations for specific therapies are likely to increase overall costs related to the provision of psychological interventions to people who self-harm, if CBT-informed psychological interventions and DBT‑A are offered to more service users. The recommendation that psychological interventions should be available could also have a resource impact depending on how many centres do not currently offer these therapies. For those that do not, training and additional staffing may be needed for these interventions to be available to all service users. Using therapeutic risk-taking approaches is unlikely to increase overall costs; instead, approaches such as discharging patients from hospital where appropriate may have a positive resource impact on, for example, the availability of hospital beds.

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Supporting people to be safe after self-harm

Recommendations 1.12.1 to 1.12.8

Why the committee made the recommendations

Where possible, the recommendations are based on evidence, but because of concerns over the quality and scarcity of evidence, the committee also used their knowledge and experience.

The committee discussed the evidence on the consistency and continuity of staffing, and agreed that this is a fundamental aspect of supporting people to be safe after self-harm because minimising the number of staff that people who have self-harmed see minimises distress and reduces the rates of repeat episodes of self-harm.

The committee discussed the limited evidence on observation for people who have self-harmed. They highlighted that observation could cause harm to people who have self-harmed if carried out by untrained clinical staff and if a therapeutic interaction is not established or maintained.

The committee discussed safety considerations when transferring between settings and agreed the importance of care plans being available to staff involved in their care in primary and secondary care and other settings to promote continuity of care.

There was limited evidence on the benefits of ensuring staff presence during periods in inpatient settings when rates of self-harm are higher. Using this and their knowledge and experience, the committee agreed that it is particularly important for staff to remain visible and accessible during handovers and busy periods to maintain continuity of care and ensure patient safety. By being visible, it minimises barriers between staff and patients, making it more likely that both parties can help and ask for help if needed.

Although it is important to ensure a safe physical environment for all mental health inpatients, the committee noted that a particular focus on safety is needed for people who have self-harmed. However, the committee agreed that safety considerations should not be prioritised over the person's autonomy and dignity, and therefore the least restrictive measures should always be used, dependant on the safety of the person.

The committee agreed that staff should consider removing certain items from the environment, according to the individual's specific needs and vulnerabilities. This could include sharp objects, potential ligatures and possible ligature points and things that might cause harm when ingested. However, the committee agreed that the need for this should be reviewed and only done when necessary to avoid excessive restrictions.

Although there was no evidence on the benefits of familiarising the patient with the procedures and physical environment of inpatient settings, the committee agreed that this is an important component of person-centred care, which should be carried out at the earliest opportunity to help reduce distress and the rate of repeat self-harm.

Although there was limited evidence, the committee highlighted the importance of all staff working in care settings knowing how to promptly raise concerns about people who have self-harmed. The committee agreed that open communication channels are important to ensure prompt responses to any signs of repeat self-harm.

How the recommendations might affect practice

These recommendations are in line with existing recommended practice, but they emphasise the importance of consistency and continuity of care and the therapeutic role of clinical observation. The recommendations may lead to trust-specific staff training in caring for people who have self-harmed.

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Safer prescribing and dispensing

Recommendations 1.13.1 to 1.13.5

Why the committee made the recommendations

There was no evidence, so the committee based the recommendations on their knowledge and experience. The committee agreed that when prescribing medicines to people after an episode of self-harm, it is important to take into account the toxicity of the prescribed medicines, the likelihood of drug or alcohol misuse and interactions with prescribed treatment, and the person's wider access to medicines prescribed for themselves or others, to limit the risk of overdose. They also agreed the need for effective communication when there are multiple prescribers.

The committee acknowledged the importance of shared decision making with people who have self-harmed when prescribing medicines in order to balance the risk of the person stockpiling medicines with their autonomy to improve patient satisfaction and adherence to medicines, and referred to the existing NICE guideline on shared decision making.

The committee agreed that a review of all current and any new medicines should be considered after an episode of self-harm. The committee identified that healthcare professionals could consider contacting the National Poisons Information Service for further advice and referred to the existing NICE guideline on medicines optimisation and STOMP-STAMP principles for people with learning disabilities or autism or both.

The committee agreed that when pharmacy staff are aware of warning signs and when healthcare professionals are prepared to use consultations to discuss self-harm, the opportunities for people to self-poison or overdose are reduced. The committee also agreed that the recommendations provide the chance for staff to enact safe prescribing principles.

The committee agreed that consultations and medicines reviews provide an opportunity for healthcare staff to assess self-harm, and therefore whether any existing or new medicines might be taken in overdose. This would allow for staff to amend any prescriptions as appropriate to reduce the potential for future self-poisoning.

How the recommendations might affect practice

These recommendations should improve safety for people after an episode of self-harm and improve person-centred care by involving people in decisions about safer prescribing practices.

For prescribers, these recommendations may mean that they review current prescriptions more routinely after an episode of self-harm with respect to the person's risks of toxicity from overdose. For primary healthcare professionals, these recommendations may increase communication with healthcare professionals from other settings, such as specialist mental health centres and specialist pharmacies when prescribing and reviewing medications. Improved communication between healthcare professionals should limit variations in prescribing practices and improve continuity of care.

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Training

Recommendations 1.14.1 to 1.14.4

Why the committee made the recommendations

The recommendations are based on the evidence from specialist and non-specialist staff, people who have self-harmed who have had care provided by specialist and non-specialist staff, and their parents and carers, which showed that there is a significant overlap between the kind of training considered important for both mental health and non-specialist professionals when working with people who have self-harmed.

Both reviews found that formal training on how to work with people who have self-harmed was considered important by all participants, so the committee agreed that all staff who work with people who self-harm should receive regular, ongoing training to address the areas where people felt their skills needed developing. The committee discussed the overlap between the specialist and non-specialist skills reviews and agreed that, although the evidence showed that similar skills are required by all staff, there would be different levels of skill required for each group of people. The committee agreed that the list of topics should be considered by those running the training to ensure the training would be appropriate to each professional's level of responsibility, because it would be unreasonable and impractical to expect specialist and non-specialist staff to receive the same level of training.

The recommendation listing topics to cover in training was based on the evidence for the skills that both specialist and non-specialist staff need. The committee agreed that specialist staff should also receive additional training about how to conduct a psychosocial assessment and risk formulation.

The committee discussed using security staff for observation of people who have self-harmed, and agreed that this is not appropriate and usually results in people feeling intimidated and distressed. They agreed, based on their knowledge and experience, that training in observation methods that promote therapeutic engagement and rapport building would allow staff to undertake therapeutic observation in a way that is least distressing for patients.

How the recommendations might affect practice

These recommendations should increase the frequency of formal self-harm specific training for all staff. There may be cost implications associated with the provision of high-quality training depending on the current frequency of formal training deemed necessary within different settings.

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Supervision

Recommendations 1.15.1 and 1.15.2

Why the committee made the recommendations

There was evidence that staff value different types of supervision for specific purposes, and the committee agreed recommendations on regular formal supervision and accessible 'on-the-job' support. The committee agreed that all staff should have the opportunity to access supervision that is distinct from general clinical supervision and case load management, but that staff who work with people who self-harm have a particular need for high-quality formal supervision and support. There was limited evidence to determine the regularity of formal self-harm supervision, and the committee agreed this would be decided on setting-specific factors, such as rates of self-harm, the acuteness of self-harm and available resources.

The committee highlighted that supervision should focus on ongoing skills development, because there was evidence that staff feel that they are not suitably trained or confident in caring for people who had self-harmed, especially in crisis situations. There was evidence that staff view reflective practice as an invaluable means to learn and improve their clinical practice; however, often this was not prioritised because of time and resource constraints. The committee agreed that formal self-harm supervision should aim to promote confidence and competence in staff when caring for people who self-harm, and this is particularly important for non-specialist staff who may feel less capable of managing difficult situations.

In addition to formal supervision, there was evidence that staff value having accessible and immediate support from senior colleagues. The committee were concerned that anxiety around fear of litigation in difficult situations could impact quality of care, and agreed that support for staff working with people who self-harm should reinforce lines of responsibility and provide advice to facilitate staff in making the most appropriate decisions.

There was evidence of the value placed on professional emotional support after an episode of self-harm or suicide, with staff describing how it helped them to process their experience and normalise their feelings and reactions and return to practice. The committee agreed that in their experience and expertise, it is often more appropriate for the member of staff to speak to someone removed from the situation and not necessarily their clinical supervisor, and agreed that all staff should have access to emotional support or emotional support services, as preferred by the member of staff, when requested.

How the recommendations might affect practice

These recommendations should increase the frequency of formal self-harm specific supervision for all staff. There may be cost implications associated with the provision of high-quality supervision depending on the frequency of formal supervision deemed necessary within different settings.

The recommendations on everyday supervision and support are in line with recommended practice but should help to foster a culture of supervision within all settings for staff working with people who self-harm. The committee discussed the cost implications of providing accessible emotional support or emotional support services to all staff and concluded that in most clinical settings, 24‑hour support was already available.

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