Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

The recommendations apply to staff from all sectors that work with people who have self-harmed, unless a recommendation or section specifically states that it is for a certain group. Because of the wide variety of criminal justice system settings that exist and the need to take other relevant national guidance into account, the recommendations in the guideline may need to be tailored for certain criminal justice system settings during implementation.

Putting recommendations into practice can take time depending on how much change in practice or services is needed. Most of the recommendations in this guideline reinforce best practice and will not need additional resources to implement if previous guidance has been followed. If changes to current local practice are needed to implement the recommendations, they may take time and significant additional resources.

The recommendations apply to all people who have self-harmed, unless a recommendation specifically states that it is for adults or children and young people only.

1.1 Information and support

1.1.1 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.

1.1.2 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).

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

1.1.4 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+.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on information and support.

Full details of the evidence and the committee's discussion are in:

1.3 Safeguarding

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

1.3.2 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.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on safeguarding.

Full details of the evidence and the committee's discussion are in evidence review C: consent, confidentiality and safeguarding.

1.4 Involving family members and carers

The recommendations in this section should be read alongside the recommendations on consent and confidentiality.

1.4.1 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.

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

1.4.3 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.

1.4.4 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.

1.4.5 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).

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on involving family members and carers.

Full details of the evidence and the committee's discussion are in evidence review D: involving family and carers in the management of people who have self-harmed.

1.5 Psychosocial assessment and care by mental health professionals

1.5.1 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.

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

1.5.3 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.

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

1.5.5 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.

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

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

1.5.8 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.

1.5.9 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.

1.5.10 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.

1.5.11 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).

1.5.12 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.

1.5.13 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.

1.5.14 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.

1.5.15 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).

1.5.16 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.

1.5.17 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.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on psychosocial assessment and care by mental health professionals.

Full details of the evidence and the committee's discussion are in:

1.6 Risk assessment tools and scales

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

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

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

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

1.6.5 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.

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

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on risk assessment tools and scales.

Full details of the evidence and the committee's discussion are in evidence review G: risk assessment and formulation.

1.7 Assessment and care by healthcare professionals and social care practitioners

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

1.7.1 When a person presents to a healthcare professional or social care practitioner following an episode of self-harm, the professional should:

  • treat the person with respect, dignity and compassion, with an awareness of cultural sensitivity

  • establish the means of self-harm and, if accessible to the person, discuss removing this with therapeutic collaboration or negotiation, to keep the person safe

  • assess whether there are concerns about capacity, competence, consent or duty of care, and seek advice from a senior colleague or appropriate clinical support if necessary; be aware and accept that the person may have a different view and this needs to be taken into account

  • seek consent to liaise with those involved in the person's care (including family members and carers, as appropriate) to gather information to understand the context of and reasons for the self-harm

  • discuss with the person and their families or carers (as appropriate), their current support network, any safety plan or coping strategies.

1.7.2 When a person presents to a healthcare professional or social care practitioner following an episode of self-harm, the professional should establish the following as soon as possible:

  • the severity of the injury and how urgently medical treatment is needed

  • the person's emotional and mental state, and level of distress

  • whether there is immediate concern about the person's safety

  • whether there are any safeguarding concerns

  • whether the person has a care plan

  • if there is a need to refer the person to a specialist mental health service for assessment.

1.7.3 Carry out concurrent physical healthcare and the psychosocial assessment as soon as possible after a self-harm episode.

1.7.4 For immediate first aid for self-poisoning, see the BNF's guidance on poisoning, emergency treatment, TOXBASE and the National Poisons Information Service.

1.7.5 Do not use aversive treatment, punitive approaches or criminal justice approaches such as community protection notices, criminal behaviour orders or prosecution for high service use as an intervention for frequent self-harm episodes.

Assessment and care in primary care

1.7.6 When a person presents in primary care after an episode of self-harm, consider referring them to mental health or social care services for a psychosocial assessment or informing their existing mental health team, with consent from the person and their family members or carers (as appropriate).

1.7.7 Make referral to mental health professionals a priority when:

  • the person's levels of concern or distress are rising, high or sustained

  • the frequency or degree of self-harm or suicidal intent is increasing

  • the person providing assessment in primary care is concerned

  • the person asks for further support from mental health services

  • levels of distress in family members or carers of children, young people and adults are rising, high or sustained, despite attempts to help.

1.7.8 If the person who has self-harmed is being supported and given care in primary care, their GP should ensure that the person has:

  • regular appointments with their GP for review of self-harm

  • a medicines review

  • information about available social care, voluntary and non-NHS sector support and self-help resources

  • care for any coexisting mental health problems, including referral to mental health services as appropriate.

Assessment and care by ambulance staff and paramedics

1.7.9 When attending a person who has self-harmed but who does not need urgent physical care, ambulance staff and paramedics should:

  • discuss with the person the best way that the ambulance service can help them

  • follow the person's care plan and safety plan if available

  • seek advice from mental health professionals, where necessary

  • record relevant information about the following, and pass this information to staff if the person is conveyed, or share it with other relevant people involved in the person's ongoing care if the person is not being conveyed:

    • home environment

    • social and family support network

    • history leading to self-harm

    • initial emotional state and level of distress

    • any medicines found at their home.

1.7.10 When attending a person who has self-harmed but who does not need urgent physical care, ambulance staff and paramedics should discuss with the person (and any relevant services) if it is possible for the person to be assessed by or receive treatment from an appropriate alternative service, such as a specialist mental health service or their GP.

1.7.11 When deciding whether the person can receive treatment from an appropriate alternative service, ambulance staff and paramedics should assess immediate safety concerns, as well as the availability and accessibility of alternative services at that time.

Assessment and care by non-mental health emergency department professionals

1.7.12 When a person attends the emergency department or minor injury unit following an episode of self-harm, emergency department staff responsible for initial assessment or triage should establish the following as soon as possible:

  • the severity of the injury and how urgently physical treatment is needed

  • the person's emotional and mental state, and level of distress

  • whether there is immediate concern about the person's safety

  • whether there are any safeguarding concerns

  • the person's willingness to accept medical treatment and mental healthcare

  • the appropriate nursing observation level

  • whether the person has a care plan.

1.7.13 When a person attends the emergency department or minor injury unit following an episode of self-harm, offer referral to age-appropriate liaison psychiatry services, or for children and young people, crisis response service (or an equivalent specialist mental health service or a suitably skilled mental health professional) as soon as possible after arrival, for a psychosocial assessment (see the section on psychosocial assessment and care by mental health professionals and the section on risk assessment tools and scales), and support and assistance alongside physical healthcare.

1.7.14 An age-appropriate liaison psychiatry professional or a suitably skilled mental health professional should see and speak to the person at every attendance after an episode of self-harm.

1.7.15 Ensure that the emergency department has a private, designated area for psychosocial assessments to take place, where it is possible to speak in confidence without being overheard.

1.7.16 Ensure that the waiting area in the emergency department for people who have self-harmed is close to staff who can provide care, support and observation.

1.7.17 Ensure that appropriate joint governance arrangements are in place so that physical and mental healthcare can be delivered together in emergency departments. This should include:

  • access to electronic record systems for both mental health services and medical treatment at the point of care

  • jointly agreed referral pathways for concurrent physical and mental healthcare

  • jointly agreed approaches to initial assessment and triage

  • monitoring of the use of mental health law and mental capacity law

  • joint safeguarding procedures

  • jointly agreed nursing observation policies

  • referral pathways to appropriate community services.

1.7.18 Do not use mechanical restraint in emergency departments to prevent self-harm or to prevent a person from leaving the emergency department.

Also see the NICE guideline on violence and aggression for recommendations about mechanical restraint.

1.7.19 Ensure that policies and procedures are in place for people who have self‑harmed who wish to leave, or have left, the emergency department before physical healthcare and mental health assessment and care is complete.

1.7.20 Ensure that policies and procedures are in place to identify people who frequently attend the emergency department or minor injury unit following an episode of self-harm so that a multidisciplinary review can be arranged in collaboration with mental health services (see recommendation 1.5.17 in the section on psychosocial assessment and care by mental health professionals).

Assessment and care in general hospital settings

1.7.21 When a person is admitted to hospital following an episode of self-harm, offer referral to age-appropriate liaison psychiatry services (or an equivalent specialist mental health service or a suitably skilled mental health professional) as soon as possible after admission for a psychosocial assessment (see the section on psychosocial assessment and care by mental health professionals and the section on risk assessment tools and scales), and support and assistance alongside physical healthcare.

1.7.22 An age-appropriate liaison psychiatry professional or a suitably skilled mental health professional should see and speak to the person at every admission after an episode of self-harm.

1.7.23 Mental health and acute ward staff should jointly decide the need for close observation on a case-by-case basis, taking into account the person's views and ensuring that observation is:

  • by appropriately skilled and trained healthcare staff

  • with the informed consent of the person or within an appropriate legal framework

  • reviewed regularly.

1.7.24 Children and young people who have been admitted to a paediatric ward following an episode of self-harm should have:

  • access to a specialist child and adolescent mental health service (CAMHS or children and young people's mental health services [CYPMHS]) or age-appropriate liaison psychiatry 24 hours a day

  • a joint daily review by both the paediatric team and children and young people's mental health team

  • daily access to their family members or carers

  • regular multidisciplinary meetings between the general paediatric team and mental health services.

Assessment and care in social care

1.7.25 When working with people who have self-harmed, social care practitioners should foster a collaborative approach with all agencies involved in the care of the person, as well as their family members and carers, as appropriate.

1.7.26 If self-harm has been identified during a social care assessment or through ongoing work, seek advice from, or refer the person to, the local urgent and emergency mental health service.

1.7.27 Continue to offer social care support and involvement to a person who has self-harmed, particularly if the person may be looked after or have ongoing social care needs.

Also see the NICE guidelines on domestic violence and abuse, looked-after children and young people, child abuse and neglect and child maltreatment.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on assessment and care by healthcare professionals and social care practitioners.

Full details of the evidence and the committee's discussion are in:

1.8 Assessment and care by professionals from other sectors

The recommendations in this section apply to all staff in non-healthcare and social care settings. Because of the wide variety of criminal justice system settings that exist and the need to take other relevant national guidance into account, staff working in the criminal justice system may need to tailor the recommendations for certain criminal justice system settings during implementation.

Principles for assessment and care by professionals from other sectors

1.8.1 When a person who has self-harmed presents to a non-health professional, for example, a teacher or a member of staff in the criminal justice system, the non-health professional should:

  • treat the person with respect, dignity and compassion, with an awareness of cultural sensitivity

  • work collaboratively with the person to ensure that their views are taken into account when making decisions

  • address any immediate physical health needs resulting from the self‑harm, in line with locally agreed policies; if necessary, call 111 or 999 or other external medical support

  • seek advice from a healthcare professional or social care practitioners, which may include referral to a healthcare or mental health service

  • ensure that the person is aware of sources of support such as local NHS urgent mental health helplines, local authority social care services, Samaritans, Combat Stress helpline, NHS111 and Childline, and that people know how to seek help promptly

  • address any safeguarding issues, or refer the person to the correct team for safeguarding.

1.8.2 When a person presents to a non-health professional, for example, a teacher or a member of staff in the criminal justice system, the non-health professional should establish the following as soon as possible:

  • the severity of the injury and how urgently medical treatment is needed

  • the person's emotional and mental state, and level of distress

  • whether there is immediate concern about the person's safety

  • whether there are any safeguarding concerns

  • whether the person has a care plan

  • if there is a need to refer the person to a specialist mental health service for assessment.

Assessment in schools and educational settings

1.8.3 Educational settings should have policies and procedures for staff to support students who self-harm. These should include:

  • how to identify self-harm behaviours

  • how to assess the needs of students

  • what do to if they suspect a student is self-harming

  • how to support the student's close friends and peer group.

1.8.4 Educational settings should have a designated lead responsible for:

  • ensuring that self-harm policies and procedures are implemented

  • ensuring that self-harm policies and procedures are regularly reviewed and kept up-to-date in line with current national guidance

  • ensuring that staff are aware of the self-harm policies and procedures and understand how to implement them

  • supporting staff with implementation if there are any uncertainties.

1.8.5 All educational staff should:

  • be aware of the policies and procedures for identifying and assessing the needs of students who self-harm

  • know how to implement the policies and procedures within their roles and responsibilities

  • know who to go to for support and supervision.

1.8.6 For students who have self-harmed, the designated lead should seek the advice of mental health professionals to develop a support plan with the student and their family members and carers (as appropriate) for when they are in the educational setting. This should include guidance from other agencies involved in the person's care, as appropriate.

1.8.7 Educational staff should take into account how the student's self-harm may affect their close friends and peer groups, and provide appropriate support to reduce distress to them and the person.

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

1.8.8 Staff in criminal justice settings and other secure settings such as immigration removal centres should be aware that those in their care have higher rates of self-harm and suicide.

1.8.9 Staff in criminal justice settings and other secure settings such as immigration removal centres should be aware of support services available to them to support their own wellbeing.

1.8.10 Staff in criminal justice settings and other secure settings such as immigration removal centres should be aware of arrangements for:

  • transferring people to a healthcare setting when necessary

  • in-reach or onsite support

  • their responsibilities for information sharing

  • how to access health services.

1.8.11 Staff in criminal justice settings and other secure settings such as immigration removal centres should follow local guidance on assessing people who have self-harmed, and healthcare professionals and social care practitioners in these settings should also follow the NICE guideline on mental health of adults in contact with the criminal justice system.

1.8.12 Staff in criminal justice settings and other secure settings such as immigration removal centres should ensure that people who have self‑harmed have a safe location to await assessment or treatment following an episode of self-harm.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on assessment and care by professionals from other sectors.

Full details of the evidence and the committee's discussion are in evidence review E: assessment in non-specialist settings.

1.9 Admission to and discharge from hospital

The recommendations in this section apply to all healthcare professionals and social care practitioners.

1.9.1 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).

1.9.2 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.

1.9.3 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.

1.9.4 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.

1.9.5 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.

1.9.6 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.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on admission to and discharge from hospital.

Full details of the evidence and the committee's discussion are in evidence review H: admission to hospital.

1.10 Initial aftercare after an episode of self-harm

The recommendations in this section apply to all healthcare professionals and social care practitioners.

1.10.1 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.

1.10.2 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.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on initial aftercare after an episode of self-harm.

Full details of the evidence and the committee's discussion are in:

1.11 Interventions for self-harm

The recommendations in this section apply to all healthcare professionals unless otherwise stated.

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

1.11.3 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.

1.11.4 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.

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

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

1.11.7 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.

1.11.8 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.

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

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

Harm minimisation

Although ways to self-harm safely are often considered a harm minimisation strategy, this guideline does not make any recommendations about the use of safer self-harm.

1.11.11 If a person is engaged in ongoing care and treatment but is not yet in a position to resist the urge to self-harm, only consider harm minimisation strategies:

  • in the spirit of hope and optimism, and to reduce the severity and/or recurrence of injury

  • as part of an overall approach to the person's ongoing recovery‑focused care and support, and not as a standalone intervention and

  • after being discussed and agreed in a collaborative way with the person and their family members or carers (as appropriate), and the wider multidisciplinary team.

1.11.12 Mental health professionals should discuss with the person harm minimisation strategies that could help to avoid, delay or reduce further episodes of self-harm and reduce complications, for example:

  • distraction techniques or coping strategies

  • approaches to self-care

  • wound hygiene and aftercare

  • providing factual information on the potential complications of self-harm

  • the impact of alcohol and recreational drugs on the urge to self-harm.

1.11.13 Be aware that harm minimisation strategies may not be appropriate for all people who self-harm.

Therapeutic risk taking

1.11.14 Therapeutic risk taking should only be used after a psychosocial assessment (see the section on psychosocial assessment and care by mental health professionals), and should:

  • use shared decision making, to ensure that the person is able to make an informed choice at all stages, and include family and carers, as appropriate

  • include other relevant professionals involved in the care of the person who has self-harmed

  • draw on the person's strengths and coping strategies and what matters to them

  • focus on positive outcomes

  • be part of an ongoing assessment to revisit the decision

  • be concurrent with psychiatric care if necessary.

1.12 Supporting people to be safe after self-harm

1.12.1 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.

1.12.3 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.

1.12.4 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.

1.12.5 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.

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

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

1.12.8 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.

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

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on supporting people to be safe after self-harm.

Full details of the evidence and the committee's discussion are in evidence review N: supporting people to be safe after self-harm.

1.13 Safer prescribing and dispensing

The recommendations in this section apply to all healthcare professionals.

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

1.13.2 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.

1.13.3 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.

1.13.4 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.

1.13.5 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).

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on safer prescribing and dispensing.

Full details of the evidence and the committee's discussion are in evidence review O: safer prescribing.

1.14 Training

1.14.1 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.

1.14.2 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.

1.14.3 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.

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

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on training.

Full details of the evidence and the committee's discussion are in:

1.15 Supervision

1.15.1 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.

1.15.2 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.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on supervision.

Full details of the evidence and the committee's discussion are in:

  • National Institute for Health and Care Excellence (NICE)