NICE BULLETIN: Managing self-harm

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Introduction

In November 2011 the National Institute for Health and Clinical Excellence (NICE) published a new clinical guideline on the longer-term care of adults, children and young people who self-harm.

This new guideline follows on from the NICE guideline on the short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care (NICE clinical guideline 16). This previous guideline focused on the first 48 hours of an episode and the care received in the Emergency Department. The new recommendations focus on the longer-term psychological treatment and management of self-harm.

Self-harm is very common and involves a wide range of methods, the most common being self-poisoning with prescribed or over the counter medicines, or self-injury by cutting. People self-harm for numerous reasons, and although self harm is not usually an attempt at committing suicide, it is a way of expressing deeper emotional feelings, such as low self-esteem, the emotional results of previous abuse and hurts. However, people who self harm are much more likely to die by suicide, and many suffer from long term physical effects of self injury and self poisoning, as well as psychiatric problems such as depression.

People may keep self-harm a secret which means it is difficult to know how widespread it is. Many cases are unreported unless medical treatment is required. However, it is thought to be common, especially amongst young people, with one UK study finding that 1 in 10 girls aged 15-16 had self-harmed in the previous year. This new guideline is an important step in improving health professionals’ understanding of self-harm and thereby helping to ensure people receive the treatment and support they need.

This new guideline on the longer term management, aims to provide healthcare professionals with clear recommendations on how to work with people who self-harm and enable them to choose the right treatment for their individual needs.

What NICE recommends

Psychosocial assessment
NICE advises that an integrated and comprehensive psychosocial assessment of needs and risks should be offered to understand and engage people who self-harm and to initiate a therapeutic relationship. This assessment of should include:
• skills, strengths and assets
• coping strategies
• mental health problems or disorders
• physical health problems or disorders
• social circumstances and problems
• psychosocial and occupational functioning, and vulnerabilities
• recent and current life difficulties, including personal and financial problems
• the need for psychological intervention, social care and support, occupational rehabilitation, and also drug treatment for any associated conditions
• the needs of any dependent children.

Risk assessment
When assessing the risk of repetition of self-harm or risk of suicide, identify and agree with the person who self-harms the specific risks for them, taking into account:
• methods and frequency of current and past self-harm
• current and past suicidal intent
• depressive symptoms and their relationship to self-harm
• any psychiatric illness and its relationship to self-harm
• the personal and social context and any other specific factors preceding self-harm, such as specific unpleasant affective states or emotions and changes in relationships
• specific risk factors and protective factors (social, psychological, pharmacological and motivational) that may increase or decrease the risks associated with self-harm
• coping strategies that the person has used to either successfully limit or avert self-harm or to contain the impact of personal, social or other factors preceding episodes of self-harm
• significant relationships that may either be supportive or represent a threat (such as abuse or neglect) and may lead to changes in the level of risk
• immediate and longer-term risks.

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

Care plans
The aims of longer-term treatment should be discussed, agreed and documented with the person who self-harms in the care plan. These aims could be to prevent escalation of self-harm or reduce or stop other risk-related behaviour. The care plan should be reviewed at agreed intervals with the person; this review should include the aims of treatment.

Risk management plans
A risk management plan should be a clearly identifiable part of the care plan and should:
• address each of the long-term and more immediate risks identified in the risk assessment
• address the specific factors (psychological, pharmacological, social and relational) identified in the assessment as associated with increased risk, with the agreed aim of reducing the risk of repetition of self-harm and/or the risk of suicide
• include a crisis plan outlining self-management strategies and how to access services during a crisis when self-management strategies fail
• ensure that the risk management plan is consistent with the long-term treatment strategy.
The person who self-harms should be informed of the limits of confidentiality and that information in the plan may be shared with other professionals.
Interventions for self-harm
Consider offering 3 to 12 sessions of a psychological intervention that is specifically structured for people who self-harm, with the aim of reducing self-harm. The intervention should be tailored to individual need and could include cognitive-behavioural, psychodynamic or problem-solving elements. Therapists should be trained and supervised in the therapy they are offering to people who self-harm and therapists should also be able to work collaboratively with the person to identify the problems causing distress or leading to self-harm.
Drug treatment should not be offered as a specific intervention to reduce self-harm.

Treating associated mental health conditions
NICE also advises that psychological, pharmacological and psychosocial interventions should be provided for any associated conditions, for example those described in the following published NICE guidance:
• Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence (NICE clinical guideline 115).
• Depression (NICE clinical guideline 90).
• Schizophrenia (NICE clinical guideline 82).
• Borderline personality disorder (NICE clinical guideline 78).
• Drug misuse (psychosocial interventions or opioid detoxification) (NICE clinical guidelines 51 and 52).
• Bipolar disorder (NICE clinical guideline 38).

Conclusion
Self-harm is a very broad term for a behaviour that can be expressed by those affected in very individual ways, which is why it is so important that each person receives the right care plan for them. The guideline offers practical, evidence-based advice for nurses and other healthcare professionals on how to care for a people who self-harm and their families or carers.
To read the full recommendations in NICE’s clinical guideline 133 on the longer-term management of self-harm, and to access tools to help nurses implement the recommendations and supporting advice that nurses can give to parents or carers, please visit: www.nice.org.uk/CG133.

This guideline is concerned with the longer-term psychological treatment and management of both single and recurrent episodes of self-harm, and does not include recommendations for the physical treatment of self-harm or for psychosocial management in emergency departments (these can be found in NICE clinical guideline 16 – http://www.nice.org.uk/guidance/CG16 or via the ‘Self-harm pathway: http://pathways.nice.org.uk/pathways/self-harm).