Self-harm:
longer-term management
Implementing NICE guidance
November 2011
NICE clinical guideline 133
Related guidance
‘Self-harm: short-term treatment and management’
(NICE clinical guideline 16) covers the treatment of
self-harm within the first 48 hours of an incident.
Self-harm: longer-term management, clinical guideline
133 , deals with the longer-term psychological treatment
and management of both single and recurrent episodes
of self-harm.
A small number of amendments have been made to
CG16 to ensure alignment with the
longer-term management guideline.
What this presentation covers
Definition
Background
Epidemiology
Scope
Key priorities for implementation
Costs and savings
Discussion
NICE Pathway and NHS Evidence
Find out more
Definition
The term self-harm is used in this guideline to refer to
any act of self-poisoning or self-injury.
This commonly involves self-poisoning with medication
or self-injury by cutting.
The term self-harm is not intended to cover harm to the
self arising from excessive consumption of alcohol or
recreational drugs, body piercing, mismanagement of
physical health conditions or starvation arising from
anorexia nervosa.
Background
Self-harm does not often result from the wish to die.
Those who self-harm may do so to communicate, to
secure help and care or to obtain relief from an
overwhelming situation.
Service provision for self-harm is varied. About half of
those presenting at an emergency department after an
incident of self-harm are assessed by a mental
health professional.
Epidemiology
• Self-harm is common, especially among younger
people
• For all age groups, annual prevalence is
approximately 0.5%
• Self-harm increases the likelihood that the person will
eventually die by suicide by between 50 and 100 fold
• Psychiatric problems such as borderline personality
disorder, depression, bipolar disorder, schizophrenia
and drug and alcohol-use disorders are
associated with self-harm.
Scope
This guideline covers:
• all people aged 8 years and older
• healthcare professionals who have direct contact
with people who self-harm
• medium and longer term care management
• primary, secondary, tertiary and community care.
Key priorities for implementation
• Working with people who self-harm
• Psychosocial assessment
• Risk assessment
• Risk assessment tools and scales
• Care plans
• Risk management plans
• Interventions for self-harm
• Treating associated mental health conditions.
Working with people who
self-harm
Health and social care professionals should:
• aim to develop a trusting and supportive relationship
• be aware of stigma and discrimination
• ensure that people are involved in decision-making
about their care
• aim to foster people’s autonomy and independence
• aim to maintain continuity of therapeutic relationships
• ensure that information about episodes of self-harm
is communicated sensitively to other
team members.
Access to services
Children and young people should have access to a full
range of treatments and services within child and
adolescent mental health services (CAMHS).
Ensure that people from black and minority ethnic groups
have the same access to services as other people and
that services are culturally appropriate.
People with a mild learning disability should have the
same access to services as other people.
Training
Health and social care professionals should be:
• trained in the assessment, treatment and
management of self-harm, and
• educated about the stigma and discrimination usually
associated with self-harm and the need to avoid
judgemental attitudes.
Routine access to senior colleagues for supervision,
consultation and support should be provided for
professionals who work with people who self-harm.
Safeguarding
CAMHS professionals should consider whether the
child’s or young person’s needs should be assessed.
If children or young people are referred to CAMHS under
local safeguarding procedures, use a multi-agency
approach including social care and education and
consider using the Common Assessment Framework.
Consider the risk of domestic or other violence and
consider local safeguarding procedures for vulnerable
adults and children in their care.
Families, carers and
significant others
Ask the person who self-harms whether they would like
their family, carers or significant others to be involved in
their care.
Subject to the person’s consent and right to
confidentiality, encourage the family, carers or significant
others to be involved where appropriate.
Managing endings and
supporting transitions
Anticipate that the ending of treatment, services or
relationships, as well as transition, can provoke strong
feelings and increase the risk of self-harm.
Plan in advance changes with the person who self-harms
and provide additional support if needed.
CAMHS and adult mental health services should work
collaboratively to ensure as smooth a transition
as possible.
Primary care
If a person presents in primary care with a history of
self-harm and a risk of repetition, consider referring them
to community mental health services for assessment.
If a person who self-harms is receiving treatment in
primary care and secondary care, primary and
secondary care and social care professionals should
ensure they work cooperatively.
Primary care professionals should monitor the
physical health of people who self-harm.
Psychosocial assessment: 1
Offer an integrated and comprehensive psychosocial
assessment of needs and risks to understand and
engage people who self-harm and to initiate a
therapeutic relationship.
During assessment, explore the meaning of self-harm
for the person and take into account that each person
self-harms for individual reasons. Each episode of selfharm should be treated in its own right.
Psychosocial assessment: 2
All people over 65 years should be assessed by mental
health professionals experienced in the assessment of
older people who self-harm. Within this age group
particular attention should be paid to the potential
presence of depression, cognitive impairment and
physical ill health.
Follow the same principles as for adults when assessing
children and young people.
Personal assessment
Assessment of needs should include:
– skills, strengths and assets
–
–
–
–
coping strategies
mental and physical health problems or disorders
social circumstances and problems
psychosocial and occupational functioning, and
vulnerabilities
– recent and current life difficulties
– the need for intervention and treatment for any
associated conditions
– the needs of any dependent children.
Risk assessment: 1
When assessing the risk of repetition of self-harm or risk
of suicide, identify and agree the person’s specific risks,
taking into account:
• methods and frequency of current and past self-harm
• current and past suicidal intent
• depressive symptoms
• any psychiatric illness
• the personal and social context and any other specific
factors preceding self-harm.
Risk assessment: 2
Also take into account:
• specific risk and protective factors that may increase
or decrease the risks associated with self-harm
• coping strategies
• significant relationships that may either be supportive
or represent a threat
• 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.
Do not use risk assessment tools and scales to
determine who should and should not be offered
treatment or who should be discharged.
Risk assessment tools may be considered to help
structure risk assessments as long as they include the
areas identified in recommendation 1.3.6 on slides 19
and 20.
Care plans: 1
Discuss, agree and document the aims of longer-term
treatment in the care plan. These aims may be to:
• prevent escalation of self-harm
• reduce harm arising from self-harm or reduce or stop
self-harm
• reduce or stop other risk-related behaviour
• improve social or occupational functioning
• improve quality of life
• improve any associated mental health conditions.
Review the care plan with them, and revise it at
agreed intervals of not more than 1 year.
Care plans: 2
Care plans should be multidisciplinary and developed
collaboratively with the person. Care plans should:
• identify realistic and optimistic long-term goals,
including education, employment and occupation
• identify short-term treatment goals (linked to the
long-term goals) and steps to achieve them
• identify the roles and responsibilities of any team
members and the person who self-harms
• include a jointly prepared risk management plan
• be shared with the person’s GP.
Risk management plans: 1
A risk management plan should be a clearly identifiable
part of the care plan and should:
• address each of the long-term and immediate risks
identified in the risk assessment
• address the specific factors 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.
Risk management plans: 2
A risk management plan should be a clearly identifiable
part of the care plan and should: (continued)
• include a crisis plan outlining self-management
strategies and how to access services during a
crisis
• ensure that the risk management plan is
consistent with the long-term treatment strategy.
Inform the person who self-harms of the limits of
confidentiality and that information in the plan may be
shared with other professionals.
Interventions for self-harm
Do not offer drug treatment as a specific intervention to
reduce 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. This
should be tailored to individual need.
Harm minimisation
If stopping self-harm is unrealistic in the short term:
• consider strategies aimed at harm reduction; reinforce
existing coping strategies and develop new strategies
as an alternative to self-harm where possible
• consider discussing less destructive or harmful
methods of self-harm with the service user, their
family, carers or significant others, and the wider
multidisciplinary team
• advise the service user that there is no safe way
to self-poison.
Treating associated mental
health conditions
Provide psychological, pharmacological and
psychosocial interventions for any associated
conditions.
When prescribing drugs for associated mental health
conditions to people who self-harm, take into account
the toxicity of the prescribed drugs in overdose.
Costs per 100,000 population
Recommendations with significant costs
Access to services
Costs
(£ per year)
800
Psychosocial assessment
19,900
Longer-term treatment and management
10,800
Estimated cost of implementation
31,500
Savings
Typical costs that could be avoided by implementing the guidance
Description
Reference (national tariff /
reference costs)
Non-elective
tariff
£
A&E attendance
Ambulance transfer cost
Intensive care cost per day
VB07Z and VB08Z
Reference cost 2009/10
Reference costs 2009/10
XC07Z Adult critical care 0 organs
supported
XB05Z Paediatric critical care –
intensive care basic
WA11V – major complications
WA11X – intermediate complications
WA11Y – without complications
110
246
Treatment for poisoning
Treatment for other wounds
or injuries
710
2225
2200
611
387
HD35A – major complications
4231
HD35B – intermediate complications 4231
HD35C – without complications
514
Discussion
• What can we do to help address the stigma and
discrimination associated with self-harm?
• Do we include within our assessment of needs all that
we should? If not, what steps do we need to take?
• How can we address the issues associated with the
transition from CAMHS to adult services for young
people who self-harm?
• What is our current practice in terms of using risk
assessment tools and scales? How can this be
improved?
NICE Pathway
The NICE self-harm
pathway covers:
•
planning of services
•
general principles of
care
•
assessment, treatment
and management
•
longer-term treatment
and management.
Click here to go to
NICE Pathways
website
NHS Evidence
Visit NHS Evidence
for the best available
evidence on all
aspects of self-harm
Click here to go to
the NHS Evidence
website
Find out more
Visit www.nice.org.uk/guidance/CG133 for:
•
•
•
•
•
•
•
the guideline
‘Understanding NICE guidance’
costing report and template
audit support and baseline assessment tool
clinical case scenarios
risk assessment podcast
service user podcast.
What do you think?
Did the implementation tool you accessed today meet
your requirements, and will it help you to put the NICE
guidance into practice?
We value your opinion and are looking for ways to
improve our tools. Please complete this short evaluation
form.
If you are experiencing problems accessing or using this
tool, please email implementation@nice.org.uk
To open the links in this slide set right
click over the link and choose ‘open link’