Self-Harm: Work with Patients to Minimise Risk and Recurrence

Dr Emma Nash Examines the New NICE Guideline on Self-Harm, Explaining Best Practice in Assessing, Supporting, Referring, and Interacting with People who Self-Harm

In September 2022, NICE published NICE Guideline (NG) 225, Self-harm: assessment, management and preventing recurrence,¹ replacing two previous guidelines on self-harm. In the guidance, self-harm is defined as 'intentional self-poisoning or injury, irrespective of the apparent purpose’.¹ This broad definition is intended to allow the guideline to address the needs of a variety of people whose self-harm may differ significantly,² and does not differentiate between self-harm with suicidal intent or without.

In this article, I will discuss self-harm in general, then focus on NG225, covering the key recommendations for primary care practitioners.

The Scale of the Issue

Self-harm is becoming more prevalent. In response to the 2014 Adult Psychiatric Morbidity Survey, 6.4% of participants aged 16–74 years stated that they had ever self-harmed, compared with 3.8% in 2007.³ Self-harm is particularly common in young people: according to the survey’s findings, 25.7% of women and 9.7% of men aged 16–24 years had self-harmed at some point in their lives.³ In 2020–2021, there were an estimated 102,472 emergency hospital admissions for self-harm in England, 41,606 of which involved people aged 10–24 years.⁴

Most people who self-harm do not go on to die by suicide.³ However, previous self-harm is strongly linked to death by suicide—a 2022 report found that 64% of people who die by suicide have previously self-harmed⁵—so self-harm should always be taken seriously, regardless of whether the person has engaged in nonsuicidal self-harm in the past.

Methods of Self-Harm

Self-harm includes those acts that happen with suicidal intent but without completed suicide, and those that do not have suicidal intent. Self-harm is broadly separated into self-poisoning and self-injury, but there are many different methods within these categories. Cutting is the most frequent form of self-harm,^3,6 but various other forms do exist, including:^3,6,7

• burning one’s skin
• swallowing harmful things (including medication overdoses)
• overeating or undereating
• excessive exercise.

When discussing a person’s self-harm, therefore, it is important to explore self-harm actions more broadly, and not limit enquiries to the most common methods.

Risk Factors for Self-Harm

As may be expected, poor mental health is the risk factor most strongly associated with suicidal thoughts and self-harm, but there are many other factors that are independently related to the occurrence of self-harm (outlined in Figure 1).^2,8–11 Greater risk of self-harm comes with severe or prolonged exposure to any of these elements, and the combination of multiple risk factors has a cumulative effect.⁸ It is useful to know the importance of these biopsychosocial factors, as their presence and severity can help in the assessment of a person's risk.

Figure 1: Key Risk Factors Influencing the Likelihood of Self-Harm^2,8–11

Common Attitudes and Misconceptions

Healthcare professionals can hold misconceptions about people who self-harm, not understanding that there is often a reason underlying this apparently self-destructive act.^6,12 In particular, self-harm is often seen as attention-seeking or manipulative behaviour¹³—this attitude can have a significant negative impact on a person who self-harms, leaving them feeling misunderstood, judged, or alone.⁷ Clinicians’ misunderstanding of self-harm can also have deleterious consequences for a person's care: poor GP experiences have been shown to deter people who self-harm from seeking future help,¹⁴ and interactions with healthcare professionals that are perceived as hostile can discourage future disclosure and increase the risk of recurrent self-harm.¹⁵

Reasons and Feelings Underlying Self-Harm

It is crucial for clinicians to recognise that nonsuicidal self-harm is not a ‘bad behaviour’, but rather a dysfunctional coping strategy. The reality is that a person who self-harms is suffering intolerable distress of some kind, but is unable to process and cope with it in a healthier way.³ A person may self-harm for myriad reasons—too many to list here—and each person who self-harms has their own reasons for doing so.¹ The focus of clinicians’ care needs to be on:

• keeping the person safe
• reducing the risk of recurrence
• addressing the underlying cause of distress
• helping the individual develop more functional coping strategies to manage distress.

Self-harm is often accompanied by feelings of regret, guilt, or shame. People’s thought processes around these feelings can vary—they may feel that they have ‘failed’ to manage their emotions, or that their actions have caused distress or inconvenience to others. In addition, in the scenario of self-harm with suicidal intent, a person may feel regret or shame that the suicide attempt was not completed. In any case, the thoughts and emotions that accompany self-harm are complex, so clinicians should never assume that they know what a person is thinking.¹ In all interactions, people should be treated with respect, dignity, and compassion, and with an awareness of cultural sensitivities around self-harm.¹

Initial Assessment in Primary Care

Initial interventions in primary care need to be person centred, and may require some negotiation. For example, if someone has used an instrument or medication to self-harm, therapeutic collaboration may facilitate removal of this means of self-harm to help keep the person safe.¹ Although not always possible, clinicians may also be able to discuss any contributing or precipitating factors for the self-harm with the person, and this may provide an opportunity to take steps towards mitigating these potential stressors.

Establishing Risk

Regarding risk, the guideline focuses on risk formulations carried out by specialist mental health practitioners;¹ however, to guide next steps, some form of risk assessment needs to be performed when a person who has self-harmed presents in primary care. The guideline is clear that risk assessment and stratification tools should not be used to predict future suicide or repetition of self-harm, or for determining treatment thresholds, as they are not accurate predictions of risk.¹ Nevertheless, risk formulation should be undertaken.¹

As primary care professionals generally have prior knowledge of the person, even if only through medical records, they are in a good position to construct a picture of risk. The Royal College of Psychiatrists describes a risk formulation as ‘[a] formulation [that] brings together an understanding of personality, history, mental state, environment, potential causes and protective factors, or changes in any of these’,¹⁶ and recommends that a formulation is structured around the questions shown in Box 1. Primary care clinicians are used to assessing risk in a variety of contexts, but an approach such as this can be helpful for structuring decision making.

Regarding self-harm specifically, NICE recommends establishing certain details whenever a person presents to healthcare after an episode of self-harm,¹ as set out in Box 2. In some cases, the person will be at very high risk, and will require referral to secondary care services.¹ Here, decisions can be made about the level of support required, and ultimately whether admission to hospital is needed.¹ If there is uncertainty, it may be best to speak with the duty team, as decisions on management and tolerance of risk—including therapeutic risk taking—are often improved by engagement with the multidisciplinary team, and by the involvement of relevant professionals involved in the person’s care.¹

Referral to Mental Health Services

NICE recommends that primary care practitioners consider referral to mental health or social care services for a psychosocial assessment when a person presents to primary care after an episode of self-harm.¹ Given the prevalence of self-harm, however, the reality is that there is insufficient capacity in secondary care to review all of these people. Hence, NICE specifies certain people for whom referral should be considered a priority (see Box 3).¹

Interventions and Harm Minimisation

For those patients who are cared for solely within a primary care setting, NICE recommends providing:¹

• regular GP appointments for review of self-harm
• a review of existing medications and treatment options
• information about available nonmedical care, such as support from the voluntary or social care sectors
• self-help resources.

Care delivered across the primary care team—including that provided by peer support workers or social prescribers—can facilitate a full biopsychosocial approach to identifying and addressing people’s needs. Self-harm is strongly associated with mental illness, so assessment for mental ill health is also required, and will sometimes prompt onward referral for specialist care.¹

Reviewing Medication

The management of self-harm needs to be considered in the context of any coexisting conditions—both physical and mental.¹ This is important for determining an approach to treatment, but also for identifying risk, as medications used to treat other conditions may be used as a means for further self-harm.¹ People who experience chronic pain are of particular concern, as they are not only at increased risk of suicide,¹⁷ but are also more likely to have access to opioids or neuropathic agents, some of which carry a high risk in overdose. If possible, in collaboration with the person who self-harms and their family or carers, limiting access to any drugs that may be toxic in overdose can be a prudent step towards harm minimisation.¹

Psychological Therapies

Psychological therapies play a key role in the management of self-harm. NICE broadly recommends interventions that are based on cognitive behavioural therapy (CBT) and tailored for people who self-harm, with specific consideration of dialectical behavioural therapy for adolescents (DBT-A) for children and young people with significant emotional dysregulation.¹ In practice, primary care practitioners will likely need to refer people to local psychological therapy services or secondary care, where assessments of need and decisions for therapy will be made. However, it is worth being aware of these recommendations, as expansion of the primary care team through programmes such as the Additional Roles Reimbursement Scheme¹⁸ is leading to increasing numbers of psychological practitioners in primary care, who may be able to deliver CBT- and DBT-A-based treatments.

Self-Management and Safety Plans

Medical and psychological concerns are natural areas to address, but attention should also be given to the role that the person can play in their own care. NICE recommends that healthcare professionals should use a strengths-based approach—talking with people about their strengths, and how they can use them to counter or manage their distress.¹ This attitude can empower them to take control of their situation.

In times of crisis, it can be hard for someone to recall their strengths, or to remember ways to manage their distress. Because of this, NICE recommends safety plans as an effective intervention that people who self-harm can use at these times.¹ Developed by a patient and a clinician, a safety plan is a ‘written, prioritised list of coping strategies and/or sources of support that the person who has self-harmed can use to help alleviate a crisis’.¹ People who self-harm can use a safety plan to define and recognise any triggers or warning signs of increased distress and self-injurious ideas, and can include lists of any protective or coping strategies that aid them when they feel distress.¹ These strategies include:¹

• preferred social support, such as family members or friends who can provide support or distraction in times of crisis
• activities that the person finds helpful for managing distress
• contact details of third-party resources, such as mental health teams, third-sector crisis organisations, or safe havens.

Some useful resources to discuss with a person who self-harms and consider for inclusion in a safety plan are listed in Box 4. These resources will vary locally, and there are many organisations that offer support both locally and nationally, so it is worth checking with a local mental health lead which services they would recommend. Bear in mind potential issues with transport, language, and accessibility when considering services, as some will be able to offer suitable adjustments.

Proactive planning is also important for a safety plan to be effective, and clinicians should:¹

• ensure that their patient has easy access to the plan
• share the plan with other relevant agencies, as well as families and carers (where appropriate)
• ensure that the actions in the plan are consistent with what the person has identified as helpful.

In the development of a safety plan, it is also useful to work together with the person to ensure that their environment is as safe as possible in advance of any crisis.¹

Harm Minimisation

Although the goal of treatment is to prevent the recurrence of self-harm, this is not always possible—for example, if a person is not psychologically ready or able to relinquish this coping strategy. This should not preclude them from ongoing treatment, however, and it may be appropriate in certain circumstances to take an approach that focuses on minimising the damage to a person from their self-harm, whether that is by reducing the severity or frequency of their self-harm or by reducing the complications of it, for example with better self-care of injuries.¹ Consultations that discuss this kind of harm minimisation should always take place with a sense of optimism, to give the person hope that there will be improvement in the future, and should be part of a wider approach to recovery and support.¹

The NICE guideline makes no recommendations on the use of safer self-harm for harm minimisation, but it does discuss the need to consider other strategies—including distraction techniques, coping strategies, self-care, and care of wounds or injuries—intended to reduce or delay further episodes of self-harm and reduce complications.¹ People should be given factual information about the potential consequences of their self-harm mechanisms, and advised that alcohol and drugs can increase impulsivity and thus make it harder for them to follow the self-management strategies that have been discussed.¹

Safeguarding

When a person discloses self-harm, it is particularly important to consider whether there are any safeguarding issues that need to be addressed—this may be for the person themselves or for others (for example, dependents that they are responsible for), and it may be more appropriate to discuss any concerns with the person alone.¹ Safeguarding issues do not just apply to children who have self-harmed—vulnerable adults can also self-harm, and the same attitude is needed in terms of protection.¹

Consent, Confidentiality, and Involving Family Members or Carers

Consent and confidentiality can be complicated in relation to self-harm. Although involvement of families or carers is recommended in NG225, clinicians do need to consider the balance between the benefits and potential risks of this involvement for the person, and be aware of the importance of confidentiality.¹ Possible consequences of involving a person’s family member or carer include any negative responses or actions of the person who is informed, which may cause further distress to the person who self-harms and lead to recurrence, as well as the potential loss of the therapeutic relationship between the healthcare professional and their patient. Involving other people or breaching confidentiality can also lead to a loss of autonomy for the person who self-harms that may make the situation worse,¹ although some people find a relief in not having to hide their distress or behaviours anymore.

In certain circumstances, it is possible that the benefits of breaching confidentiality may outweigh the risks.¹ However, the circumstances around breaching confidentiality will need addressing, in line with relevant legislation, and a person’s capacity to agree to the involvement of others needs to be carefully considered.¹ The guideline therefore recommends that all healthcare professionals in contact with people who self-harm should understand when and how to apply the principles of the relevant legislation, including:¹

• the Mental Capacity Act 2005 and its code of practice
• the Mental Health Act 2007 and its code of practice
• the Care Act 2014 and its statutory guidance
• the Children Act 1989
• the Children and Families Act 2014.

NICE also recommends that staff working with people who self-harm should be able to discuss issues regarding capacity and consent with a specialist, and should have access to legal advice.¹

As time goes on, a person may change their mind about whether they want family involvement, so this should be reviewed at regular intervals during an episode of care.¹ Clinicians should not assume that because consent was once given or withheld, this will always be the case.¹

Conclusion

Self-harm can be a complicated area for healthcare practitioners to navigate, with competing considerations of risk, confidentiality, and safeguarding. Indeed, self-harm is often misunderstood by healthcare practitioners, and this can significantly impact patient outcomes. It is crucial that healthcare professionals who interact with people who self-harm treat them with respect and without judgement, as this is the basis of any effective treatment.