Therapeutic Assessment of Patients following Self-Harm

Abstract

Self-harm is an important health issue. It is more prevalent in the UK than the rest of Europe. An estimated 170 000 people present to hospital each year but most acts of self-harm do not result in presentation for medical attention; so self-harm is largely a community problem with real-term figures an unknown. This article explains the terminology associated with self-harm, provides explanations for the different motives and suggest ways in which primary care can contribute to assessing and responding to patients engaging in self-harm. It will also explain a process to mitigate risk.

The GP curriculum and self-harm

Several GP curriculum statements are relevant to self-harm in primary care:

Curriculum statement 1: Being a GP states that a GP should have an awareness of self: an understanding that their own attitudes and feelings are important determinants of how they practise. A person-centred approach means always seeing the patient as a unique person in a unique context and taking into account patient preferences and expectations at every step in a patient-centred consultation.

Curriculum statement 5: Healthy people requires GPs to negotiate a shared understanding of problems and their management (including self-management) with the patient, so that the patient is empowered to look after his or her own health and has a commitment to health promotion and self-care.

Curriculum statement 7: Care of acutely ill people includes mental health emergencies within its knowledge base. It requires GPs to be able to make mental state assessments and ensure patient safety, accept responsibility for action, at the same time recognizing any need for involvement of more experienced personnel including deciding whether urgent action is necessary, thus protecting patients with non-urgent and self-limiting problems from the potentially detrimental consequences of being over-investigated, over-treated or deprived of their liberty.

Curriculum statement 13: Care of people with mental health problems states that GPs should understand that their own attitudes and feelings are important determinants of how they react to people with mental health problems including people who self-harm.

Although the function of self-harm is not to end one's life, there is a link between self-harm and suicide. Self-harm is a manifestation of emotional distress, an indication that something is wrong rather than a primary disorder. Every contact with individuals who self-harm is a chance to address the unbearable emotional distress that they are feeling. If addressing self-harming behaviours is seen solely as the preserve of specialist mental health services, opportunities for intervention will be missed. Primary care offers ample opportunity to intervene. In so doing, we can minimize distress and reduce the likelihood of a coping mechanism becoming well established and entrenched.

Terminology

‘Self-harm’ is the accepted terminology for behaviours that have the motive of harming oneself in some way. Other terms used include self-mutilation and deliberate self-harm (Box 1). However, these terms are pejorative in terms of semantics and perpetuate judgemental attitudes. The use of emotive and pejorative language is likely to create barriers for those wishing to disclose that they use harmful ways to cope with distress. The National Institute for Health and Clinical Excellence (NICE, 2004) simply recommends that the term self-harm is sufficient.

Box 1.

Terminology regarding self-harm

Self-harm: is the accepted terminology for behaviours that have the motive of harming oneself in some way.

Direct self-harm: is an intentional act of self-injury or self-poisoning irrespective of the type of motivation or degree of suicidal intent. Thus, it includes suicide attempts as well as acts where little or no suicidal intent is involved.

Non-suicidal self-injury (NSSI): is becoming an increasingly popular term to describe self-injury. It further defines the motivations of injuring as a way of modifying emotional pain rather than as a means to complete suicide thus making it clear and distinct from other direct and indirect self-harming behaviours. The terms self-injury and NSSI are used specifically to describe injury to the body.

Self-poisoning: is a direct self-harming behaviour that is not associated with self-injury. The ingestion of more than one substance, including alcohol, is more likely to indicate that suicide was the motivation rather than alleviation of distressing emotions.

Indirect self-harm: covers a range of socially acceptable and unacceptable behaviours. These include smoking, drinking, drug taking, eating disorders, antisocial, risky, destructive and dangerous behaviours. As with direct self-harm, such behaviours are coping mechanisms to help deal with emotional distress, the frequency and dangerousness increasing as the distress worsens. These behaviours are a good indication that a person is in distress and may be contemplating direct self-harm.

Behaviours that cause harm to the body are either direct with immediate tissue damage (direct self-harm) or indirect, potentially leading to progressive long-term illness. Self-harm can also include behaviours that cause harm to one's mind and prospects (a form of indirect self-harm). Box 2 overviews the different types of self-harm with examples of each. Direct self-harm (self-poisoning and self-injury) is the focus of this paper and for the purposes of simplicity will be referred to from now on as self-harm.

Why do people self-harm?

Box 3 summarizes the reasons why people may self-harm. Self-harm is a physical manifestation of attempting to deal with very strong emotional responses. It is a way of coping with difficult or intolerable situations, such as trauma, distressing life events and inability to cope with a situation. For each person, the contributing circumstances are different.

Box 2.

Types of self-harm

Direct self-harm

Cutting

Burning

Scalding

Picking

Head banging

Hair pulling (including eyelashes, eyebrows, etc.)

Excessive nail biting

Swallowing sharp objects or harmful substances

Inserting foreign bodies into skin or body cavities

Indirect harming behaviours

Driving too fast

Getting into fights

Self-denigration

Risky sexual practices and multiple sexual partners

Alcohol, especially binge drinking and other substance use (frequently associated with loss of control, increased recklessness and threat to life)

Involvement with crime

Putting oneself into dangerous situations

Remaining in unsatisfactory relationships/situations (not to be mistaken for situations of domestic abuse where the victim is unable to leave)

Isolation (often self-imposed)

Box 3.

Reasons for self-harming behaviour

Expression of personal distress—often unbearably intense emotional distress (a ‘bright red scream’)

Concealment of distress—a ‘private pain’

Inability to cope with emotional or physical pain any longer

Desperation

Trauma or abuse (often relating to childhood experiences)

Belief that the individual deserves to be punished (usually relating to abusive experiences, poor self-esteem and/or self-hatred)

To destroy the body and make it less attractive

Guilt

Isolation and lack of a sense of belonging

Being in a minority group

To ‘feel real’ i.e. validation of existence acquired through sight of blood/flesh

Increased control

Escalation of less concerning injuries or behaviours

To act out the care that the individual would like to be shown (e.g. to enable the individual to dress the wounds thus affording care to himself or herself)

Although the motivation to self-harm is generally to sustain life, 72% of young people who self-harm admit to having thoughts of suicide, and the incidence of suicide for this group of people is greater than that of the general population. Risk of suicide is increased further for those who repeatedly self-harm, and the continued use of weak analgesics to self-poison is a particularly strong indicator of future suicide (Qin et al., 2009). For some people, self-harming is the only coping mechanism to resist acting on chronic suicidal thoughts and they report that following self-harm, they experience a reduction in intolerable emotional pain and a reduction in the intensity of their suicidal thoughts.

Epidemiology of self-harm

Lifetime prevalence of self-harm in the UK is 4.8% in males and 16.7% in females, the highest rate in Europe. Incidence has risen steadily over the past 20 years.

Within the UK, between 1 in 12 and 1 in 15 of adolescents self-harm. This figure drops to 4 in 100 in the adult population. The highest rates of self-harm are among young Black and South Asian women.

Of those who present to the Accident and Emergency Department (A&E), 80% have self-poisoned. The remainder have self-injured, mostly by cutting (the most common method of self-injury for females). Self-harm is the most common reason for women to be admitted to medical wards. Half of all those that present to A&E following self-harm have seen their GP in the previous month. Additionally, a similar proportion will visit their GP within 2 months of attending A&E after self-harming.

However, it is important to note that the studies from which these epidemiological data are derived rely predominantly on inpatient (admission for treatment) samples. Therefore, findings are not a true representation of those who do not seek help from services.

Risk factors for self-harm

Box 4 lists evidence-based risk factors for self-harm. A more comprehensive table of risk factors is available as supplementary material for this article on the InnovAiT website. Of note, those most at risk are least likely to engage in follow-up services (Bolger et al., 2004). Therefore, contact with primary care is frequently the only opportunity to connect with an individual at risk.

Box 4.

Risk factors for increasing likelihood of self-harm

Demographic factors

Adolescence

Gender (female greater than male)

Socio-economic class (high and low)

Minority group (e.g. Black or Asian young women)

Media effects—influence and awareness of self-harm in others

Personal history

Chronic or acute physical illness—particularly epilepsy and newly diagnosed human immunodeficiency virus infection

Mental health problems (20 times more likely to report self-harm than others)

Personality disorder

Previous self-harm

Substance misuse (alcohol and both prescribed and illegal drugs)

Offending/antisocial behaviour

Education, training or employment issues e.g. unemployment

Emotional and behavioural factors

High achievers

Poor coping skills

Inability to articulate emotions

Impaired decision making

Negative thoughts e.g. hopelessness, helplessness, guilt

Unbearable emotional distress, e.g. feelings of abandonment, rage, suicidal thoughts

Gender and sexuality issues (young gay men in rural areas are at increased risk of self-harm and suicide)

Regular risky sexual behaviour

Personal relationships

Social isolation and perception of lack of social support

Major relationship instability

Recent bereavement

Young carer

Childhood abuse (80% of children presenting with self-harm have suffered abuse)

Institutionalization, e.g. looked-after-child, prison

Family factors

Illness in the family e.g. parental mental or physical illness, especially young carers

Domestic violence

Absent or detained family member

Parental criticism

Family history, e.g. mental health problems, substance misuse

Non-disclosure of self-harm

Shame and fear of discovery mean that people often keep self-harm a secret. Unless medical treatment is required, self-harm is not usually reported. The reasons why people do not seek help following self-harm are not known but it is assumed that stigma is an important factor. Some may not disclose their self-harming behaviours because the issue is not directly addressed. Therefore, when presented with a patient who is displaying characteristics of depression or emotional distress, the authors suggest that it may prove valuable to routinely ask about thoughts and acts of self-harm. Of those who do seek help, future engagement with clinical services may be compromised by negative experiences (Taylor et al., 2009).

Negative attitudes towards self-harm can be associated with a lack of understanding of its complexity. Historically, terminology with inherent semantics has tended to confuse rather than illuminate the different behaviours and motivations involved. Clinicians are therefore ill prepared and feel powerless to help a person who is ‘assumed’ not to want help themselves. Common feelings can be described as ‘a combination of horrified, guilty, furious, betrayed, disgusted and sad’ (Favazza, 1998). Skills training is fundamentally important to enable practitioners to develop and practise the skills needed to engage safely and effectively with patients who self-harm.

Personal reflections

People who have self-harmed should be treated with the same care, respect and privacy afforded to any other patient. In addition, health care professionals should take full account of the likely distress associated with self-harm.

In order to achieve this, GPs may need to acknowledge the reactions and feelings that these patients evoke in themselves and ensure that this does not lead to professional polarization or have a direct impact in terms of affecting the doctor—patient relationship and therapeutic interventions. An important aspect of caring for our patients is actually self-care.

Primary care professionals can be personally distressed and professionally challenged while managing patients who regularly engage in self-harm. Discussion of cases with and supervision from an experienced colleague with interest and expertise in mental health issues will be crucial in helping GPs in training gain the attitudes and competences required to respond compassionately, confidently and safely to individuals who self-harm. The principle of reflective practice is crucial here.

Treating the injury

The first consideration when a person has self-harmed is treatment of the injury. Does it require first aid or professional medical attention? However, not everyone wishes to have their wounds treated and consideration must be given to patients' wishes unless the injury is life threatening. Self-poisoning has been covered in depth in another issue of InnovAiT (Whitehouse, 2010). In the event of self-poisoning, hospital admission is generally necessary for further assessment. The authors advocate that if patients have ingested medication with the intention of self-harm (or have taken greater than the recommended dose where self-harm is suspected as a motive), they should always be advised to attend A&E as in some cases, the quantity ingested may be unknown or the individual may be reluctant to admit to the extent of tablets taken. Box 5 lists specific points to consider if self-harm includes ingestion of tablets.

Box 5.

Specific points to consider if the self-harm includes ingestion of tablets

Did they buy or otherwise obtain the method specifically for this episode of self-harm? If an overdose, did they take all of the available tablets?

Is there evidence of planning or was there a note? One of every six people who complete suicide leave a note; some people now use texts to say goodbye or alert others if they are ambivalent

Did they believe the method would kill them? Someone may genuinely think that eight antibiotic tablets may be more serious than 30 paracetamol tablets

Did they make attempts not to be discovered?

What did they do following self-harm, did they tell anyone? And, especially important, how did they get to hospital?

What do they think about it now? Assess current mental state and in particular, the degree of hopelessness. Are they disappointed that they did not complete their suicide, i.e. die? Do they now regret it and feel ashamed or embarrassed? If ‘yes’, minimize their self-loathing, praise life-preserving tactics and instil hope.

Further assessment

Rapport building

The key to assessing and managing patients who have self-harmed is to respond in an empathic and non-judgemental way. This will create a good foundation for your relationship with the patient. This in turn will enhance the willingness to accept further help and thus may lead to reduction of self-harming behaviours. Rapport building techniques should include:

Active listening

Open body language

Safe environment

Non-judgemental/no blame approach

Appropriate eye contact

Reflection

Calm and caring manner

Frequently, a patient will present to primary care for another reason other than self-harm. In these cases, self-harm can be a difficult subject to broach. Northumberland Tyne and Wear NHS Foundation Trust have a self-help leaflet available by download (website: www.ntw.nhs.uk/pic/selfhelp/#) as do the National Self-Harm Network (website: www.nshn.co.uk). These information and self-help leaflets can be invaluable as an icebreaker, starting a conversation between the practitioner and the patient, and as a take-away resource.

Risk assessment

The assessment of a person who has self-harmed requires a person-centred bio-psychosocial approach, which assesses problems, needs and in so far as is possible understands the risks of further self-harm. All people who have self-harmed should be assessed for risk. This assessment should include identification of the main clinical and demographic features known to be associated with risk of further self-harm and/or suicide (Box 4) and identification of the key psychological characteristics associated with risk, in particular depression, hopelessness and continuing suicidal intent.

The act of self-harm can be a coping strategy for patients and prevent them from taking their own life. However, there are times when the escalation of self-harming behaviours may result in unintentional suicide. There are also times, where the function of the harmful behaviour is no longer sufficient to ward off the overwhelming and unbearably intense emotions that the individual may be feeling. Suicide may thus be viewed as the only way to cope, the only option left. Assessing the motivation of the patient is therefore essential.

Assessment of self-harm

Your assessment of self-harm should explore the events leading up to the self-injury in depth. This includes exploring the current situation, recent events and current problems; exploring the patient's emotional and psychological state both leading up to the event and afterwards; exploring how the individual has self-harmed and determining whether there is an immediate risk of self-harming again. To help GPs assessing patients who have self-harmed, Wadman and Cole-King propose the new mnemonic ‘SOS’:

Severity: How severe is the situation? Is medical treatment required? Can wounds be managed in-house? Does the patient need to be referred to A&E? (Recommended for all cases of overdose). How severe was the emotional distress when the patient self-harmed? How severe is it now? How severe is any mental illness? How severe are the patient's psychosocial problems/life events and has anything changed?

Outcome: What was the intended outcome of the self-harm? Was there a death wish? Did the individual secure the means specifically for the self-harm? What was the extent of planning and preparation? Were there any attempts not to be discovered? What was the individual thinking at the moment of self-harm? Were any boundaries in place to ensure safety or possibility of rescue? e.g. someone close by, informed someone, did not use all available means, depth of cut, number of cuts etc. Does the individual regret self-harming?

Support systems: Explore the patient's network of supportive family/friends. Beware of social isolation (perceived or real), relationship instability or recent loss e.g. via bereavement. Are there adequate and appropriate support systems in place?

It may be useful to consider this process in relation to both self-harm and suicide risk as many people may engage in self-harm in addition to having suicidal thoughts.

Assessing children and adolescents

It can be particularly difficult to gain essential and often crucial information from children and adolescents. Questions need to be asked skilfully, tactfully, clearly and directly in a way that elicits an honest answer, fostering trust and rapport with the younger patient. Collaborative interagency work that is child focused and empowering is key to addressing issues that contribute to self-harming behaviours in children. It is also important to remember safeguarding issues in this age group. Take advice from your local safeguarding lead if you are in doubt.

Treatment strategies

The first priority when deciding upon treatment is to establish whether suicidal intent was the motivating factor for the current self-harm. If the answer is ‘yes’, treatment must be geared towards keeping the patient safe with a full suicide risk assessment and plan of action and support appropriate to the risk is necessary. Undertaking a primary care assessment of risk is covered in another article in this special issue of InnovAiT (The assessment and management of patients with suicidal thoughts).

If the answer is ‘no’ and self-injury was intended to relieve emotional pain and distress, safe-planning concentrates on mitigating against repetition or escalation of the self-harming behaviour by working with the patient to minimize the harmful behaviours. The difference between suicide prevention and self-harm mitigation is that one is to save life while the other is to preserve life and support emotional health; both necessitate different management approaches.

Mitigating the risk of self-harm

Identification of the function of the self-harming behaviour is essential if we are to impact on reducing harmful behaviours. If the underlying reasons for self-harm are not addressed, can we reasonably expect a patient willingly to give up a coping strategy that works for them and reduces their unbearably intense and distressing emotions? By asking directly about behaviours, thoughts, actions and responses to events in your assessment process, further information can be gathered and a bigger picture may be observed. However, occasionally patients may not actually be sure themselves why they self-harmed. They might have been so overwhelmed that they were not thinking clearly and did not have any actual suicidal intent even though they engaged in a potentially dangerous act, but simply ‘wanted the pain to go away’.

Remember that self-harm is a coping strategy. You cannot simply take it away. The aim is to address underlying psychosocial issues, as part of a strategy to improve emotional health. The key principles informing the care and treatment of the individual should be to:

engage the individual in seeking and accepting help for their underlying problems

promote resilience and self-efficacy—this includes offering alternative coping strategies, such as problem solving and support to resolve social issues

Hawton et al. (1999) in their Cochrane review of psychosocial and pharmacological treatments for self-harm highlighted that despite much research, the optimum treatment for self-harm remains elusive. We suggest that this may be due to the approach of ‘managing self-harm’, focusing on the self-harm itself rather than on the needs of the individual. Furthermore, any treatment strategy relies heavily on an empathic therapeutic relationship and the ability of the practitioner to demonstrate a validating and compassionate approach and this cannot be prescribed.

Table 1 summarizes ways in which GPs may mitigate risk of self-harm. These strategies may require you to signpost services provided by local authorities and voluntary (third sector) organizations, as well as statutory services.

However, it is important to note that referrals to services providing psychological therapies and formal social support services may take time, which could leave the patient vulnerable until help is available. It is essential to support the patient during this period and offer interim measures to, at best, help minimize the risk of repeated self-harm or at least to reduce its dangerousness and frequency.

Enhancing resilience by instilling a sense of self-efficacy and personal control within your patient can make the difference. In addition, the more appropriate supportive opportunities available for an individual who self-harms, the greater the likelihood distress can be minimized. Personal connections and opportunities to discuss events and situations responsible for causing emotional distress (‘Talking not Harming’) is an important transition in the road to recovery. To this end, asking your patient to identify someone they have in their immediate circle of family and friends who is able to support them is crucial. Furthermore, by encouraging patients to bring ‘their’ identified personal resource to appointments can help with continuity of care and community support.

Voluntary (or third) sector organizations can be helpful in supporting patients within the community (Box 6).

Web resources can also be invaluable. The National Self-Harm Network (Box 6) has a forum and resources for those who self-harm and for professionals who support them. They also operate a freephone helpline. Get connected (Box 6) offers help specifically for young people who self-harm via e-mail and a helpline. However, it is important to remember that some Internet sites contain triggering text and images too, and so the Internet is not always helpful. Therefore, it is imperative that before signposting people who self-harm to any website, content and credentials are checked.

Those that are not ready to stop self-harming

It is important to note that a patient may not want to or may not be ready to stop self-harming behaviour. If the function of the behaviour is to cope with stressful events and/or stave off thoughts of suicide, it may not be appropriate to expect or negotiate immediate cessation of self-harming behaviour. However, attempts can still be made to mitigate the risk factors and underlying issues contributing to the self-harm as in Table 1.

Table 1.

Examples of ways to mitigate risk of self-harm

Biological	Psychological	Social
Initially
Symptomatic relief Optimize treatment of any mental illness or extreme emotional distress Optimize treatment of any medical illness, especially pain	Non-judgemental, empathic, person-centred, supportive relationship with practitioner Show compassion and validate distress Increase resilience and empower the young person to identify alternative coping strategies Optimize protective factors, praise resilience in coping thus far Promote the importance of self-care and emotional well-being	Immediate crisis management. Safety of the child/young person is of paramount importance. Do referrals need to be made? e.g. social services, police, specialist child and adolescent mental health services, other support services within health, education, social care and the voluntary sector. Identify formal and informal support systems; create a ‘support map’ with friends, family, community and emergency contacts, helplines and website details Speedy and regular review with the patient and involved agencies
Longer term
Optimize treatment if there is a mental illness or physical illness, review diagnosis Monitor concordance with treatment regimes and self-care Enhance physical well-being and encourage physical activity Encourage regular healthy eating Monitor sleep patterns Establish if incidences of self-harm correspond with phases of the menstrual cycle and treat as appropriate	Maximize the therapeutic relationship Increase resilience by enhancing: • emotional well-being • coping/problem-solving skills Identify and promote adoption of alternative coping strategies Identify and recognize ‘trigger times‘ Deal with any losses e.g. Cruse; Winston's wish; local child-focused loss and bereavement support services Deal with any ongoing issues e.g. abuse, domestic violence, parental illness/absence, difficult life events Increase engagement with services as required Set clear boundaries where required; this may necessitate multidisciplinary professional meetings.	Enhance social relationships, social inclusion, sense of belonging and support systems Enhance family relationships and consider support for parents/carers Look at ways to reduce stress and conflict; consider family mediation services Physical and restful activity and self-care Meaningful activities: encourage hobbies, social inclusion and alternative coping strategies Lifestyle changes if indicated (these can be hard for a child or young person to implement—adult intervention/assistance may be required) Revisit the support map for amendments/additions Retain and promote a sense of connection and belonging

Serious self-harm

Serious self-harm is usually managed in secondary care, i.e. hospital medical care and mental health services. Approximately half of the people who present to A&E following an episode of self-harm are assessed by a mental health professional. Specialist treatments include psychosocial and pharmacological interventions, risk reduction and harm minimization approaches.

Conclusions

Self-harm is a difficult area that many GPs find a challenge. Careful history taking, exploring the factors that led to self-harm, and circumstances surrounding self-harm, and including a risk assessment is essential. If there is no suicidal intent involved, management is aimed at building rapport and engaging the individual in seeking and accepting help for the issues that led to their self-harm and providing strategies to promote resilience and self-efficacy. This involves co-operation between health, social and voluntary sector services. We would urge practitioners to seek further training in this area and a list of suitable courses is included in Box 7.

Box 6.

Support Organisations for patients that self-harm and their families

Samaritans Telephone: 08457 909 090 (24 /7). Website: www.samaritans.org

Provides round-the-clock confidential emotional support for people who are experiencing feelings of emotional distress or despair, including those that may lead to suicide.

PAPYRUS HOPELine UK Telephone: 0800 068 41 41

PAPYRUS aims to prevent young people taking their own lives. It provides a professionally staffed helpline providing support, practical advice and information to young people worried about themselves and anyone concerned that a young person may be at risk of harming themselves.

PAPYRUS also produces a range of suicide prevention resources, including HOPELine UK contact cards. Many can be downloaded from www.papyrus-uk.org or call 01282 432 555 for a sample pack.

The National Self-Harm Network Telephone: 0800 622 6000 (19.00–23.00 hours). Website: www.nshn.co.uk Forum and resources for those who self-harm and for professionals who support them.

Get Connected Telephone: 080 8808 4994 (13.00–23.00 hours). Website: www.getconnected.org.uk/home Offers help specifically for young people (under 25) who self-harm and also provides e-mail support.

Consumer Credit Counselling Services website: www.cccs.co.uk Free on-line support service providing anonymous and practical advice about money matters and debt.

Additional resources

ChildLine. Telephone: 0800 1111

CRUSE (Bereavement helpline). Telephone: 0870 167 1677

Winston's wish (Bereavement support for children). Website: winstonswish.org.uk

Parentline Plus. Telephone: 0808 800 2222

NHS Direct. Telephone: 0845 46 47

National Debtline (helpline). Telephone: 0808 808 4000

Mental Health Advocacy Scheme. Telephone: 01248 353343

Drinkline Helpline. Telephone: 0800 9178 282

National Drugs Helpline. Telephone: 0800 77 66 00

MIND (Counselling Service). Telephone: 0845 7660163

Box 7.

Further training

STORM Training: Through a process of practice and appraisal participants enhance their skills, feeling more able to assess a person considered to be at risk of self-harm or suicide and to manage the immediate crisis. Contact e-mail: storm.enquiries@manchester.ac.uk; website: www.medicine.manchester.ac.uk/storm

Connecting with People Self-Harm Awareness Training. This 2 hour session raises awareness of the subject area and provides simple clinical tools to aid the assessment of patients presenting with self-harm. It forms part of a key module of the RCGP Accredited Diploma in Mental Health. Contact e-mail: info@openminds.org.uk

Royal College of Psychiatrists College Education and Training Centre. One day training course in self-harm. Designed and co-delivered by a liaison psychiatrist and a person with lived experience, this provides an overview of self-harm including cultural aspects and how to respond empathically to a person who engages in self-harm. Contact e-mail: egeorge@rcpsych.ac.uk; website: www.rcpsych.ac.uk/cetc

Cariad yn Cyfri ‘Patience and Plasters’ self-harm training. This full-day training covers all aspects of self-harm. There is an emphasis on engagement skills, safeguarding children procedures, inter-agency working, supporting the family and community systems. Contact e-mail: info@cariadyncyfri.co.uk; website: www.cariadyncyfri.co.uk or contact.

Key points

Self-harm is a manifestation of emotional distress

Almost half who end their life by suicide have previously self-harmed; practitioners need to remain vigilant as to the possibility of escalation of self-harming behaviour, substitution to more lethal methods and the heightened risk of suicide

For some individuals, self-harm becomes an established coping mechanism—often in childhood and adolescence that follows into adult years; early intervention can prevent escalation of behaviours and can establish other coping strategies that are not harmful

Primary care professionals can be personally distressed and professionally challenged while managing patients who regularly engage in self-harm; peer support is crucial

Treatment involves increasing the resilience of your patient through identifying and enabling alternative coping strategies and addressing the issues that caused self-harm; this involves co-operation across health and social care and third sector boundaries

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