Note from the National Guideline Clearinghouse (NGC): This guideline was developed by the National Collaborating Centre for Mental Health (NCCMH) on behalf of the National Institute for Health and Clinical Excellence (NICE). See the Availability of Companion Documents field for the full version of this guidance.
This guideline follows on from Self-harm: the short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care (NICE clinical guideline 16), which covered the treatment of self-harm within the first 48 hours of an incident.
General Principles of Care
Working with People Who Self-Harm
Health and social care professionals working with people who self-harm should:
- Aim to develop a trusting, supportive and engaging relationship with them
- Be aware of the stigma and discrimination sometimes associated with self-harm, both in the wider society and the health service, and adopt a non-judgemental approach
- Ensure that people are fully involved in decision-making about their treatment and care
- Aim to foster people's autonomy and independence wherever possible
- Maintain continuity of therapeutic relationships wherever possible
- Ensure that information about episodes of self-harm is communicated sensitively to other team members
Health and social care professionals who work with people who self-harm should be:
- Familiar with local and national resources, as well as organisations and websites that offer information and/or support for people who self-harm
- Able to discuss and provide advice about access to these resources
Access to Services
Children and young people who self-harm should have access to the full range of treatments and services recommended in this guideline within child and adolescent mental health services (CAMHS).
Ensure that children, young people and adults from black and minority ethnic groups who self-harm have the same access to services as other people who self-harm based on clinical need and that services are culturally appropriate.
When language is a barrier to accessing or engaging with services for people who self-harm, provide them with:
- Information in their preferred language and in an accessible format
- Psychological or other interventions, where needed, in their preferred language
- Independent interpreters
Self-Harm and Learning Disabilities
People with a mild learning disability who self-harm should have access to the same age-appropriate services as other people covered by this guideline.
When self-harm in people with a mild learning disability is managed jointly by mental health and learning disability services, use the Care Programme Approach (CPA).
People with a moderate or severe learning disability and a history of self-harm should be referred as a priority for assessment and treatment conducted by a specialist in learning disabilities services.
Training and Supervision for Health and Social Care Professionals
Health and social care professionals who work with people who self-harm (including children and young people) should be:
- Trained in the assessment, treatment and management of self-harm
- Educated about the stigma and discrimination usually associated with self-harm and the need to avoid judgemental attitudes.
Health and social care professionals who prove training about self-harm should:
- Involve people who self-harm in the planning and delivery of training
- Ensure that training specifically aims to improve the quality and experience of care for people who self-harm
- Assess the effectiveness of training using service-user feedback as an outcome measure
Routine access to senior colleagues for supervision, consultation and support should be provided for health and social care professionals who work with people who self-harm. Consideration should be given of the emotional impact of self-harm on the professional and their capacity to practice competently and empathically.
Consent and Confidentiality
Health and social care professionals who work with people who self-harm should be trained to:
- Understand and apply the principles of the Mental Capacity Act (2005) and Mental Health Act (1983; amended 1995 and 2007)
- Assess mental capacity
- Make decisions about when treatment and care can be given without consent
Be familiar with the principles of confidentiality with regard to information about a person's treatment and care, and be aware of the circumstances in which disclosure of confidential information may be appropriate and necessary.
Offer full written and verbal information about the treatment options for self-harm, and make all efforts necessary to ensure that the person is able, and has the opportunity, to give meaningful and informed consent.
Take into account that a person's capacity to make informed decisions may change over time, and that sometimes this can happen rapidly in the context of self-harm and suicidal behaviour.
Understand when and how the Mental Health Act (1983; amended 1995 and 2007) can be used to treat the physical consequences of self-harm.
Health and social care professionals who work with people who self-harm should have easy access to legal advice about issues relating to capacity and consent.
Health and social care professionals who have contact with children and young people who self-harm should be trained to:
- Understand the different roles and uses of the Mental Capacity Act (2005), the Mental Health Act (1983; amended 1995 and 2007) and the Children Act (1989; amended 2004) in the context of children and young people who self-harm
- Understand how issues of capacity and consent apply to different age groups
- Assess mental capacity in children and young people of different ages
They should also have access at all times to specialist advice about capacity and consent.
CAMHS professionals who work with children and young people who self-harm should consider whether the child's or young person's needs should be assessed according to local safeguarding procedures.
If children or young people who self-harm are referred to CAMHS under local safeguarding procedures:
- Use a multi-agency approach, including social care and education, to ensure that different perspectives on the child's life are considered
- Consider using the Common Assessment Framework*; advice on this can be sought from the local named lead for safeguarding children
If serious concerns are identified, develop a child protection plan.
When working with people who self-harm, consider the risk of domestic or other violence or exploitation and consider local safeguarding procedures for vulnerable adults and children in their care. Advice on this can be obtained from the local named lead on safeguarding adults.
*It should be noted that the Common Assessment Framework is not applicable in Wales.
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.
When families, carers or significant others are involved in supporting a person who self-harms:
- Offer written and verbal information on self-harm and its management, including how families, carers and significant others can support the person
- Offer contact numbers and information about what to do and whom to contact in a crisis
- Offer information, including contact details, about family and carer support groups and voluntary
- Organisations, and help families, carers or significant others to access these
- Inform them of their right to a formal carer's assessment of their own physical and mental health needs, and how to access this
CAMHS professionals who work with young people who self-harm should balance the developing autonomy and capacity of the young person with perceived risks and the responsibilities and views of parents or carers.
*'Significant other' refers not just to a partner but also to friends and any person the service user considers to be important to them.
Managing Endings and Supporting Transitions
Anticipate that the ending of treatment, services or relationships, as well as transitions from one service to another, can provoke strong feelings and increase the risk of self-harm, and:
- Plan in advance these changes with the person who self-harms and provide additional support, if needed, with clear contingency plans should crises occur.
- Record plans for transition to another service and share them with other health and social care professionals involved.
- Give copies to the service user and their family, carers or significant others if this is agreed with the service user.
CAMHS and adult health and social care professionals should work collaboratively to minimise any potential negative effect of transferring young people from CAMHS to adult services.
- Time the transfer to suit the young person, even if it takes place after they reach the age of 18 years.
- Continue treatment in CAMHS beyond 18 years if there is a realistic possibility that this may avoid the need for referral to adult mental health services.
Mental health trusts should work with CAMHS to develop local protocols to govern arrangements for the transition of young people from CAMHS to adult services, as described in this guideline.
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 they are under 18 years, consider referring them to CAMHS for assessment. Make referral a priority when:
- Levels of distress are rising, high or sustained
- The risk of self-harm is increasing or unresponsive to attempts to help
- The person requests further help from specialist services
- Levels of distress in parents or carers of children and young people are rising, high or sustained despite attempts to help
If a person who self-harms is receiving treatment or care in primary care as well as secondary care, primary and secondary health and social care professionals should ensure they work cooperatively, routinely sharing up-to-date care and risk management plans. In these circumstances, primary health and social care professionals should attend CPA meetings.
Primary care professionals should monitor the physical health of people who self-harm. Pay attention to the physical consequences of self-harm as well as other physical healthcare needs.
Psychosocial Assessment in Community Mental Health Services and Other Specialist Mental Health Settings: Integrated and Comprehensive Assessment of Needs and Risks
Offer an integrated and comprehensive psychosocial assessment of needs (see recommendations below) and risks (see recommendations below) to understand and engage people who self-harm and to initiate a therapeutic relationship.
Assessment of Needs
Assessment of needs 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
All people over 65 years who self-harm should be assessed by mental health professionals experienced in the assessment of older people who self-harm. Assessment should follow the same principles as for working-age adults (see recommendations above). In addition:
- Pay particular attention to the potential presence of depression, cognitive impairment and physical ill health.
- Include a full assessment of the person's social and home situation, including any role they have as a carer.
- Take into account the higher risks of suicide following self-harm in older people.
Follow the same principles as for adults when assessing children and young people who self-harm (see recommendations above), but also include a full assessment of the person's family, social situation, and child protection issues.
During assessment, explore the meaning of self-harm for the person and take into account that:
- Each person who self-harms does so for individual reasons
- 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
A risk assessment is a detailed clinical assessment that includes the evaluation of a wide range of biological, social and psychological factors that are relevant to the individual and, in the judgement of the healthcare professional conducting the assessment, relevant to future risks, including suicide and self-harm.
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
Consider the possible presence of other coexisting risk-taking or destructive behaviours, such as engaging in unprotected sexual activity, exposure to unnecessary physical risks, drug misuse or engaging in harmful or hazardous drinking.
When assessing risk, consider asking the person who self-harms about whether they have access to family members', carers' or significant others' medications.
In the initial management of self-harm in children and young people, advise parents and carers of the need to remove all medications or, where possible, other means of self-harm available to the child or young person.
Be aware that all acts of self-harm in older people should be taken as evidence of suicidal intent until proven otherwise.
Risk Assessment Tools and Scales
Risk assessment tools and scales are usually checklists that can be completed and scored by a clinician or sometimes the service user depending on the nature of the tool or scale. They are designed to give a crude indication of the level of risk (for example, high or low) of a particular outcome, most often suicide.
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 the recommendations above.
Developing an Integrated Care and Risk Management Plan
Summarise the key areas of needs and risks identified in the assessment (see recommendations above) and use these to develop a care plan (see recommendations below) and a risk management plan (see recommendations below) in conjunction with the person who self-harms and their family, carers or significant others if this is agreed with the person. Provide printed copies for the service user and share them with the general practitioner (GP).
If there is disagreement between health and social care professionals and the person who self-harms about their needs or risks, consider offering the person the opportunity to write this in their notes.
Longer-Term Treatment and Management of Self-Harm
Provision of Care
Mental health services (including community mental health teams and liaison psychiatry teams) should generally be responsible for the routine assessment (see section on psychosocial assessment above) and the longer-term treatment and management of self-harm. In children and young people this should be the responsibility of tier 2 (primary care) and 3 (community child and adolescent health teams) CAMHS.
Discuss, agree and document the aims of longer-term treatment in the care plan with the person who self-harms. 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 person's care plan with them, including the aims of treatment, and revise it at agreed intervals of not more than 1 year.
Care plans should be multidisciplinary and developed collaboratively with the person who self-harms and, provided the person agrees, with their family, carers or significant others. 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 (see below)
- Be shared with the person's GP
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
Inform the person who self-harms of the limits of confidentiality and that information in the plan may be shared with other professionals.
Update risk management plans regularly for people who continue to be at risk of further self-harm. Monitor changes in risk and specific associated factors for the service user, and evaluate the impact of treatment strategies over time.
Provision of Information about the Treatment and Management of Self-Harm
Offer the person who self-harms relevant written and verbal information about, and give time to discuss with them, the following:
- The dangers and long-term outcomes associated with self-harm
- The available interventions and possible strategies available to help reduce self-harm and/or its consequences (see recommendations under 'General Principles of Care' above and under 'Harm Reduction' below )
- Treatment of any associated mental health conditions (see section below)
Ensure that people who self-harm, and their families, carers and significant others where this is agreed with the person, have access to the 'Understanding NICE guidance' booklet for this guideline and for the short-term management of self-harm (NICE clinical guideline 16).
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. In addition:
- 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.
- Therapists should also be able to work collaboratively with the person to identify the problems causing distress or leading to self-harm.
Do not offer drug treatment as a specific intervention to reduce self-harm.
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 where this has been agreed with the service user, 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, for example those described in the following published NICE guidance:
When prescribing drugs for associated mental health conditions to people who self-harm, take into account the toxicity of the prescribed drugs in overdose. For example, when considering antidepressants, selective serotonin reuptake inhibitors (SSRIs) may be preferred because they are less toxic than other classes of antidepressants. In particular, do not use tricyclic antidepressants, such as dosulepin, because they are more toxic.