Transcript Self-harm and Suicide

Working with Young People:
Self-harm and Suicide
A local, multi-disciplinary approach to supporting children and young people in Cheshire
and Merseyside
Join the conversation
#STORMevent
Working with Young People
Self-Harm and Suicide
7th October 2015
Birchwood Conference Centre
Warrington
Dr Gemma Trainor
Consultant Nurse
Clinical Lead for Tier 4
Day & Out Patient Clinic
The FACTS
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Major public health problem
UK has the highest rates in Europe
Used to be a rare event 12
19,000 adolescents admitted to general hospitals per annum
– only 1 in 8 present to hospital (Hawton et al 2010)
• Major girls aged 12 to 15years,
• Boys 4 x use drugs & alcohol commit suicide
• It is the second of death in young people
• It is a marker for completed suicide
FACTS Cont’d
• 14.9 million children under 20 in UK (25%)
• 20% of children & adolescents experience
psychological difficulties
• Clear consensus that there has been a substantial
increase in psychological difficulties since Second
World War
• Recent statistics from Samaritans shows increase in
self-harming – 1 in 10
• 20% of CAMHS referrals in the UK are for self-harm
Difficulties in the management
of self-harm in young people
• Difficult to reach
• Present in crisis / drop out of treatment
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Co-morbidity /
co –existing problems
• Expensive, consume resources – Therapeutic
communities
• Little evidence of effective treatments
• Lack of containment in the whole system
• Protracted inpatient admissions can be counter
therapeutic
The Dilemmas with Definitions
• Not possible to arrive at a universally accepted
definition
• Self-harm/suicide are often used interchangeably
confusion for professionals researchers and young
people
• Often self-harm is not about ending life and move
about regulating emotions and survival
• Self-harm and suicide have differing endpoints
• However, self-harm is a common precursor to suicide
Continuum of Suicidality
• Suicidal Ideation
• Self-injury, non suicidal self injury (NSSI) (Nock et al 2009) non
suicidal injurious behaviour (NSIB)
• Self poisoning – exclude accidental overdoses of recreational
alcohol and drugs
• Attempted suicide – Ligaturing
- Hanging
• Completed suicide
Unique act each time for the individual
Differing End Point
Terminology
• Direct self-harm – Suicide attempts, overdosing, hanging, humping, selfinjury, wrist an arm-cutting
• Indirect self-harm – substance abuse, eating disorders, risk-taking
behaviour
• Deliberate self-injury – perceived as a pejorative term by service users
• Non-suicidal Self-injury (NSSI) – Deliberate destruction of one’s own body
tissue in the absence of intent to die (Nock et at 2009)
• Non-suicidal self-injurious Behaviour (NSIB) – without conscious suicidal
intent
No one term absolutely or accurately defines all acts. Therefore “intent”
needs to be ascertained. Young People are encouraged to describe the
behaviour and their motivations in detail in their own words.
Reasons for self-injury
• “I wanted to get relief from a terrible state of mind”
(72.89%)
• “I wanted to die” (52.8%)
• “I wanted to punish myself” (46.3%)
• “I wanted to frighten someone” (21%)
• “I wanted some attention” (24%)
• “I wanted to find out whether someone loved me”
(31.3%)
• “I wanted to get my own back on someone” (14.3%)
Hawton et al 2002
The Way Forward
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Early intervention proactive vs reactive
Focus on high risk groups
Establish which Factors contribute to contagion
Effects of new media on self-harm
Developing better understanding of individual meanings
of self-harm
• Strong crisis management / self management techniques
• Individualised collaborative security plans shared with
Multi Disciplinary Team
• Containment
Working with Young People:
Self-harm and Suicide
A local, multi-disciplinary approach to supporting children and young people in Cheshire
and Merseyside
Join the conversation
#STORMevent
Evidence-based approaches to
helping young people who self-harm
Prof Steven Pryjmachuk
School of Nursing, Midwifery & Social Work
Sources of evidence/guidance
• National Institute of Health & Clinical Excellence (NICE)
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CG16 on short-term management, 2004; currently ‘static’
CG133 on longer-term management, 2011
• Social Care Institute for Excellence (SCIE)
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Research Briefing 16 and 17 considered risk and therapies in self-harm in young people but
haven’t been updated since 2005
Knowledge Review 22 (Kilpatrick et al 2008) looking specifically at residential care (cites
research that 39% have felt or thought about killing themselves within last month)
• Department for Education (DfE)
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Departmental advice for school staff on mental health and behaviour in schools (March 2015)
has some very limited information about self-harm
Funded the PSHE Association’s Teacher Guidance on MH and Emotional Wellbeing (2015)
• The research literature
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Children and Yong People’s Mental Health relatively under-researched
Risk assessment and management
• Can be an art more than a science but high levels of distress (in the YP or
carers), repetition, and unresponsiveness to intervention are indicators
of increased risk
• Personal resources (resilience, coping strategies) can mitigate risk
• Safeguarding issues
• RCPsych (2014) recommend a ‘developmentally sensitive and riskproportionate’ approach with 16-17 year olds
• NICE guidance: (in the initial management of self-harm) ‘advise parents and
carers of the need to remove all medications or, where possible, other
means of self-harm’ (NICE 2011)
SERIOUS SELF-HARM IS
A MEDICAL EMERGENCY
THAT MAY REQUIRE
ADMISSION TO A&E
NICE guidance for the short term management of self harm kicks in
(CG16, NICE 2004)
RCPsych (2014) also has useful advice here
Individual therapies
• Cognitive-behaviour therapy (CBT): has some value in adolescent
depression though Goodyer et al (2007) found no benefit in combining CBT
with an SSRI over an SSRI alone
• Dialectical Behaviour Therapy (DBT): some limited, emerging evidence
that DBT may be useful with young people who self-harm (James et al 2008)
• Other approaches: e.g. ‘green card’ system, ‘emergency boxes’, ‘no-suicide’
contracts’ – some hints they help some YP but no substantive evidence;
harm minimisation (‘safe’ self-harming) controversial and lacks evidence
• NICE guidance: NICE (2011) recommend 3-12 sessions of a psychological
intervention (e.g. CBT, psychodynamic or problem solving approaches)
tailored to individual need
Family and group therapies
• Small amount of evidence for family therapy (Wolpert et al, 2006)
• Brief, home-based family therapy – social work approach; a large RCT
(Harrington et al, 1998) showed no benefit over routine care
• Systemic family therapy – SHIFT trial (due for completion Oct 2016)
• Developmental group therapy: an eclectic approach; exploratory trial
(Wood et al, 2001) showed positive results but these not replicated in larger
trials
• NICE (2011) and RCPsych (2014) suggest it may be useful to involve
parents and other family members in treatment
Medication
• SSRIs: treating depression in young people with SSRIs is controversial
(Cotgrove and Timini debate in the BMJ in October 2007)
• Depot flupenthixol: some promising results in adults but no evidence to
support its use in YP.
• NICE guidance: ‘Do not offer drug treatment as a specific intervention to
reduce self-harm’ (NICE 2011)
Summary of the evidence
Evidence for effective therapies in self-harm in young people
is pretty limited …
… however, the research, together with consultations with
young people (e.g. Truth Hurts, NIHR research, local
consultations), can offer some practical guidance for helping
young people who self-harm …
Take home messages
• In the absence of robust evidence for the effectiveness of interventions,
NICE, RCPsych and DfE (PSHE Association) guidance offer the most value
to professionals
• Stigma surrounding self-harm (and MH issues) in YP needs to be reduced
• YP’s perspectives are often (very) different to those of adults and need to
be taken seriously
• It’s OK for professionals to ask about self-harm; indeed, it is necessary for
accurate and thorough risk assessment
• Staff and environments need to be YP-friendly, flexible and accessible;
ongoing support is important
Take home messages
• Hospital may be the safest place for a YP but it can run the risk of
‘contagion’ (RCPsych ‘risk-proportionate’ approach in 16-17 year olds means
admission may not be appropriate in this age group)
• Self-care can play a role but it needs to be supported by expert facilitators;
in any case, YP should be actively involved in their care
• Peer support can play an important role
• The Internet is not necessarily a dangerous place (RCPsych recommend an
assessment of a YP’s ‘digital life’)
• Multi-agency approaches underpin best practice
Working with Young People:
Self-harm and Suicide
A local, multi-disciplinary approach to supporting children and young people in Cheshire
and Merseyside
Join the conversation
#STORMevent