Principles for assessment and care by healthcare professionals and social care practitioners

1.7.1.

When a person presents to a healthcare professional or social care practitioner following an episode of self-harm, the professional should:

• treat the person with respect, dignity and compassion, with an awareness of cultural sensitivity
• establish the means of self-harm and, if accessible to the person, discuss removing this with therapeutic collaboration or negotiation, to keep the person safe
• assess whether there are concerns about capacity, competence, consent or duty of care, and seek advice from a senior colleague or appropriate clinical support if necessary; be aware and accept that the person may have a different view and this needs to be taken into account
• seek consent to liaise with those involved in the person’s care (including family members and carers, as appropriate) to gather information to understand the context of and reasons for the self-harm
• discuss with the person and their families or carers (as appropriate), their current support network, any safety plan or coping strategies.

1.7.2.

When a person presents to a healthcare professional or social care practitioner following an episode of self-harm, the professional should establish the following as soon as possible:

• the severity of the injury and how urgently medical treatment is needed
• the person’s emotional and mental state, and level of distress
• whether there is immediate concern about the person’s safety
• whether there are any safeguarding concerns
• whether the person has a care plan
• if there is a need to refer the person to a specialist mental health service for assessment.

1.7.3.

Carry out concurrent physical healthcare and the psychosocial assessment as soon as possible after a self-harm episode.

1.7.4.

For immediate first aid for self-poisoning, see the BNF’s guidance on poisoning, emergency treatment, TOXBASE and the National Poisons Information Service.

1.7.5.

Do not use aversive treatment, punitive approaches or criminal justice approaches such as community protection notices, criminal behaviour orders or prosecution for high service use as an intervention for frequent self-harm episodes.

Assessment and care in primary care

1.7.6.

When a person presents in primary care after an episode of self-harm, consider referring them to mental health or social care services for a psychosocial assessment or informing their existing mental health team, with consent from the person and their family members or carers (as appropriate).

1.7.7.

Make referral to mental health professionals a priority when:

• the person’s levels of concern or distress are rising, high or sustained
• the frequency or degree of self-harm or suicidal intent is increasing
• the person providing assessment in primary care is concerned
• the person asks for further support from mental health services
• levels of distress in family members or carers of children, young people and adults are rising, high or sustained, despite attempts to help.

1.7.8.

If the person who has self-harmed is being supported and given care in primary care, their GP should ensure that the person has:

• regular appointments with their GP for review of self-harm
• a medicines review
• information about available social care, voluntary and non-NHS sector support and self-help resources
• care for any coexisting mental health problems, including referral to mental health services as appropriate.

Assessment and care by ambulance staff and paramedics

1.7.9.

When attending a person who has self-harmed but who does not need urgent physical care, ambulance staff and paramedics should:

• discuss with the person the best way that the ambulance service can help them
• follow the person’s care plan and safety plan if available
• seek advice from mental health professionals, where necessary
• record relevant information about the following, and pass this information to staff if the person is conveyed, or share it with other relevant people involved in the person’s ongoing care if the person is not being conveyed:

  –

  home environment

  –

  social and family support network

  –

  history leading to self-harm

  –

  initial emotional state and level of distress

  –

  any medicines found at their home.

1.7.10.

When attending a person who has self-harmed but who does not need urgent physical care, ambulance staff and paramedics should discuss with the person (and any relevant services) if it is possible for the person to be assessed by or receive treatment from an appropriate alternative service, such as a specialist mental health service or their GP.

1.7.11.

When deciding whether the person can receive treatment from an appropriate alternative service, ambulance staff and paramedics should assess immediate safety concerns, as well as the availability and accessibility of alternative services at that time.

Assessment and care by non-mental health emergency department professionals

1.7.12.

When a person attends the emergency department or minor injury unit following an episode of self-harm, emergency department staff responsible for initial assessment or triage should establish the following as soon as possible:

• the severity of the injury and how urgently physical treatment is needed
• the person’s emotional and mental state, and level of distress
• whether there is immediate concern about the person’s safety
• whether there are any safeguarding concerns
• the person’s willingness to accept medical treatment and mental healthcare
• the appropriate nursing observation level
• whether the person has a care plan.

1.7.13.

When a person attends the emergency department or minor injury unit following an episode of self-harm, offer referral to age-appropriate liaison psychiatry services, or for children and young people, crisis response service (or an equivalent specialist mental health service or a suitably skilled mental health professional) as soon as possible after arrival, for a psychosocial assessment (see the section on psychosocial assessment and care by mental health professionals and the section on risk assessment tools and scales), and support and assistance alongside physical healthcare.

1.7.14.

An age-appropriate liaison psychiatry professional or a suitably skilled mental health professional should see and speak to the person at every attendance after an episode of self-harm.

1.7.15.

Ensure that the emergency department has a private, designated area for psychosocial assessments to take place, where it is possible to speak in confidence without being overheard.

1.7.16.

Ensure that the waiting area in the emergency department for people who have self-harmed is close to staff who can provide care, support and observation.

1.7.17.

Ensure that appropriate joint governance arrangements are in place so that physical and mental healthcare can be delivered together in emergency departments. This should include:

• access to electronic record systems for both mental health services and medical treatment at the point of care
• jointly agreed referral pathways for concurrent physical and mental healthcare
• jointly agreed approaches to initial assessment and triage
• monitoring of the use of mental health law and mental capacity law
• joint safeguarding procedures
• jointly agreed nursing observation policies
• referral pathways to appropriate community services.

1.7.18.

Do not use mechanical restraint in emergency departments to prevent self-harm or to prevent a person from leaving the emergency department.

Also see the NICE guideline on violence and aggression for recommendations about mechanical restraint.

1.7.19.

Ensure that policies and procedures are in place for people who have self-harmed who wish to leave, or have left, the emergency department before physical healthcare and mental health assessment and care is complete.

1.7.20.

Ensure that policies and procedures are in place to identify people who frequently attend the emergency department or minor injury unit following an episode of self-harm so that a multidisciplinary review can be arranged in collaboration with mental health services (see recommendation 1.5.17 in the section on psychosocial assessment and care by mental health professionals).

Assessment and care in general hospital settings

1.7.21.

When a person is admitted to hospital following an episode of self-harm, offer referral to age-appropriate liaison psychiatry services (or an equivalent specialist mental health service or a suitably skilled mental health professional) as soon as possible after admission for a psychosocial assessment (see the section on psychosocial assessment and care by mental health professionals and the section on risk assessment tools and scales), and support and assistance alongside physical healthcare.

1.7.22.

An age-appropriate liaison psychiatry professional or a suitably skilled mental health professional should see and speak to the person at every admission after an episode of self-harm.

1.7.23.

Mental health and acute ward staff should jointly decide the need for close observation on a case-by-case basis, taking into account the person’s views and ensuring that observation is:

• by appropriately skilled and trained healthcare staff
• with the informed consent of the person or within an appropriate legal framework
• reviewed regularly.

1.7.24.

Children and young people who have been admitted to a paediatric ward following an episode of self-harm should have:

• access to a specialist child and adolescent mental health service (CAMHS or children and young people’s mental health services [CYPMHS]) or age-appropriate liaison psychiatry 24 hours a day
• a joint daily review by both the paediatric team and children and young people’s mental health team
• daily access to their family members or carers
• regular multidisciplinary meetings between the general paediatric team and mental health services.

Assessment and care in social care

1.7.25.

When working with people who have self-harmed, social care practitioners should foster a collaborative approach with all agencies involved in the care of the person, as well as their family members and carers, as appropriate.

1.7.26.

If self-harm has been identified during a social care assessment or through ongoing work, seek advice from, or refer the person to, the local urgent and emergency mental health service.

1.7.27.

Continue to offer social care support and involvement to a person who has self-harmed, particularly if the person may be looked after or have ongoing social care needs.

Also see the NICE guidelines on domestic violence and abuse, looked-after children and young people, child abuse and neglect and child maltreatment.

Principles for assessment and care by professionals from other sectors

1.8.1.

When a person who has self-harmed presents to a non-health professional, for example, a teacher or a member of staff in the criminal justice system, the non-health professional should:

• treat the person with respect, dignity and compassion, with an awareness of cultural sensitivity
• work collaboratively with the person to ensure that their views are taken into account when making decisions
• address any immediate physical health needs resulting from the self-harm, in line with locally agreed policies; if necessary, call 111 or 999 or other external medical support
• seek advice from a healthcare professional or social care practitioners, which may include referral to a healthcare or mental health service
• ensure that the person is aware of sources of support such as local NHS urgent mental health helplines, local authority social care services, Samaritans, Combat Stress helpline, NHS111 and Childline, and that people know how to seek help promptly
• address any safeguarding issues, or refer the person to the correct team for safeguarding.

1.8.2.

When a person presents to a non-health professional, for example, a teacher or a member of staff in the criminal justice system, the non-health professional should establish the following as soon as possible:

• the severity of the injury and how urgently medical treatment is needed
• the person’s emotional and mental state, and level of distress
• whether there is immediate concern about the person’s safety
• whether there are any safeguarding concerns
• whether the person has a care plan
• if there is a need to refer the person to a specialist mental health service for assessment.

Assessment in schools and educational settings

1.8.3.

Educational settings should have policies and procedures for staff to support students who self-harm. These should include:

• how to identify self-harm behaviours
• how to assess the needs of students
• what do to if they suspect a student is self-harming
• how to support the student’s close friends and peer group.

1.8.4.

Educational settings should have a designated lead responsible for:

• ensuring that self-harm policies and procedures are implemented
• ensuring that self-harm policies and procedures are regularly reviewed and kept up-to-date in line with current national guidance
• ensuring that staff are aware of the self-harm policies and procedures and understand how to implement them
• supporting staff with implementation if there are any uncertainties.

1.8.5.

All educational staff should:

• be aware of the policies and procedures for identifying and assessing the needs of students who self-harm
• know how to implement the policies and procedures within their roles and responsibilities
• know who to go to for support and supervision.

1.8.6.

For students who have self-harmed, the designated lead should seek the advice of mental health professionals to develop a support plan with the student and their family members and carers (as appropriate) for when they are in the educational setting. This should include guidance from other agencies involved in the person’s care, as appropriate.

1.8.7.

Educational staff should take into account how the student’s self-harm may affect their close friends and peer groups, and provide appropriate support to reduce distress to them and the person.

Assessment and care in the criminal justice system and other secure settings

1.8.8.

Staff in criminal justice settings and other secure settings such as immigration removal centres should be aware that those in their care have higher rates of self-harm and suicide.

1.8.9.

Staff in criminal justice settings and other secure settings such as immigration removal centres should be aware of support services available to them to support their own wellbeing.

1.8.10.

Staff in criminal justice settings and other secure settings such as immigration removal centres should be aware of arrangements for:

• transferring people to a healthcare setting when necessary
• in-reach or onsite support
• their responsibilities for information sharing
• how to access health services.

1.8.11.

Staff in criminal justice settings and other secure settings such as immigration removal centres should follow local guidance on assessing people who have self-harmed, and healthcare professionals and social care practitioners in these settings should also follow the NICE guideline on mental health of adults in contact with the criminal justice system.

1.8.12.

Staff in criminal justice settings and other secure settings such as immigration removal centres should ensure that people who have self-harmed have a safe location to await assessment or treatment following an episode of self-harm.

Harm minimisation

Although ways to self-harm safely are often considered a harm minimisation strategy, this guideline does not make any recommendations about the use of safer self-harm.

1.11.11.

If a person is engaged in ongoing care and treatment but is not yet in a position to resist the urge to self-harm, only consider harm minimisation strategies:

• in the spirit of hope and optimism, and to reduce the severity and/or recurrence of injury
• as part of an overall approach to the person’s ongoing recovery-focused care and support, and not as a standalone intervention and
• after being discussed and agreed in a collaborative way with the person and their family members or carers (as appropriate), and the wider multidisciplinary team.

1.11.12.

Mental health professionals should discuss with the person harm minimisation strategies that could help to avoid, delay or reduce further episodes of self-harm and reduce complications, for example:

• distraction techniques or coping strategies
• approaches to self-care
• wound hygiene and aftercare
• providing factual information on the potential complications of self-harm
• the impact of alcohol and recreational drugs on the urge to self-harm.

1.11.13.

Be aware that harm minimisation strategies may not be appropriate for all people who self-harm.

Therapeutic risk taking

1.11.14.

Therapeutic risk taking should only be used after a psychosocial assessment (see the section on psychosocial assessment and care by mental health professionals), and should:

• use shared decision making, to ensure that the person is able to make an informed choice at all stages, and include family and carers, as appropriate
• include other relevant professionals involved in the care of the person who has self-harmed
• draw on the person’s strengths and coping strategies and what matters to them
• focus on positive outcomes
• be part of an ongoing assessment to revisit the decision
• be concurrent with psychiatric care if necessary.

Why the committee made the recommendations

There was evidence on the information that people who had self-harmed and their family members and carers want to receive, and how they want to receive it. The committee based the recommendations on the evidence, their knowledge and experience, and the NICE guidelines on patient experience in adult NHS mental health services, and patient experience in adult NHS services.

Much of the evidence on the information needs of people who had self-harmed was consistent with that of family and carers, who want information about self-harm to be shared with them. However, there was conflicting evidence about whether people want information to be shared with family members. The committee agreed that information should be available to the person’s family and carers where appropriate and in agreement with the person.

There was evidence that family members and carers have additional information and support needs specific to their experience that are often unmet. The committee agreed that further information and support should be provided to family members and carers as appropriate.

There was evidence that people who had self-harmed and their family and carers perceived support (or a lack of it) based on how they had been communicated with, and that they value support from a range of sources. There was also evidence that people who had self-harmed value information that is specific to their circumstances, and the committee agreed that information should be tailored to the individual. The evidence also suggested that people and their family and carers find it difficult to get the information or support they need.

The committee discussed existing NICE guidelines that have important information about how to appropriately provide information and support to people and agreed that the guidelines are relevant for people who have self-harmed.

The recommendation that people from protected groups should have additional support was based on the committee’s experience and knowledge that forms of discrimination are often causal factors for self-harm.

How the recommendations might affect practice

The recommendations should make it easier for people who have self-harmed and their family members and carers to get support and information after an episode of self-harm, and reduce the variation in the information provided. It should also lead to a higher quality of care.

The impact for providers will vary according to what information and support they currently offer. The recommendations may mean that providers need to change the information they give, but the cost should be minimal and will result in people who self-harm and their family and carers being better informed about self-harm and their care options. The recommendations may mean that family members seek further care for themselves more frequently than they currently do, but it is difficult to estimate the effect this will have on practice.

Return to recommendations

Why the committee made the recommendations

There was no evidence so the committee based the recommendations on their knowledge of current best practice as well as existing guidance and protocols. Without evidence, the committee could not be more specific about how consent and confidentiality should be considered specifically for people who have self-harmed.

The committee agreed that existing guidance covers any issues that might arise about consent and assessing capacity to consent in children and young people of different ages. Staff should be aware of these principles while still feeling empowered to seek additional advice, and to feel confident in situations when consent to care may not be given. The committee also agreed that access to independent mental capacity advocates (IMCAs) would allow the person who has self-harmed to feel confident about decisions about their care.

The committee discussed the risk of legal repercussions for staff either when making decisions about a person’s care without their consent or when breaching confidentiality. They recommended that staff have access to experienced colleagues for advice at all times, and to legal advice as needed to allow them to provide care with confidence.

The recommendation about the limitations of confidentiality was based on the consensus statement from the National Suicide Prevention Strategy Advisory Group, which states that confidentiality can often be a barrier to information sharing, to the detriment of other staff members and family members and carers. The committee agreed that confidentiality could also limit collaboration between staff across different clinical settings.

The committee agreed that sharing information about a person’s care with family members and carers has multiple benefits that often improve outcomes, such as allowing the person to receive appropriate care outside of clinical settings. The committee discussed the risks attached to information sharing and agreed it is still necessary to seek consent from the person, especially before sharing information with family members and carers. This was supported by qualitative evidence from review for involving family members and carers, that family members and carers want to be more involved in the management of self-harm, whereas people who have self-harmed find information sharing without their consent to be a breach of trust.

The committee discussed the risks of breaching confidentiality and agreed that it can lead to feelings of disempowerment and further distress for the person who has self-harmed. The committee therefore agreed that the person should still be included in decisions after confidentiality has been breached, and if possible, be informed about this decision to promote autonomy.

How the recommendations might affect practice

These recommendations are in line with existing recommended practice, and should result in easier access to legal advice and better awareness of the benefits of information sharing.

Return to recommendations

Why the committee made the recommendations

The recommendations are based on the committee’s knowledge of current best practice, as well as existing guidance on safeguarding in healthcare. The committee agreed that staff should always consider whether such concerns exist for children and adults who have self-harmed, and be prepared to follow safeguarding procedures when necessary. This will enable staff to intervene in situations where safeguarding is a concern to reduce the risk of further harm to the person.

The committee agree that a multi-agency approach to safeguarding would promote collaborative working between different sectors, allowing for information sharing and therefore improving the service provided to the person.

How the recommendations might affect practice

These recommendations are in line with existing recommended practice, but may also enable better communication and transitions across services through multi-agency approaches.

Return to recommendations

Why the committee made the recommendations

There was conflicting evidence on if and how family members and carers should be involved in the support and treatment of people who have self-harmed. The evidence showed both potential harms and benefits, so the committee based the recommendations on the evidence and their own knowledge and experience. The committee agreed that because involving family members and carers is linked to issues around consent and confidentiality, the recommendations should be read in conjunction with the recommendations on consent and confidentiality.

There was good evidence that involving family members and carers can have a positive effect on care and that a collaborative approach to care is helpful as long as the person continues to consent to their family and carers’ involvement. The committee recognised that there may be circumstances where involving family members or carers is not appropriate, so agreed that involvement should be encouraged and accommodated where appropriate, after taking into account the person’s preferences and capacity, and the potential harms and benefits.

There was also evidence that family members, school staff and healthcare professionals value two-way communication to enable information sharing about any changes in the life or treatment of the person who has self-harmed.

The committee highlighted if the person has not given consent, family and carers can still share information with healthcare professionals, which can provide helpful insights to make a holistic assessment of, and base their professional judgements on, the needs of the person who has self-harmed.

There was evidence that people who had self-harmed and their family and carers value being able to communicate using non-verbal means. The committee agreed that this can encourage positive communication because it can often be difficult for the person to express their needs when they are very distressed. The use of non-verbal forms of communication can reduce the need for the person to explain how they are feeling, and help to build the initial therapeutic rapport and understanding of the person’s needs.

How the recommendations might affect practice

These recommendations should make it easier for healthcare professionals to recognise when it is appropriate to involve family members and carers in the care of people who have self-harmed, and allow people who have self-harmed to make decisions about the involvement of family and carers. They should also enable family members and carers to be involved in care in a way that is collaborative and helpful for the person who has self-harmed.

Providers may need to change how they involve family members and carers, but the costs are expected to be small and will result in a higher quality of care for people who self-harm.

Return to recommendations

Why the committee made the recommendations

The recommendations are based on the available evidence, but because of concerns over the quality and scarcity of evidence, most are based on the committee’s knowledge and experience.

There was evidence that an assessment model incorporating therapeutic elements such as identification of the target problem has a positive effect on satisfaction. The committee agreed the factors to take into account in the psychosocial assessment, and what it should include.

The committee agreed that delaying a psychosocial assessment could result in the person receiving inappropriate treatment. They discussed that if the person is not able to meaningfully engage in the assessment (for example, if the person is unconscious or has very high levels of intoxication), they should be regularly reviewed so that it can take place as soon as appropriate, and that any care plan should always be followed to optimise the psychosocial assessment.

The committee agreed that breathalysers and blood alcohol tests do not accurately assess the ability of a person to meaningfully engage with an assessment, and could be used to wrongly deny someone an assessment.

The committee agreed that care plans should be followed where possible to ensure a higher standard of care and inform the assessment, including whether certain questions should be prioritised.

There was evidence that people value privacy and having a safe and trusted environment when discussing self-harm.

The committee agreed the self-harm functions and factors to explore. The committee agreed these would allow coexisting conditions to be taken into account and enable staff to provide a higher quality of care. The committee also agreed that using the psychosocial assessment to develop a care plan could have a positive impact on the person’s engagement with follow-up. Qualitative evidence was consistent with the committee’s agreement that including family and carers in the person’s care has a positive impact.

The committee agreed that children, young people, older adults and people with learning disabilities should be assessed by staff with appropriate experience to ensure a higher standard of care. They also agreed that there are additional factors to consider for children, young people and older adults, which would enable the assessment to be more individualised.

The committee discussed that briefly assessing the person if they chose to leave before a full assessment had taken place could prevent repeat self-harm or attempted suicide.

The committee agreed that providing the person with a copy of their care plan would increase transparency and improve trust. Additionally, the committee agreed that providing any other relevant healthcare professionals and social care practitioners with the care plan would ensure that all staff are up-to-date about the person’s preferences, improving the quality of their care and their transition between services.

There was insufficient evidence for the committee to define how frequent attendance for self-harm would have to be to trigger a multidisciplinary review. However, the committee agreed that this recommendation was still important based on their knowledge that the individual circumstances of the person, including whether they are continuing to self-harm, should be assessed to evaluate whether a multidisciplinary review is necessary. The committee agreed that a multidisciplinary review should enable staff to reconsider current care, finding the most suitable care approach for the person and therefore preventing further repeat self-harm.

How the recommendations might affect practice

The recommendations should change how psychosocial assessments are conducted, to reduce the potential for distress during assessment and improve the person’s satisfaction and engagement with services. The recommendations should also allow for more involvement of family members and carers when appropriate, which could result in better quality care.

Most of the recommendations are based on existing recommended practice with some additional considerations that should have a minimal effect on costs, depending on how services currently assess people who have self-harmed.

Return to recommendations

Why the committee made the recommendations

The committee agreed that risk assessment tools and scales cannot accurately predict risk of self-harm or suicide, and that determining access to treatment or hospital admission based on inaccurate risk assessment tools could lead to repeat self-harm, distress and lower patient satisfaction.

The committee agreed that the potential harms of risk stratification, including the implication that risk is static instead of dynamic, outweigh any benefits it has as a clinical communication tool or an adjunct to clinical assessment, so agreed that risk stratification should not be used.

The committee agreed that assessment of a person’s needs, vulnerabilities, and safety should be a part of every assessment and that ‘risk’ should not be used to determine care management in isolation of other factors. They agreed that all staff should use their clinical judgement when assessing someone who has self-harmed and they should refer to the non-specialist assessment recommendations for what to do in the event they are concerned about the person and their safety. Additionally, mental health staff should conduct a risk formulation to place the person’s safety considerations in context with their strengths and difficulties.

How the recommendations might affect practice

The recommendations should change how assessments are conducted to take into account the person’s needs and safety as standard and reduce reliance on assessment of a person’s ‘risk’ in isolation of other factors. This should result in a reduction in the occurrence of arbitrary thresholds being used to determine access to care.

Risk assessment tools and scales are still used in some settings to determine access to treatment and care. The recommendations might have an initial effect on costs, depending on how services currently assess people who have self-harmed; however, service provision should already be determined by a person’s needs rather than risk thresholds. Additionally, the change in practice should result in lower costs over time because people will receive the care they need rather than have it determined by unreliable risk tools and scales, potentially reducing repeat self-harm.

Return to recommendations

Why the committee made the recommendations

There was no evidence, so the committee made recommendations mostly based on their knowledge and experience, supplemented by qualitative evidence from the reviews on information and support needs, and staff skills. They agreed it is important to give advice about assessment and care in different settings, but the lack of evidence meant they were unable to be more specific.

The committee made a recommendation for research on the most effective approaches to assessment in non-specialist settings to better inform future guideline development. Because of a lack of evidence, the committee also made a recommendation for research on models of care for children and young people who self-harm.

How the recommendations might affect practice

The recommendations should change the way in which assessments are conducted in a range of settings, to reduce the potential for distress after self-harm and improve the person’s satisfaction and engagement with services.

Most of the recommendations are based on existing best practice with some additional considerations that should have a minimal effect on costs, depending on how services currently assess people who have self-harmed. The recommendation that people who have self-harmed should have access to age-appropriate liaison psychiatry in emergency departments and general hospital settings should not have a cost or resource impact because this should already be standard practice.

Return to recommendations

Why the committee made the recommendations

There was no evidence, so the committee based the recommendations on their knowledge and experience. They agreed it is important to give advice about assessment and care in different settings, but the lack of evidence meant they were unable to be more specific.

The committee made a recommendation for research on the most effective approaches to psychosocial assessment in non-specialist settings to better inform future guideline development.

How the recommendations might affect practice

The recommendations should change the way in which assessments are conducted in a range of settings to reduce the potential for distress after self-harm and improve the person’s satisfaction and engagement with services. The recommendations should also allow for better communication between services, including between non-health and healthcare settings.

Most of the recommendations are based on existing best practice with some additional considerations that should have a minimal effect on costs, depending on how services currently assess people who have self-harmed.

Return to recommendations

Why the committee made the recommendations

The evidence showed that there were no significant short- or long-term differences in repeat self-harm by poisoning, regardless of whether people were admitted to hospital or discharged home. There was no evidence for other types of self-harm or other outcomes. The recommendations are based on the available evidence and the committee’s experience and knowledge that admission to hospital carries a greater risk of distress to people of all ages than any potential benefit.

The committee agreed that despite the lack of evidence for the benefit of admitting people to hospital, in some cases it can be helpful to give the person time to recover or if there are safeguarding concerns.

If it is necessary to admit a young person who has self-harmed into hospital, the committee agreed that it can be distressing for them to be admitted to a ward that is not equipped to meet the needs of young people.

The committee agreed that treatment for physical injuries should never be used as a reason to delay or deny a psychosocial assessment because this would be considered malpractice, potentially resulting in heightened distress or neglect of the person’s other healthcare needs.

The committee discussed current practice about what happens when a person self-harms while in hospital, and agreed that full investigations should continue to be recommended when an incident occurs to consistently improve services and ensure that further incidents are prevented.

The committee also agreed that discharging a person before they had been assessed and a plan for further management drawn up could be detrimental because people who have self-harmed are likely to need further care and support. A lack of a plan could result in repeat self-harm or suicide, and would create a barrier to care for the person.

The committee made a recommendation for research on routine or automatic hospital admission for young people or adults to better inform future guideline development.

How the recommendations might affect practice

The recommendations should reduce variation in practice, and reduce the potential for distress because of any unnecessary admissions.

The recommendations could increase the number of beds available in hospitals and reduce overall costs related to overnight admissions to hospital for people who have self-harmed.

Return to recommendations

Why the committee made the recommendations

There was evidence that discharge protocols with enhanced initial aftercare provide important benefits such as increased engagement with services and treatment, and reduced rates of repeat self-harm compared with usual discharge. The committee based the recommendations on the evidence and their knowledge and experience that prioritising person-centred care and empowering people who have self-harmed to make decisions about their own care could improve service-user satisfaction and reduce distress or hopelessness. The committee agreed that any aftercare arrangements should be shared with the person, based on their knowledge that this is an important facet of collaborative care, and that providing contact details encourages engagement with care.

The committee discussed that people who have self-harmed are most likely to repeat self-harm within 2 to 3 days of their previous episode of self-harm. They discussed current best practice in line with the existing NICE guideline on transition between inpatient mental health settings and community or care home settings, which includes follow-up within 48 hours of presentation. Quantitative evidence was consistent with this, because it showed that telephone contact within 48 hours after discharge had a positive effect on service engagement. The evidence also found a possible important reduction in the number of suicide attempts for those receiving initial contact 3 days after discharge compared with those receiving initial contact within 7 days of discharge, although the different settings in which follow-up was conducted may also have affected the outcomes. Qualitative evidence from the review on information and support needs for people who have self-harmed also showed that people value proactive, prompt follow-up and find long waiting times frustrating. However, there were concerns about resourcing and capacity to provide initial aftercare to all patients within this timeframe. The committee agreed that, although follow-up within 48 hours would be ideal for everyone, not all people who have self-harmed will need immediate aftercare. To ensure priority is given to those who need it most, aftercare within 48 hours should be provided to people with ongoing safety concerns to reduce rates of repeat self-harm.

There was limited evidence that continuity of personnel has a positive effect on service engagement and repeat self-harm. The committee agreed, based on their experience, that continuity of personnel from initial assessment to aftercare allows people to gain familiarity with particular professionals, improving satisfaction and service engagement, and reducing the risk of distress or hopelessness. Evidence from the review on models of care showed that a continuity chain protocol has a possible important benefit in terms of engagement with services compared with usual care. The committee agreed that this is most important for people who have received treatment from a mental health service, based on their knowledge that the person who had self-harmed would have spent more time with mental health staff and may have built up trust with particular staff members, as well as evidence from the review on models of care, which showed that specialist community mental health follow-up has an important benefit in terms of self-harm repetition over 12 months.

How the recommendations might affect practice

The recommendations are mostly in line with current practice. They should lead to a reduction in people waiting for up to 72 hours for aftercare following presentation for self-harm. Providing initial aftercare within 48 hours for people if there are ongoing safety concerns should reduce repeat self-harm and suicide, and improve satisfaction and engagement with services. Any resource impact associated with this would be a worthwhile use of resources.

The recommendations for continuity of personnel may have a resource impact depending on how often the same staff members who have carried out an assessment or mental healthcare also carry out aftercare. Where this is not the case, there will be an increased workload for these healthcare professionals.

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Why the committee made the recommendations

The committee agreed that the psychosocial assessment should be used to develop a meaningful narrative that would inform the care plan. They agreed this would ensure that treatment for any coexisting conditions that could be linked to self-harm are prioritised, enabling healthcare professionals to provide the most appropriate intervention for the individual, and resulting in more person-centred, higher-quality care. The committee referred to a number of other NICE guidelines for conditions that can be linked to self-harm, and agreed it is important that healthcare professionals plan treatment for people who have self-harmed in line with the guidance for any underlying or coexisting conditions before other interventions are considered.

The evidence showed that psychotherapies informed by cognitive behavioural therapy (CBT) have positive effects on repetition of self-harm at long-term follow-up and on depression, hopelessness and suicidal ideation over time for adults. However, the evidence did not show an effect on repeat self-harm at other follow-up times. Additionally, the evidence was limited by the wide interpretation of ‘CBT-based psychotherapies’ as being inclusive of other types of therapies in addition to CBT, and the indistinct categorisation of all interventions throughout the evidence review. The committee agreed other therapies might be effective for adults who have self-harmed as long as they are informed by CBT, as indicated by the evidence.

The evidence also showed that dialectic behavioural therapy for adolescents (DBT-A) has a positive effect on repetition of self-harm at post-intervention for adolescents. However, the evidence was limited by the fact that participants in studies had all self-harmed more than once, were all older than 12 years and most were female, and there was no evidence of effect of DBT-A on repeat self-harm by 12-month follow-up. The committee extrapolated the evidence based on their confidence that DBT-A is likely to be similarly effective in younger children and boys as it is in over-12s and girls; however, the committee agreed they could not be sure that DBT-A would be similarly effective for children and young people who did not frequently self-harm.

The evidence for other therapies was uncertain, and the evidence for the effects of pharmacological interventions was limited. The pharmacological evidence showed an uncertain effect of newer-generation antidepressants or antipsychotics on repetition of self-harm for adults, and no evidence of effect for mood stabilisers or natural products on repetition of self-harm for adults. The recommendations are based on the available evidence and the committee’s knowledge and experience of the current practice of offering psychological or psychosocial interventions.

The committee agreed that any therapy offered should be delivered by staff with training in the relevant therapy and who are receiving appropriate supervision. This is to ensure the competence of the professional delivering the training allows for the needs of the person to be met and for the treatment to be tailored for people who self-harm. The committee agreed that further limitations on which staff could deliver therapies were unnecessary and could result in implementation difficulties and delays in treatment provision.

The recommendation that treatment should be offered without delay was based on the committee’s knowledge that delaying treatment could lead to further self-harm or suicide, and on evidence from the review on involving families and carers in the management of self-harm, which showed that long waiting times for treatment is often a barrier to seeking help.

The safety planning recommendations were based on the committee’s knowledge and experience that safety plans equip people who have self-harmed with the ability to identify and use their strengths and sources of support to overcome crisis moments and prevent repeat self-harm. This was supplemented by qualitative evidence from both staff skills reviews, which showed that individualised coping strategies are important to people who have self-harmed, and that specialist staff identified safety planning as an important technique to help manage self-harm. The committee considered the components of safety planning interventions from 3 studies included in the Cochrane review on psychosocial interventions, and used this evidence to recommend important aspects of safety plans that the committee agreed would prevent further self-harm.

The recommendations about how the safety plan should be implemented were based on the committee’s knowledge and experience that collaborative decision making improves engagement with services, and that ensuring a copy is available to the person emphasises this collaborative aspect. The committee agreed that sharing the care plan with family and friends when appropriate could provide the benefit of social connectedness between the person and their sources of support, which is a protective factor against self-harm. The committee agreed that safety plans should always be accessible to ensure that people receive the most appropriate care, especially if they are too distressed to remember their plan.

The committee agreed that psychological or psychosocial interventions should always be available for those who may need them, based on their knowledge and experience that exclusion from these services even when they are appropriate for the individual increases the potential for repeat self-harm or suicide.

The committee agreed, based on the uncertain evidence on pharmacological interventions and their knowledge and experience, that drug treatment is usually offered for other comorbidities such as depression, and should not be offered specifically for self-harm.

The committee made a recommendation for research on specific psychological interventions (digital and/or face-to-face) to better inform future guideline development.

How the recommendations might affect practice

The recommendations should increase the number of people receiving psychological interventions after an episode of self-harm, and reduce the number of people denied appropriate interventions because of limited or no availability. In turn, this should reduce repeat self-harm and suicide, and improve satisfaction and engagement with services. The recommendations should also ensure that a therapeutic risk-taking approach will not lead to the withholding of assessment or treatment for people who have self-harmed, potentially improving the quality of care provided, service user satisfaction, and reducing the rates of repeat self-harm or suicide.

The recommendations for specific therapies are likely to increase overall costs related to the provision of psychological interventions to people who self-harm, if CBT-informed psychological interventions and DBT-A are offered to more service users. The recommendation that psychological interventions should be available could also have a resource impact depending on how many centres do not currently offer these therapies. For those that do not, training and additional staffing may be needed for these interventions to be available to all service users. Using therapeutic risk-taking approaches is unlikely to increase overall costs; instead, approaches such as discharging patients from hospital where appropriate may have a positive resource impact on, for example, the availability of hospital beds.

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Why the committee made the recommendations

Where possible, the recommendations are based on evidence, but because of concerns over the quality and scarcity of evidence, the committee also used their knowledge and experience.

The committee discussed the evidence on the consistency and continuity of staffing, and agreed that this is a fundamental aspect of supporting people to be safe after self-harm because minimising the number of staff that people who have self-harmed see minimises distress and reduces the rates of repeat episodes of self-harm.

The committee discussed the limited evidence on observation for people who have self-harmed. They highlighted that observation could cause harm to people who have self-harmed if carried out by untrained clinical staff and if a therapeutic interaction is not established or maintained.

The committee discussed safety considerations when transferring between settings and agreed the importance of care plans being available to staff involved in their care in primary and secondary care and other settings to promote continuity of care.

There was limited evidence on the benefits of ensuring staff presence during periods in inpatient settings when rates of self-harm are higher. Using this and their knowledge and experience, the committee agreed that it is particularly important for staff to remain visible and accessible during handovers and busy periods to maintain continuity of care and ensure patient safety. By being visible, it minimises barriers between staff and patients, making it more likely that both parties can help and ask for help if needed.

Although it is important to ensure a safe physical environment for all mental health inpatients, the committee noted that a particular focus on safety is needed for people who have self-harmed. However, the committee agreed that safety considerations should not be prioritised over the person’s autonomy and dignity, and therefore the least restrictive measures should always be used, dependant on the safety of the person.

The committee agreed that staff should consider removing certain items from the environment, according to the individual’s specific needs and vulnerabilities. This could include sharp objects, potential ligatures and possible ligature points and things that might cause harm when ingested. However, the committee agreed that the need for this should be reviewed and only done when necessary to avoid excessive restrictions.

Although there was no evidence on the benefits of familiarising the patient with the procedures and physical environment of inpatient settings, the committee agreed that this is an important component of person-centred care, which should be carried out at the earliest opportunity to help reduce distress and the rate of repeat self-harm.

Although there was limited evidence, the committee highlighted the importance of all staff working in care settings knowing how to promptly raise concerns about people who have self-harmed. The committee agreed that open communication channels are important to ensure prompt responses to any signs of repeat self-harm.

How the recommendations might affect practice

These recommendations are in line with existing recommended practice, but they emphasise the importance of consistency and continuity of care and the therapeutic role of clinical observation. The recommendations may lead to trust-specific staff training in caring for people who have self-harmed.

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Why the committee made the recommendations

There was no evidence, so the committee based the recommendations on their knowledge and experience. The committee agreed that when prescribing medicines to people after an episode of self-harm, it is important to take into account the toxicity of the prescribed medicines, the likelihood of drug or alcohol misuse and interactions with prescribed treatment, and the person’s wider access to medicines prescribed for themselves or others, to limit the risk of overdose. They also agreed the need for effective communication when there are multiple prescribers.

The committee acknowledged the importance of shared decision making with people who have self-harmed when prescribing medicines in order to balance the risk of the person stockpiling medicines with their autonomy to improve patient satisfaction and adherence to medicines, and referred to the existing NICE guideline on shared decision making.

The committee agreed that a review of all current and any new medicines should be considered after an episode of self-harm. The committee identified that healthcare professionals could consider contacting the National Poisons Information Service for further advice and referred to the existing NICE guideline on medicines optimisation and STOMP-STAMP principles for people with learning disabilities or autism or both.

The committee agreed that when pharmacy staff are aware of warning signs and when healthcare professionals are prepared to use consultations to discuss self-harm, the opportunities for people to self-poison or overdose are reduced. The committee also agreed that the recommendations provide the chance for staff to enact safe prescribing principles.

The committee agreed that consultations and medicines reviews provide an opportunity for healthcare staff to assess self-harm, and therefore whether any existing or new medicines might be taken in overdose. This would allow for staff to amend any prescriptions as appropriate to reduce the potential for future self-poisoning.

How the recommendations might affect practice

These recommendations should improve safety for people after an episode of self-harm and improve person-centred care by involving people in decisions about safer prescribing practices.

For prescribers, these recommendations may mean that they review current prescriptions more routinely after an episode of self-harm with respect to the person’s risks of toxicity from overdose. For primary healthcare professionals, these recommendations may increase communication with healthcare professionals from other settings, such as specialist mental health centres and specialist pharmacies when prescribing and reviewing medications. Improved communication between healthcare professionals should limit variations in prescribing practices and improve continuity of care.

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Why the committee made the recommendations

The recommendations are based on the evidence from specialist and non-specialist staff, people who have self-harmed who have had care provided by specialist and non-specialist staff, and their parents and carers, which showed that there is a significant overlap between the kind of training considered important for both mental health and non-specialist professionals when working with people who have self-harmed.

Both reviews found that formal training on how to work with people who have self-harmed was considered important by all participants, so the committee agreed that all staff who work with people who self-harm should receive regular, ongoing training to address the areas where people felt their skills needed developing. The committee discussed the overlap between the specialist and non-specialist skills reviews and agreed that, although the evidence showed that similar skills are required by all staff, there would be different levels of skill required for each group of people. The committee agreed that the list of topics should be considered by those running the training to ensure the training would be appropriate to each professional’s level of responsibility, because it would be unreasonable and impractical to expect specialist and non-specialist staff to receive the same level of training.

The recommendation listing topics to cover in training was based on the evidence for the skills that both specialist and non-specialist staff need. The committee agreed that specialist staff should also receive additional training about how to conduct a psychosocial assessment and risk formulation.

The committee discussed using security staff for observation of people who have self-harmed, and agreed that this is not appropriate and usually results in people feeling intimidated and distressed. They agreed, based on their knowledge and experience, that training in observation methods that promote therapeutic engagement and rapport building would allow staff to undertake therapeutic observation in a way that is least distressing for patients.

How the recommendations might affect practice

These recommendations should increase the frequency of formal self-harm specific training for all staff. There may be cost implications associated with the provision of high-quality training depending on the current frequency of formal training deemed necessary within different settings.

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Why the committee made the recommendations

There was evidence that staff value different types of supervision for specific purposes, and the committee agreed recommendations on regular formal supervision and accessible ‘on-the-job’ support. The committee agreed that all staff should have the opportunity to access supervision that is distinct from general clinical supervision and case load management, but that staff who work with people who self-harm have a particular need for high-quality formal supervision and support. There was limited evidence to determine the regularity of formal self-harm supervision, and the committee agreed this would be decided on setting-specific factors, such as rates of self-harm, the acuteness of self-harm and available resources.

The committee highlighted that supervision should focus on ongoing skills development, because there was evidence that staff feel that they are not suitably trained or confident in caring for people who had self-harmed, especially in crisis situations. There was evidence that staff view reflective practice as an invaluable means to learn and improve their clinical practice; however, often this was not prioritised because of time and resource constraints. The committee agreed that formal self-harm supervision should aim to promote confidence and competence in staff when caring for people who self-harm, and this is particularly important for non-specialist staff who may feel less capable of managing difficult situations.

In addition to formal supervision, there was evidence that staff value having accessible and immediate support from senior colleagues. The committee were concerned that anxiety around fear of litigation in difficult situations could impact quality of care, and agreed that support for staff working with people who self-harm should reinforce lines of responsibility and provide advice to facilitate staff in making the most appropriate decisions.

There was evidence of the value placed on professional emotional support after an episode of self-harm or suicide, with staff describing how it helped them to process their experience and normalise their feelings and reactions and return to practice. The committee agreed that in their experience and expertise, it is often more appropriate for the member of staff to speak to someone removed from the situation and not necessarily their clinical supervisor, and agreed that all staff should have access to emotional support or emotional support services, as preferred by the member of staff, when requested.

How the recommendations might affect practice

These recommendations should increase the frequency of formal self-harm specific supervision for all staff. There may be cost implications associated with the provision of high-quality supervision depending on the frequency of formal supervision deemed necessary within different settings.

The recommendations on everyday supervision and support are in line with recommended practice but should help to foster a culture of supervision within all settings for staff working with people who self-harm. The committee discussed the cost implications of providing accessible emotional support or emotional support services to all staff and concluded that in most clinical settings, 24-hour support was already available.

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