Tackling self-harm:Tackling self-harm:challenges of needs challenges of needs

assessmentassessment

Stephen PlattStephen PlattRUHBC, University of EdinburghRUHBC, University of Edinburgh

Lanarkshire self-harm health needs Lanarkshire self-harm health needs assessment: stakeholder consultation assessment: stakeholder consultation

meetingmeetingHamilton, 16 July 2008Hamilton, 16 July 2008

Content of presentationContent of presentation

What is self-harm?How does self-harm differ from suicide and attempted suicide?Epidemiology of self-harmChoose Life and self-harmServices for people who self-harmTowards a framework for assessing need among people who self-harm

Definition of self-harmDefinition of self-harm

“Self-harm is [non-accidental] self-poisoning or self-injury, irrespective of the apparent purpose of the act”

NICE NICE National Clinical Practice Guideline Number 16, 2004

Common terms used to Common terms used to describe self-harm (NICE)describe self-harm (NICE)Deliberate self-harmDeliberate self-harm

Intentional self-harmIntentional self-harm

ParasuicideParasuicide

Attempted suicideAttempted suicide

Non-fatal suicidal behaviourNon-fatal suicidal behaviour

Self-inflicted violenceSelf-inflicted violence

Types of self-harmTypes of self-harm

Self-poisoning and self-injurySelf-injury also referred to as self-mutilation, self-injurious behaviour, non-suicidal self-injury, parasuicideSelf-injury is intentional harm to the outside of the body, often by cutting with a sharp object (most common)– also by burning, biting, hitting/punching,

banging (head), scratching, jumping from height, swallowing objects

Suicide, suicide attempt, Suicide, suicide attempt, self-harm: what’s in a self-harm: what’s in a

name? name? (1)(1)Suicide: an intentional (i.e. non-accidental) and fatal act of self-harmSome of these acts will have been intended to result in death, with high suicidal intent (“suicide attempt”)But some deaths classified as suicide may result from acts which were not intended to cause death or where the motivation (suicidal intent) was equivocalLikewise, some acts of self-harm may be intended to result in death but are foiled by, e.g., timely intervention (rescue) from others, imperfect knowledge, choice of method or some other reason

Suicide, suicide attempt, Suicide, suicide attempt, self-harm: what’s in a self-harm: what’s in a

name? name? (2)(2)Many (most?) acts of self-harm are not intended to end a person’s life (not “suicide attempt”)– Thus, not all self-harming behaviour should

be considered suicidal behaviourHowever, people who harm themselves are at increased risk of completing suicide on some subsequent occasionNevertheless, the vast majority of people who self-harm do not go on to take their own life

Epidemiology of self-harm Epidemiology of self-harm (1)(1)

Major source of information is hospital admission/ discharge data80-85% of presentations to A&E following self-harm are self-poisoningHowever, people who self-poison are more likely to seek help than those who self-injureEpisodes of self-harm leading to hospital admission are probably only a minority of all such episodesStudies of people who attend A&E paint a different picture about the prevalence of self-poisoning versus self-injury from studies of the general populationSelf-injury is more common than self-poisoning in the population, perhaps by a ratio of 2:1 among teenagers

Hospital admissions due to Hospital admissions due to intentional self-harm (Scotland, intentional self-harm (Scotland,

2006)2006) 4205 males (crude rate: 170/100,000)5560 females (crude rate: 210/100,000)

(Discharges from non-obstetric and non-psychiatric hospitals. Excludes A&E attendances that do not result in ‘admission’)

Epidemiology of self-harm Epidemiology of self-harm (2)(2)

A national interview survey suggests that between 4.6% and 6.6% of people in Great Britain have self-harmed (lifetime prevalence)However, even this may be an underestimateIn a school-based survey of 15/16 yr olds, lifetime prevalence of self-harm was 13% and annual prevalence was 7%Overall, women more likely to self-harm than men. Gender difference most pronounced in adolescence: girls may be three times more likely to self-harm than boysSelf-harm can occur at any age but is most common in adolescence and young adulthood

Choose LifeChoose Life and self-harm and self-harm (1)(1)

“This strategy includes only those aspects of self-harming behaviour which might be considered as an indication of risk of suicide. It is recognised that there are other dimensions and manifestations of deliberate self-harm that are not covered within the strategy’s scope.”

Choose Life strategy, page 12

Choose LifeChoose Life and self-harm and self-harm (2)(2)

Objective 1 (early prevention and intervention): “increasing the awareness of suicide, deliberate self-harm and suicidal risk factors”Objective 7 (knowing what works): “establishing … indicators on suicidal behaviour, the incidence of completed suicides, self-harm and other ‘at risk’ factors”NIST will “evaluate the National Strategy and Action Plan … monitoring trends in suicide and self-harm.”By March 2006 “national capacity for collection of data on suicide and self-harm [will be] established”“Perceived neglect of the complex issue of deliberate self-harm (DSH)” in the consultation document.– “Respondents identified the need to distinguish more clearly

between suicide [sic] and DSH.”

Choose LifeChoose Life and self-harm and self-harm (3)(3)

Possible interventions in relation to children and young people might include– actions to “equip teachers and other children

and young people’s workers with the knowledge, skills and training to enable them to talk openly about suicide and deliberate self-harm …”

– ensuring that those who deal with young people who self-harm (e.g. in A&E) are good at recognising those at risk of further self-harm”

Services for people who self-Services for people who self-harm: Penumbraharm: Penumbra

Penumbra provides range of person-centred Penumbra provides range of person-centred support services for people with mental health support services for people with mental health problems across Scotlandproblems across ScotlandOne of main organisations in Scotland working in One of main organisations in Scotland working in field of self-harm, especially 16-25 age groupfield of self-harm, especially 16-25 age groupUser-led support services to young people who User-led support services to young people who self-harm; also explore training and support self-harm; also explore training and support needs of parents, carers and professionalsneeds of parents, carers and professionals– AberdeenAberdeen– EdinburghEdinburgh– West Lothian (Hawthorn Project)West Lothian (Hawthorn Project)– North AyrshireNorth Ayrshire– Fife (early response service to people aged 18+ who Fife (early response service to people aged 18+ who

have been involved in recent self-harm incident)have been involved in recent self-harm incident)

Other self-harm projectsOther self-harm projects

The Corner (Dundee): offers wide range of health and information services to young people (11-25); address/investigate factors leading to mental health problems, self-harm and suicide in young peopleHazardous drinking screening in A&E (Highland): identifies people with hazardous drinking habits and provide timely support, especially when associated with self-harmLifelink (Glasgow): crisis intervention service for people aged 12+ who self-harm and/or are at risk of suicide; immediate front-line support, effective referral and thorough aftercareLife coaching project (Glasgow): peer support to vulnerable adults released from prison, with a view to reducing risk of suicide, attempted suicide and self-harm

Defining needDefining need

Many definitions of 'need' have been developed“It may be an illusion to suppose that there might ever be a consensus about the meaning of needs“*

*Culyer A. Need - is a consensus possible? *Culyer A. Need - is a consensus possible? J Med Ethics J Med Ethics 1998;1998;2424:77–80:77–80

Bradshaw’s typology of Bradshaw’s typology of need need

Normative: need which is identified according to a norm (or standard), usually set by experts– Example: social security benefit levels

Comparative: problems which emerge by comparison with others– Example: comparison of social problems in different areas

in order to determine which areas are most deprived

Felt: need which people feel - that is, need from the perspective of the people who have itExpressed: need which people say they have– People can feel need which they do not express and they

can express needs they do not feel

Bradshaw J. A taxonomy of social need. New Society 1972; 640-3.

Assessing self-harm needs Assessing self-harm needs (based on Bradshaw’s (based on Bradshaw’s typology): challengestypology): challenges

Normative: what evidence will be used to establish norm?Comparative: which are the appropriate comparison groups? Felt: how to measure felt need which is not expressed?Expressed: how to distinguish ‘real’ from ‘artificial’ needs?

Which areas of need should Which areas of need should be measured?be measured?

Medical (aftermath of self-harm)Medical (aftermath of self-harm)

Physical ill-healthPhysical ill-health

Psychiatric (e.g. untreated or inadequately Psychiatric (e.g. untreated or inadequately treated mental illness)treated mental illness)

Dependence on alcohol/drugsDependence on alcohol/drugs

Social (e.g. interpersonal loss, severe life Social (e.g. interpersonal loss, severe life events)events)

Socio-economic (e.g. worklessness, low income)Socio-economic (e.g. worklessness, low income)

Living environment (socio-economic deprivation, Living environment (socio-economic deprivation, poor housing conditions) poor housing conditions)

Different intervention Different intervention approachesapproaches

Universal targets the general population or a population group (not identified on basis of risk)Selective strategies target at-risk groups that have greater probability of becoming suicidal, aiming to prevent onset of suicidal behaviourIndicated strategies target specific high-risk individuals who show early signs of suicidal potential

Needs in relation to Needs in relation to different intervention different intervention

approachesapproachesGeneral population (especially young people): ‘universal’ interventions to strengthen resilience/protective processes, enhance knowledge, remove barriers to treatment/services, improve knowledge and understanding (e.g. in schools)At risk groups: ‘selective’ interventions to help reduce risk of self-harm among those in crisis/especially vulnerable (e.g. homeless, suffering abuse)Vulnerable individuals: ‘indicated’ interventions to reduce risk of chronic self-harm (e.g. preventing repetition)

Key questions/challengesKey questions/challenges

How is self-harm to be defined (especially in operational terms)?Which people or groups are to be targeted?– Universal, selected or indicated approaches?– Promotion, prevention or treatment?

How are needs to be established?– What about felt needs that are not expressed (among

those at risk of self-harm as well as those who have self-harmed)?

– Formal services deal only with expressed need (but not all such need)

– Some need expressed to informal sources of support (e.g. peers, family) or self-help groups

– What procedures will be used to measure need?– What types of need will be covered?

Focus of needs assessment: Focus of needs assessment: filling the gapsfilling the gaps

Source of meeting needSource of meeting needFelt needFelt need

Not Not expresseexpresse

dd

ExpresseExpressedd

Statutory services: hospital-basedStatutory services: hospital-based ??

Statutory services: other medical (e.g. Statutory services: other medical (e.g. GP)GP) ?? ??

Statutory services: other (e.g. social Statutory services: other (e.g. social work)work) ?? ??

Voluntary sector (e.g. Penumbra)Voluntary sector (e.g. Penumbra) ?? ??

Self-help groups (e.g. HUG)Self-help groups (e.g. HUG) ?? ??

Informal (e.g. peers, family)Informal (e.g. peers, family) ?? ??