"These Things Don't Work." Young People's Views on Harm Minimization Strategies as a Proxy for Self-Harm: A Mixed Methods Approach

A Systematic Review of the Use, Acceptability, Perceived Effectiveness and Effectiveness of Self-Help Toolkits

Self-harming behaviours can include cutting the skin, ligaturing and taking overdoses. These actions can result in infection, blood loss, or even death. A young person's risk of dying by suicide increases if they engage in self-harm. Self-help empowers people to utilise different coping strategies and implement life changes without reliance on a clinical intervention, "helping people to help themselves". Self-help toolkits contain a variety of items that are selected by the person to help them manage the urge to self-harm. The items included sensory objects, distractions, prompts to seek help and creative prompts such as colouring books and pens and personal items that trigger positive memories. AMED, EMBASE, APA Psycinfo and MEDLINE were searched with no language restriction or date restriction. Of the 368 studies screened, 13 met the inclusion criteria. The studies were mainly small scale or case studies pertaining to the use of self-help toolkits or similar. They described the need for a flexible and/or individualised approach to self-help toolkits. Abstracts and studies were screened separately by two members of the research team for inclusion. Qualitative data was analysed using Grounded Theory. Nine themes were identified: Creativity, Hope, Social contact/help seeking, calming/relaxing, sensory items, reflection, distractions, therapeutic prompts and emotional release. Self-efficacy and self-awareness were the two main mechanisms identified. Self-help toolkits were found to be acceptable and helpful, but the limited evidence base means their efficacy for reducing self-harm episodes has not been established.

Young adults looking back at their experiences of treatment and care for nonsuicidal self-injury during adolescence: a qualitative study

BACKGROUND

Nonsuicidal self-injury (NSSI) is associated with stigma, and negative attitudes among healthcare professionals toward NSSI have been reported. A person-centered approach that focuses on how individuals with lived experience of NSSI perceive the treatment and care they receive is invaluable in reducing barriers to help-seeking and improving treatment and mental healthcare services. The aim of the current qualitative study was to explore the perceptions of young adults when they look back upon their experiences of psychiatric treatment for NSSI during adolescence.

METHODS

Twenty-six individuals with lived experience of NSSI who were in contact with child and adolescent psychiatry during adolescence were interviewed. The interviews were analyzed using thematic analysis.

RESULTS

Three main themes were developed: Changed perceptions in retrospect, The importance of a collaborative conceptualization and Lasting impression of the relationship. Participants' perception of themselves as well as the treatment changed over time. The importance of a joint understanding of NSSI and an agreed-upon treatment focus was emphasized. The relationship to the mental health professionals, and experiences of how NSSI was communicated, were salient several years later.

CONCLUSIONS

Healthcare professionals need to communicate about NSSI in a respectful manner and include the perspective of the adolescent with lived experience of NSSI in a joint conceptualization of NSSI and treatment focus.

What helps people to reduce or stop self-harm? A systematic review and meta-synthesis of first-hand accounts

BACKGROUND

Self-harm is an important public health problem but therapeutic interventions, particularly for people who have a history of multiple repetition, are not always taken up or effective when they are. The aim of this review is to explore first-hand accounts of what helps outside therapy and identify actions and processes, which can support the reduction or cessation of self-harm.

METHODS

A systematic review and thematic meta-synthesis of the first-person accounts of what has helped to reduce or stop self-harm reported in primary studies.

RESULTS

The meta-synthesis combined 546 participant excerpts from 56 studies. Two over-arching themes were identified: (i) breaking the chain incorporated actions taken to break the link between a person's current psychological or social state and the act of self-harm and (ii) building a new foundation for change captured actions over the longer-term, focusing on practical changes in relationships and in a person's way of life, such as work or living arrangements.

CONCLUSIONS

The results emphasize the importance of interpersonal change in reducing or stopping self-harm. While interpersonal factors are acknowledged as important reasons behind self-harm, they are often under-represented in self-management advice and therapeutic interventions that focus on individual psychopathology.

Scoping review: Alternatives to self-harm recommended on mental health self-help websites

Less than half of all young people with mental health difficulties will seek professional treatment. Due to the private nature of self-harm it is estimated that only 1:28 young males and 1:18 young females who self-harm ever present to hospital. Self-help supports improved coping strategies and life changes without reliance on a clinical intervention which could be used to reduce self-harming behaviours. The study objective is to review self-help alternatives to self-harm on mental health websites that can be accessed by young people. Google, Bing, and Yahoo search engines were used to search for appropriate websites. Eighty-two unique websites on mental health were identified, of which 55 met the inclusion criteria. A total of 1177 self-help suggestions were found for those struggling with self-harm urges. The average number of suggestions per site was 42 (Range 3-252). The main techniques suggested were: seeking social contact/help, physical activity, displacement/mimicking techniques, relaxing/comforting techniques, sensory techniques, fun/diverting techniques, aggressive techniques, creative/reflective techniques. This review found not all strategies were suitable for young people and that the large number of possible strategies could be challenging for a young person to navigate. However, mental health self-help websites were generally of high quality and gave a range of potentially helpful strategies. The categories created from this review could be used as a guide to consider with the young person when making an individualized self-help plan to manage self-harm urges. Further research is required to assess if and how these techniques could be used individually or in combination to reduce self-harm.

Further Silencing the Voiceless: The Role of Gatekeepers in Accessing Information About Self-Injury

ABSTRACT

Gatekeepers play a pivotal role in protecting individuals under their care and are central to keeping people safe and away from harm. In the field of nonsuicidal self-injury (NSSI), a range of gatekeepers exist, including those who protect access to vulnerable research participants, those who protect school children, those charged with making decisions about funding priorities, and those in charge of clinical care for people who self-injure. The aim of this commentary is to outline the roles these different gatekeepers have in protecting access to research participants, access to NSSI knowledge, and access to clinical care for individuals who self-injure. We provide examples in which gatekeepers may present barriers and offer solutions for how to work with gatekeepers for mutual benefit.

Self-Injury During COVID-19: Views From University Students With Lived Experience

Concerns have been raised about the impact of the COVID-19 pandemic on individuals with lived experience of nonsuicidal self-injury (NSSI). Yet, few efforts have explored this. Accordingly, using a mixed-methods approach, we sought to examine whether emerging adults who have self-injured experienced changes in NSSI urges and behavior during the pandemic and what may have accounted for these changes. To do so, university students with lived experience of NSSI completed online questions asking about NSSI and self-reported changes in urges and behavior since the onset of COVID-19. They then answered open-ended questions asking what contributed to these changes and how they have coped during this timeframe. Approximately 80% of participants reported no change or a decrease in NSSI urges and behavior. Participants discussed removal from stressors (e.g., social stress) that previously evoked NSSI, as well as having time for self-care and to develop resilience as accounting for this. Nevertheless, some participants reported challenges amid the pandemic (i.e., exacerbated stress, isolation); approximately one fifth of participants reported increases in NSSI urges and behavior. Our findings add to recent evidence that many individuals with prior mental health difficulties, including NSSI, can demonstrate resilience in the face of collective adversity. Research and clinician implications are discussed.

Harm minimisation for self-harm: a cross-sectional survey of British clinicians' perspectives and practices

OBJECTIVE

Harm minimisation for self-harm is an alternative to preventive strategies and focuses on maximising safety when self-harming. We explored the views of clinicians on harm minimisation for self-harm to describe reported use and acceptability in clinical practice.

DESIGN

A cross-sectional study using an online survey consisting of fixed-choice and open-ended questions.

SETTING

Primary and secondary care practices in England, Scotland and Wales.

PARTICIPANTS

Snowball sampling of UK-based clinicians (n=90; 67% female) working with people who self-harm and who have or have not previously recommended harm minimisation methods to patients.

RESULTS

Of the 90 clinicians sampled, 76 (84%) reported having recommended harm minimisation techniques to people in their care who self-harm. Commonly recommended techniques were snapping rubber bands on one's wrist and squeezing ice. Other techniques, such as teaching use of clean instruments when self-harming, were less likely to be recommended. Perceived client benefits included harm reduction and promotion of the therapeutic relationship. Perceived potential limitations of a harm minimisation approach for self-harm were (a) potential worsening of self-harm outcomes; (b) ethical reservations; (c) doubts about its effectiveness and appropriateness; and (d) lack of training and clear policies within the workplace.

CONCLUSIONS

In our sample of UK-based clinicians in various settings, harm minimisation for self-harm was broadly recommended for clients who self-harm due to perceived client benefits. However, future policies on harm minimisation must address clinicians' perceived needs for training, well-defined guidelines, and clear evidence of effectiveness and safety to mitigate some clinician concerns about the potential for further harm.

Valued attributes of professional support for people who repeatedly self-harm: A systematic review and meta-synthesis of first-hand accounts

Therapeutic interventions are an important adjunct to self-help strategies for people who self-harm. There is little guidance for those offering therapy on the effective components of interventions for people who self-harm. This was a systematic review aiming to identify the factors that contribute to positive experiences of therapy as described by people who have reduced or stopped self-harm. The review followed PRISMA guidelines to locate and synthesize peer-reviewed qualitative studies describing experiences of therapy among people who had reduced or stopped self-harm. Study selection, data extraction, and quality assessment were peer reviewed and conducted for at least two researchers independently. Relevant first-hand quotations were extracted from eligible studies and synthesized using a thematic analysis in collaboration with experts with personal and professional experience of self-harm. Twenty-three studies met eligibility criteria. Themes identified in the reported accounts were arranged under two meta-themes. 'Positive aspects of seeing a professional' identified aspects of professional care that were common to all encounters: the value of sharing, space to talk and reflect, and the boundaries inherent in contact with a professional. 'Positive attributes of individual professionals' depended upon individual characteristics: the ability to build reciprocal trust by being non-judgemental, showing genuine empathic concern, and being confident to talk about and respond directly to self-harm. Our review indicates that therapeutic alliance is perceived as key to effective professional help for self-harm, irrespective of underlying principles of therapy. All forms of therapy should be timely and reliable and centred around the needs of the individual and their experience of self-harm.

Harm minimisation for the management of self-harm: a mixed-methods analysis of electronic health records in secondary mental healthcare

BACKGROUND

Prevalence of self-harm in the UK was reported as 6.4% in 2014. Despite sparse evidence for effectiveness, guidelines recommend harm minimisation; a strategy in which people who self-harm are supported to do so safely.

AIMS

To determine the prevalence, sociodemographic and clinical characteristics of those who self-harm and practise harm minimisation within a London mental health trust.

METHOD

We included electronic health records for patients treated by South London and Maudsley NHS Trust. Using an iterative search strategy, we identified patients who practise harm minimisation, then classified the approaches using a content analysis. We compared the sociodemographic characteristics with that of a control group of patients who self-harm and do not use harm minimisation.

RESULTS

In total 22 736 patients reported self-harm, of these 693 (3%) had records reporting the use of harm-minimisation techniques. We coded the approaches into categories: (a) 'substitution' (>50% of those using harm minimisation), such as using rubber bands or using ice; (b) 'simulation' (9%) such as using red pens; (c) 'defer or avoid' (7%) such as an alternative self-injury location; (d) 'damage limitation' (9%) such as using antiseptic techniques; the remainder were unclassifiable (24%). The majority of people using harm minimisation described it as helpful (>90%). Those practising harm minimisation were younger, female, of White ethnicity, had previous admissions and were less likely to have self-harmed with suicidal intent.

CONCLUSIONS

A small minority of patients who self-harm report using harm minimisation, primarily substitution techniques, and the large majority find harm minimisation helpful. More research is required to determine the acceptability and effectiveness of harm-minimisation techniques and update national clinical guidelines.

A Qualitative Study of Understanding Reasons for Self-Harm in Adolescent Girls

Objective: Self-harm is an important public health issue in the UK. Young people who self-harm frequently feel misunderstood, and unable to access help. Improving understanding is key to informing the development and delivery of effective treatments and services. Methods: In this qualitative study, we interviewed nine adolescent girls (13–17 years old) with recurrent self-harm, recruited from NHS specialist child and adolescent mental health services. Data were analysed using Interpretative Phenomenological Analysis (IPA). Results: Findings revealed that self-harm is experienced as powerful mental and physical urges, sated only by self-harming, suggesting that self-harm could be considered a compulsive rather than impulsive disorder, representing a new perspective on the behaviour. Five themes emerged: emotion regulation; an addictive urge; self-harm to survive; interpersonal triggers; interpersonal relationships, not mechanical distractors, reduce self-harm. Conclusions: This study provides further evidence that non-suicidal self-injury may be engaged in to reduce suicidal risk. Seeking the company of helpful friends or family members may reduce the urge to self-harm. Repetitive self-harm may be a compulsive behaviour.

What do young people who self-harm find helpful? A comparative study of young people with and without experience of being looked after in care

BACKGROUND

Self-harm amongst young people is an increasing problem, with looked-after young people at higher risk. Despite this, little research exists on what young people who self-harm find helpful.

METHOD

One hundred and twenty-six 11-21 year olds (53 who had experience of the care system and 73 who did not) were recruited from the community and NHS. All participants had self-harmed in the past 6 months. Participants completed an Audio Computer-Assisted Self-interview (ACASI) regarding their views about the support they had received, how helpful it was, and what further help they felt they needed.

RESULTS

Looked-after young people reported the three most helpful sources of support were Child and Adolescent Mental Health Services (CAMHS), friends and pets and the least helpful were CAMHS, Accident and Emergency (A&E) and Social services. For non-looked-after young people, CAMHS, counselling and Harmless (user-led support service for self-harm) were most helpful and CAMHS, cognitive behavioural therapy (CBT) and general practitioner (GP) were the least. Compared with the other group, more looked-after young people had received help from A&E and CAMHS, whereas more non-looked-after young people had accessed GPs, parents, psychological therapies, self-help books and websites. More looked-after young people found support groups helpful, and more non-looked-after young people reported that distraction techniques, medication and their siblings were helpful.

CONCLUSION

Young people who self-harm have mixed views about CAMHS. Differences in the pattern of access and preferences for support between looked-after and non-looked-after young people should be reflected in service availability and commissioning.

KEY PRACTITIONER MESSAGE

Little is known about what young people who self-harm find helpful, particularly for looked-after young people. CAMHS was named amongst the most helpful and the least helpful services by both looked-after and non-looked-after young people. Social services and A&E were frequently cited amongst the least helpful sources of support. Young people report finding informal support helpful, including family and friends. There appears to be a need for explorations of the reasons behind the apparent negative perception of statutory services in young people, and what is required to shift that.