Pilot service evaluation of a brief psychological therapy for self-harm in an emergency department: Hospital Outpatient Psychotherapy Engagement Service

The Relational Approach to Treating Self-Harm (RELATE): study protocol for a feasibility randomised controlled trial study of cognitive analytic therapy for adults who self-harm versus treatment at usual

BACKGROUND

Self-harm is a prevalent behaviour that has a major detrimental impact on a person's life. Psychological therapies have the potential to help, but evidence of effective interventions remains limited. Access and acceptability of interventions can also be a significant challenge, with individuals either being unable to access help or having to endure long waiting lists. Cognitive analytic therapy (CAT) is a time-limited and relationally-focused psychotherapy that may provide a valuable treatment option for people who self-harm. This protocol outlines the methodology for the first feasibility randomised controlled trial (RCT) of CAT for adults that self-harm. The trial will aim to determine the feasibility, acceptability and safety of undertaking larger-scale evaluations of CAT for self-harm within an RCT context.

METHOD

An RCT design with 1:1 allocation to CAT plus treatment as usual (TAU) or TAU alone. Participants will be adult outpatients with three or more instances of self-harm in the past year (target sample of n = 60). CAT will be 8 one-to-one weekly 60-min sessions plus a follow-up session up to 8 weeks after the last session. Assessments will occur at baseline, 12 weeks and 18 weeks after randomisation. Qualitative interviews with participants will gain insights into the feasibility and acceptability of CAT. Feasibility outcomes will be judged against progression criteria.

DISCUSSION

CAT may be an effective and accessible treatment option for people who self-harm, providing a more relationally orientated alternative to more behavioural therapies. The proposed feasibility RCT is an important first step in evaluating CAT as a treatment for self-harm.

TRIAL REGISTRATION

The trial was pre-registered (21/10/22) on ISR CTN (ISRCTN code: ISRCTN75661422).

Pilot Evaluation of a Remote Psychotherapy Service for Students Who Self-Harm: University-Community Outpatient Psychotherapy Engagement (U-COPE)

Self-harm is becoming increasingly common in student populations. Brief psychological therapies might be helpful for those who have recently self-harmed. The current paper reports on an evaluation of a brief psychotherapy service delivered via remote means, namely University-Community Outpatient Psychotherapy Engagement (U-COPE). The service combines elements of psychodynamic interpersonal and cognitive analytic therapy to help students who present with self-harm related difficulties. The primary aim was to understand students' and practitioners' experiences of a remote psychotherapy service. Semi-structured interviews were conducted with a total of nine participants (seven students and two practitioners). Interview data were analysed using thematic analysis. Analyses of the interviews across the stakeholders revealed three overarching themes: 'Accessibility'; 'Therapeutic experiences'; and 'Spaces and places of therapy'. Students appreciated the rapid access to intervention, especially as student services are typically characterised by long waiting lists. Despite the brief nature of the intervention, many students reported feeling a sense of control over the direction and pace of the therapeutic sessions, which is an important consideration for those who self-harm. The findings suggest that U-COPE may be helpful to students with difficulties related to self-harm. Further investigation of this brief intervention is warranted in order to ascertain whether U-COPE has a long-term impact on difficulties and distress-related behaviours.

What is important to service users and staff when implementing suicide-focused psychological therapies for people with psychosis into mental health services?

Introduction

Suicide is a leading cause of death globally. People with psychosis are at increased risk of suicide death and up to half experience suicidal thoughts and/or engage in suicidal behaviors in their lifetime. Talking therapies can be effective in alleviating suicidal experiences. However, research is yet to be translated into practice, demonstrating a gap in service provision. The barriers and facilitators in therapy implementation require a thorough investigation including the perspectives of different stakeholders such as service users and mental health professionals. This study aimed to investigate stakeholders' (health professionals and service users) perspectives of implementing a suicide-focused psychological therapy for people experiencing psychosis in mental health services.

Methods

Face-to-face, semi-structured interviews with 20 healthcare professionals and 18 service users were conducted. Interviews were audio recorded and transcribed verbatim. Data were analyzed and managed using reflexive thematic analysis and NVivo software.

Results

For suicide-focused therapy to be successfully implemented in services for people with psychosis, there are four key aspects that need to be considered: (i) Creating safe spaces to be understood; (ii) Gaining a voice; (iii) Accessing therapy at the right time; and (iv) Ensuring a straightforward pathway to accessing therapy.

Discussion

Whilst all stakeholders viewed a suicide-focused therapy as valuable for people experiencing psychosis, they also recognize that enabling successful implementation of such interventions will require additional training, flexibility, and resources to existing services.

"Cover up your arms, you're triggering people": A Mixed-Methods Investigation of Shame in those who Self-Injure

BACKGROUND

Shame can be a powerfully aversive emotion that is associated with a wide variety of mental health difficulties including non-suicidal self-injury (NSSI). This study used a novel mixed-methods design (Qualitative Experiential Sequence Tracking; QUEST) to investigate the experiences of shame in a sample of individuals who self-injure.

METHODS

Six participants received prompts to complete brief online diaries three times per day over a period of 2 weeks. These diaries captured information about the experience of negative emotions, especially shame. Participants then underwent an individualised qualitative interview about their experiences over the previous 2 weeks.

RESULTS

Thematic analysis suggested that participants experienced shame as a social and relational emotion. Further themes included shame being associated with feelings of failure, being trapped, dangerous or contaminated, and hidden or exposed. The phenomenology of shame, and coping with shame, were also themes. NSSI could occur as a response to shame, but often shame was triggered or exacerbated by the responses of others to NSSI.

CONCLUSIONS

Consistent with previous research, shame was described as an aversive emotion occurring within interpersonal and broader societal contexts and involving a negative self-focus. A lack of compassion or understanding in response to NSSI, or anticipation of negative responses from others often triggered more intense shame than the NSSI itself. Future studies could use QUEST methodology with more diverse samples or different populations to further investigate experiences of shame.

The interpersonal processes of non-suicidal self-injury: A systematic review and meta-synthesis

BACKGROUND

Understanding the processes underlying non-suicidal self-injury (NSSI) is important given the negative consequences of this behaviour. Qualitative research has the potential to provide an in-depth exploration of this. There has been limited research regarding the interpersonal processes associated with NSSI; therefore, a meta-synthesis was conducted to investigate this.

METHODS

A search of PsycINFO, MEDLINE, Web of Science, and CINAHL electronic databases from date of inception to November 2020 was conducted. In total, 30 papers were included in the final review. A meta-ethnographic approach was utilized to synthesize the data.

RESULTS

Two overarching themes were found. Within 'Powerful relational dynamics', NSSI was cited as a response to participants becoming stuck in aversive or disempowering relational positions with others. Within the 'Taking matters into their own hands' subtheme, NSSI was reported as a way for participants to get interpersonal and emotional needs met.

LIMITATIONS

Several included papers did not comment on the researcher-participant relationship, which may have affected qualitative results. A small number of potentially eligible papers were unavailable for synthesizing.

CONCLUSION

Findings provide a more nuanced investigation of the interpersonal processes underlying NSSI. Consistent with relevant theories, NSSI appears to be a way of mitigating difficult interpersonal experiences or getting interpersonal needs met. NSSI may be engaged in as a substitute to other, less damaging ways to cope. An argument is made for a more empathetic understanding of NSSI and the use of relational interventions.

PRACTITIONER POINTS

Self-injury may occur in response to interpersonal stressors Self-injury can be a means to get interpersonal needs met Self-injury may replace other means of coping that become blocked or thwarted Emotional distress can be closely linked with interpersonal factors for this group Relational therapies may be beneficial where interpersonal processes are linked to NSSI.

Community Outpatient Psychotherapy Engagement Service for Self-harm (COPESS): a feasibility trial protocol

Background

People who self-harm are at high risk for future suicide and often suffer considerable emotional distress. Depression is common among people who self-harm and may be an underlying driver of self-harm behaviour. Self-harm is often repeated, and risk of repetition is highest immediately after an act of self-harm. Readily accessible brief talking therapies show promise in helping people who self-harm, but further evaluation of these approaches is needed. A brief talking therapy intervention for depression and self-harm has been designed for use in a community setting. This mixed methods feasibility study with repeated measures will examine the feasibility and acceptability of the Community Outpatient Psychological Engagement Service for Self-Harm (COPESS) for people with self-harm and depression in the community, compared to routine care.

Methods

Sixty participants with a history of self-harm within the last six months, who are also currently depressed, will be recruited to take part in a feasibility single-blind randomised controlled trial (RCT). Participants will be randomised 1:1 to receive COPESS plus treatment as usual (TAU) or TAU alone. Recruitment will be via General Practitioners (GP) and self-referral. Assessment of feasibility and acceptability will be assessed via quantitative and qualitative methods including measures of recruitment and retention to the feasibility trial, participants’ experience of therapy, completion/completeness of outcome measures at relevant time-points and completion of a service use questionnaire.

Discussion

The results will indicate whether it is feasible to conduct a definitive full trial to determine whether COPESS is a clinically and cost effective intervention for people who self-harm in the community. Qualitative and quantitative data will in addition help identify potential strengths and/or challenges of implementing brief community-based interventions for people who self-harm.

Trial registration

NCT04191122 registered 9th December 2019.