A CAT-derived one to three session intervention for repeated deliberate self-harm: a description of the model and initial experience of trainee psychiatrists in using it

A Brief Cognitive Analytic Therapy-Informed Approach for Young People That Have Self-Injured (CATCH-Y): A Case Series

BACKGROUND

Non-suicidal self-injury (NSSI) presents an increasingly prevalent problem for young people; however, there remains a scarce evidence base for effective, scalable treatments for adolescents. This study aimed to assess the feasibility and acceptability of a brief, cognitive analytic therapy (CAT)-informed intervention for young people who engage in NSSI (CATCH-Y).

METHODS

A case series design recruited 13 young people who met the inclusion and exclusion criteria to participate in the five-session intervention. Eligible participants were aged 13-17 years (M = 15.15, SD = 1.28) and had engaged in NSSI at least once in the previous 6 months. Feasibility and acceptability were measured via recruitment, retention, qualitative feedback and missing data. The secondary outcome measures of personal recovery and motivation were administered pre- and post-assessment, with measures of depressive symptoms and urges to self-injure.

RESULTS

The intervention was found to be largely feasible and acceptable with high rates of recruitment, retention and pre-/post-assessment data completeness. Measures showed preliminary support for positive change in rates of NSSI, urges to self-harm, low mood and personal recovery, although results were mixed. Completion rates for remote assessments were low.

CONCLUSIONS

The findings of this study support further evaluation of the CATCH-Y intervention on a larger scale. In-person assessments may be preferable to remote to ensure good completion rates.

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.

Investigating self-concept in self-harm: A repertory grid study

OBJECTIVES

The way that individuals perceive themselves and others may be relevant in understanding difficulties with self-harm. Repertory grids provide a relatively underutilized means of investigating self-concept in people who self-harm. This study aimed to examine the association between self-concept, captured through a repertory grid method, and self-harm.

METHOD

Ninety-eight participants with a history of self-harm took part in the study. A repertory grid was used to derive distances between four elements ('current self', 'ideal self', 'self-harming self', and 'others who self-harm'). Associations between these distances and measures of self-harm behaviour, well-being and perceived recovery, were estimated.

RESULTS

Repertory grid distances were significantly associated with self-harm. When adjusting for covariates, self-harm in the past year was positively associated with a greater distance (or less perceived similarity) between current and ideal self, and a smaller distance (greater perceived similarity) between current self and others who self-harm. Repertory grid distances were also associated with well-being and perceived recovery.

CONCLUSIONS

The results are consistent with the idea that self-perception is associated with self-harm and related difficulties. The results also highlight the potential utility of repertory grids as a tool for exploring self-concept. The cross-sectional nature of the study precludes inferences about directionality or the temporal characteristics of associations.

PRACTITIONER POINTS

More recent experiences of self-harm may be reflected in the way individuals perceive or construe themselves. The way in which individuals who self-harm perceive or construe themselves may also be related to their current well-being and perceived recovery. Repertory grids may be a useful tool in clinical practice for investigating self-concept in those who self-harm. Repertory grids may provide a more idiographic, clinical outcome assessment in those who self-harm.

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

BACKGROUND

Brief psychological therapies may be helpful for people who have recently self-harmed. The current paper reports on a service evaluation of a novel brief therapy service based within an Emergency Department, Hospital Outpatient Psychotherapy Engagement (HOPE) Service. This service combines elements of psychodynamic interpersonal and cognitive analytic therapy to help people who present with self-harm-related difficulties. The primary aim of this service evaluation was to ascertain the feasibility of HOPE in terms of attendance rates. The study also examined variables associated with engagement, and change over time in psychological distress for those attending the service.

METHOD

The HOPE service was evaluated over a ten-month period. Consenting patients completed measures of psychological distress and working alliance across four therapy sessions and one follow-up session. Measures of emotion regulation style and self-harm function were also completed at the point of referral.

RESULTS

Eight-nine patients were referred to the service (83 eligible referrals). Fifty-three (64%) attended at least one therapy session. Baseline variables did not distinguish people who attended and people who did not. Psychological distress decreased significantly across the sessions. Most people reported a good working alliance with their therapist.

CONCLUSIONS

The results of this service evaluation support the feasibility of the HOPE service, demonstrating good engagement rates given the complexity of the population and context. Whilst there was evidence of reductions in distress, randomized controlled trials are needed to determine if HOPE has clinical efficacy.

PRACTITIONER POINTS

Rates of engagement with HOPE suggest the service is feasible in an Emergency Department context Working alliance scores were positive for the majority of patients The HOPE service shows promise as a brief intervention for people who self-harm but requires further evaluation Randomized controlled trials are needed to determine the clinical efficacy of the HOPE service.

An examination of the relationship between shame, guilt and self-harm: A systematic review and meta-analysis

Self-harm is a major public health concern associated with suicide risk and significant psychological distress. Theories suggest that aversive emotional states are an important process that drives self-harm. Shame and guilt may, in particular, be important emotions in self-harm. This review therefore sought to provide a systematic review and meta-analysis of the relationship between shame, guilt, and self-harm. A systematic search of electronic databases (PsycINFO; Medline; CINAHL Plus; Web of Science and ProQuest) was undertaken to identify studies measuring shame, guilt and self-harm (including suicidal and non-suicidal behaviour). Meta-analysis was undertaken where papers focused on the same subtype of shame or guilt and shared a common outcome. Thirty studies were identified for inclusion. Most forms of shame were associated with non-suicidal self-injury (NSSI), but research was sparse concerning suicidal behaviour. Fewer studies examined guilt and findings were more varied. Methodological issues included a paucity of longitudinal designs and lack of justification for sample sizes. Results of this review support the link between shame and self-harm, particularly NSSI. The direction of this relationship is yet to be established. Clinically, consideration should be given to the role of shame amongst individuals who present with NSSI. This review was pre-registered on PROSPERO (CRD42017056165).

Distinguishing people with current, past, and no history of non-suicidal self-injury: Shame, social comparison, and self-concept integration

OBJECTIVE

Non-Suicidal Self-Injury (NSSI) can have a major impact on the lives of individuals and those around them. The way in which a person feels about and perceives themselves (i.e. self-concept) appears central to understanding NSSI. The current study investigates three variables linked to self-concept: shame, social comparison, and self-concept integration. We examine how well these variables differentiate people who report past NSSI, people who report current NSSI, and people who have never engaged in NSSI.

DESIGN

Cross-sectional.

METHOD

Individuals reporting NSSI in the past year (n = 51), individuals with a history of NSSI but none in the past year (n = 44), and individuals with no history of NSSI (n = 110) were compared on measures of shame, social comparison, and self-concept integration.

RESULTS

Shame was elevated in people with a history of NSSI but did not distinguish between past and current NSSI when other variables were controlled for. Self-concept integration was poorer in people reporting current NSSI than people reporting past NSSI, even when controlling for other variables.

CONCLUSIONS

The results support the role of shame as a general marker for NSSI risk, but suggest self-concept integration may fluctuate more dynamically in relation to the recency of NSSI. The study is limited by a non-matched student control group.

Hospital staff experiences of their relationships with adults who self-harm: A meta-synthesis

PURPOSE

This review aimed to synthesize qualitative literature exploring inpatient hospital staff experiences of their relationships with people who self-harm.

METHODS

Nine studies were identified from a systematic search of five research databases. Papers included the experiences of physical health and mental health staff working in inpatient settings. The studies employed various qualitative research methods and were appraised using an adapted quality assessment tool (Tong, Sainsbury, & Craig, 2007). A meta-synthesis was conducted using traditional qualitative analysis methods including coding and categorizing data into themes.

RESULTS

Three main themes derived from the data. 'The impact of the system' influenced the extent to which staff were 'Fearing the harm from self-harm', or were 'Working alongside the whole person'. A fear-based relationship occurred across mental health and physical health settings despite differences in training; however, 'Working alongside the whole person' primarily emerged from mental health staff experiences. Systemic factors provided either an inhibitory or facilitative influence on the relational process.

CONCLUSIONS

Staff experiences of their relationship with people who self-harm were highlighted to have an important impact on the delivery and outcome of care. Increasing support for staff with a focus on distress tolerance, managing relational issues, and developing self-awareness within the relationship may lead to a more mutually beneficial experience of care. Equally, structure, clarity, and support within inpatient systems may empower staff to feel more confident in utilizing their existing skills.

PRACTITIONER POINTS

Working with people who self-harm can be emotionally challenging and how staff cope with this can significantly impact on the engagement of staff and patients. Increasing the skills of staff in managing relational issues and tolerating distress, as well as providing support and reflective practice groups may be useful in managing emotional responses to working with people who self-harm. Refining the supportive, procedural, and environmental structures surrounding the caregiving relationship may help enable better integration of physical and mental health care.

Accident and emergency staff's perceptions of deliberate self-harm: Attributions, emotions and willingness to help

OBJECTIVES

The study applied Weiner's (1980, 1986) attributional model of helping behaviour to Accident and Emergency (A&E) staff's care of patients presenting with deliberate self-harm. It was hypothesized that where staff attributed precipitants of the act of deliberate self-harm to controllable, internal, and stable patient factors, then staff would display greater negative affect, less optimism, and less willingness to help the patient.

DESIGN

Using four hypothetical scenarios in a two-factor between-subjects design, contextual factors describing a self-harm patient were manipulated.

METHOD

Participants were 89 A&E medical and nursing staff. They were asked to rate attributions for the cause of the deliberate self-harm and their emotional responses, optimism for change, and willingness to help change the behaviour. Their general attitudes towards deliberate self-harm patients and perceived needs for training in the care of these patients were also assessed.

RESULTS

The findings were consistent with Weiner's attributional model of helping. The greater attributions of controllability, the greater the negative affect of staff towards the person, and the less the propensity to help. The higher the ratings of stability of outcome, the less staff optimism for the success of their input. Male staff and medical staff had more negative attitudes, and medical staff saw less need for further training.

CONCLUSION

Formulating A&E staff's responses to deliberate self-harm using a cognitive-emotional model offers the possibility of working with staffs' beliefs, emotions, and behaviour to improve the care and treatment of deliberate self-harm patients.

The clinical assessment of patients admitted to hospital following an episode of self-harm: a qualitative study

Based upon qualitative interviews with clinicians responsible for assessing patients admitted to hospital following an episode of self-harm by overdose, this paper documents interactional factors that shape both how clinicians conduct these assessments and their understanding of what 'causes' someone to harm themselves. The analysis first documents how the patients' overdoses are framed as essentially impulsive acts committed in response to adverse circumstances. This is achieved by clinicians' avoidance of any engagement with, or assessment of, a patient's reasons for taking an overdose. Secondly, the analysis considers why the patients' reasons for taking an overdose do not feature in the clinicians' assessments, and shows, by an examination of two deviant cases, that clinicians avoid engaging with patients' motivations so as to: minimise the risk of generating bedside disagreements; avoid the possibility of being drawn into the emotional life of a patient, and shield themselves from the social and economic inequalities that are a feature of many patients' lives. The paper concludes with a discussion of how bedside assessments that do not engage with patients' reasons for taking an overdose might be experienced by the patients themselves and the deleterious effect this could have upon their clinical management.

Community psychiatric nurses' experience of working with people who engage in deliberate self-harm

This paper reports on a study that explored community psychiatric nurses' experiences of working with people who self-harm. Interpretative Phenomenological Analysis was used with eight experienced community psychiatric nurses who participated in semi-structured interviews. Established quality control procedures were utilized including audit of the analysis process and validating the results with participants. The participants described struggling to conceptualize self-harm behaviour and generally reported finding working with people who self-harm stressful particularly in terms of managing the emotional impact upon themselves and the boundaries of their professional responsibilities in relation to managing risk. The therapeutic relationship was viewed as crucial and a variety of coping methods to manage the impact of the work, which had largely developed through 'on the job', experience were described. The results highlight the potential difficulties faced by community staff and can be translated into clear recommendations for training and support.

A controlled trial of personal construct psychotherapy for deliberate self-harm

Evidence for the effectiveness of psychological therapies for people who self-harm is limited. Personal construct theory provides a model of self-harm and a framework for therapeutic intervention, which was evaluated in the present study. Sixty-four adults presenting to Accident and Emergency departments following self-harm were allocated to a personal construct psychotherapy or a 'normal clinical practice' condition. They completed various measures at assessment points pre- and post-therapy. Repetition of self-harm was assessed over a 3-year period. Participants in the intervention condition showed significantly greater reduction in suicidal ideation, hopelessness and depression post-treatment than the control group; and significantly more reconstruing at this point and 6-month follow-up. There was some evidence suggestive of a lower frequency of repetition of self-harm in the intervention than in the control group. It is concluded that brief personal construct psychotherapy may be effective for people who self-harm and merits further exploration.

Australian and New Zealand clinical practice guidelines for the management of adult deliberate self-harm

BACKGROUND

The Royal Australian and New Zealand College of Psychiatrists is co-ordinating the development of clinical practice guidelines (CPGs) in psychiatry, funded under the National Mental Health Strategy (Australia) and the New Zealand Health Funding Authority.

METHOD

For these guidelines, the CPG Team for Deliberate Self-harm reviewed the treatment outcome literature (including meta-analyses) and consulted with practitioners and patients.

TREATMENT RECOMMENDATIONS

(i) Organization of general hospital services to provide: emergency department admission; a safe environment; integrated medical and psychiatric management; risk assessment; identification of psychiatric morbidity, and adequate follow-up. (ii) Detection and treatment of any psychiatric disorder. (iii) Dialectical behaviour therapy, psychoanalytically orientated partial hospitalization or home-based interpersonal therapy (for certain patients) to reduce repetition of deliberate self-harm (DSH).

CONCLUSION

Deliberate self-harm is common and is costly in terms of both individual distress and service provision. General hospitals are often the first point of clinical contact, but may not be appropriately organized to care for these patients. Evidence for the effectiveness of psychological treatments is based on single RCTs without replication. The three recommended psychological treatments are not widely available in Australia and New Zealand, and the interventions that are, such as cognitive behaviour therapy, problem solving and 'green cards' (an agreement guaranteeing access to services), do not reduce repetition of DSH. The effect of follow-up in psychiatric hospitals or in the community is poorly understood. We need to develop and evaluate interventions that will reduce repetition of both fatal and non-fatal deliberate self-harm and improve the person's functioning and quality of life.