Self Harm

Overview

Please read in conjunction with Remedy page on Suicidal Thoughts

Self-harm can be a way of handling a range of difficult and overwhelming emotions.

Self-harm can act as a release for these feelings leading to a feeling of calm and control. 

It can also be accompanied by further feelings of self-hate or guilt. 

The behaviour can have an addictive quality and those who self-harm may be doing so on a regular basis. 

The attached document has two poems about understanding self harm from a service user perspective.

Things to consider when a patient presents after an episode of self-harm

• Complete assessment of presenting situation and need and how to support their immediate and long-term psychological and physical safety.
• Assess severity of injury and whether treatment is required e.g. need ED attendance, refer to TOXBASE
• Assess risk (See section on risk assessment questions for further information if required. Please note that NICE guidance does not suggest the use of risk assessment tools to predict future self-harm or suicide) – consider whether onward referral to local mental health trust is required for further support – this may be if levels of distress are acute, there are concerns about the patient's ability to maintain their safety, practitioners feel unable to support patient in primary care safely or a patient is requesting extra support from mental health services.
• Discuss removing access to ongoing risks
• Consider capacity and safeguarding.
• Ensure the patient has a follow up appointment arranged before leaving the consultation and safety net patient appropriately (see section on safety planning for further information).
• Consider a medication review – particularly if there are concerns around overdose. If you are starting an antidepressant, arrange a 7 day review appointment as risk to self can increase on initiation (particularly in those under 25).
• Consider contacting NOK/loved one/family member with patient consent to ensure patient is well supported and provide them with literature on self-harm and suicidal ideation and local support services (see section of services/resources)
• Offer information/referral to available social care, voluntary and non-NHS sector support and self-help resources around self-harm and suicidal ideation (see section of services/resources)
• If a patient is already under a mental health team, to update them on the consultation.

Harm Minimisation

NICE guidance does not make any recommendations about the use of safer self-harm.

If an individual is engaging with support and treatment but does not feel ready to make changes to their self-harm, harm minimization should only be considered as part of an episode of care and not as a standalone approach and should be a collaborative agreement with the person, their support system and wider team.

Harm minimisation strategies can include:

• Distraction techniques/coping strategies
• Self-care
• Wound hygiene and aftercare
• Providing factual information on the potential complications of self-harm
• The potential impact on alcohol and drug use on the urge to self-harm

It is important to note that harm minimisation may not be appropriate for all individuals who engage with self-harm.

Please see NICE Guidance for further information:

Self Harm (2022): https://www.nice.org.uk/guidance/ng225

Depression in Adults (2022): https://www.nice.org.uk/guidance/ng222

Red Flags

Red flags are significant risk factors that alert us to a person being at increased risk of attempting suicide at time of assessment.

Please see the Suicidal thoughts page of Remedy for information on assessing risk and safety planning.

Resources for self-management

Alternatives to self-harm info can be found on the free distrACT app: distrACT app - Expert Self Care .  The distrACT app gives easy, quick and discreet access to information and advice about self-harm and suicidal thoughts. It contains links to local services and ideas that could also be used in a safety plan.

Other support available as apps or online:

• Free: Calm https://calmharm.co.uk/
• Free: Stay Alive https://www.stayalive.app/
• Free: SAM https://www.mindgarden-tech.co.uk/
• Free: Five Ways to Wellbeing 5 Ways to Wellbeing | Mind - Mind
• Free 7 day trial: Headspace https://www.headspace.com/

Self Injury Support

Self Injury Support is the mental health charity for people of all ages and genders who are affected by self-harm.

The organisation offers free, confidential, non-judgemental support services run by trained volunteers and staff who can provide support and a listening ear. The support services can be accessed via:

Telephone: 0808 800 8088

Text: 07537 342444

Email: tessmail@selfinjurysupport.org.uk

and webchat. 

Their website has a wide range of information and self-help resources about self-harm and related topics, some also available in several different languages, and guidance for family, friends and professionals. They offer a referral-based peer support service as well as wellbeing groups for people using self-harm, and they are also experts in self-harm training and regularly deliver courses to professionals and individuals.

Please consider recommending Self Injury Support to patients who you feel may benefit from these services. 

Office/Admin Number: 0117 927 9600

Email: info@selfinjurysupport.org.uk

For more information, please visit www.selfinjurysupport.org.uk.

Self-harming - assessment questions to ask

Below are some questions that you may want to ask when assessing someone's level of risk. Please note, not all of these questions may be applicable to each patient and a person-centred approach is required.

Current self-harming

• How do you self-harm?
  • Ask about whether they practice harm minimisation – using clean implements, wound care, are they aware of signs of infection?
• What led to your last episode of self-harming?
  • What purpose did this play for you? Did it help how you were feeling?
• Do you try to delay your self-harming with distraction techniques – what does/doesn't help
• Is this a coping strategy that you want to change?
• Have you been having thoughts of ending your life/suicide?
  • Have you made any plans or been researching how you may do this?
  • Have you been getting your affairs in order – amending wills/clearing out the house/giving things away/writing suicide notes
  • Ask about protective factors - What's currently keeping you safe from acting on thoughts?

Historical use of self-harm

• Do you have a history of self-harming?
• How did you previously self-harm?
• If there are changes in how they self-harm and frequency, this may indicate escalating risk
• Have you ever required medical attention for your self-harm?
• Have you ever had suicidal thoughts?
• Have you ever planned or researched ending your life?
• What has previously kept you safe from acting on thoughts?
• Have you ever attempted to end your life? - did you seek medical attention/did someone find you?
  • How do you feel about this experience now? - if upset they were found, this may indicate ongoing risk

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.