Working with Suicidal Risks in Young people: assessment and Interventions

1. Working with Suicidal Risks in Young people: assessment and Interventions Professor Stephen Briggs Centre for Social Work Research University of East London

2. Overview of this talk: • Reviews current evidence, and explores routes from evidence into practice: • National suicide prevention strategy and clinical guidance for self-harm: evidence for assessment in practice • Experiences of care; service user perspectives • Management and interventions • Working with relationships and emotions

3. Suicide prevention and Clinical guidelines: evidence for practice

4. National Suicide Prevention Strategy Preventing suicide in England: A cross-government outcomes strategy to save lives (2012) Key Objectives • a reduction in the suicide rate in the general population in England, and • better support for those bereaved or affected by suicide.

5. Six key areas for action to support delivery of these objectives 1: Reduce the risk of suicide in key high-risk groups 2: Aim to improve mental health in specific groups 3: Reduce access to the means of suicide 4: Provide better information and support to those bereaved or affected by suicide 5: Support the media in delivering sensitive approaches to suicide and suicidal behaviour 6: Support research, data collection and monitoring

6. How do we know if someone is at risk of suicide? The likelihood of a person taking their own life depends on several factors. These include: • gender– males are three times as likely to take their own life as females; • age – people aged 35-49 now have the highest suicide rate; • mental illness; • the treatment and care they receive after making a suicide attempt; • physically disabling or painful illnesses including chronic pain; and • alcohol and drug misuse • Vulnerable children need a ‘tailored approach’ to their mental health • including LAC and care leavers, and those in the youth justice system • (Preventing suicide in England, p9)

7. Suicide, self-harm and suicidal thoughts self-harmis defined as: • any act of intentional harm to the self, irrespective of method used or intended outcome; therefore including suicide attempts (NICE 2011; Hawton et al 2012) • methods commonly include self-cutting, self-poisoning, hanging, jumping, use of firearms • Why this definition? • Self-harm is a complex behaviour, not a diagnosis (despite DSM5) • Conscious intention is not a good guide: • intention changes over time, and is often multiple, and ambivalent • the Golden Gate Bridge study: Hale (2008) • signs and communications of distress can be difficult to interpret (Owens et al 2011) • Self-harm is a key risk factor for repetition and suicide completion

8. Self-harm increases the risks of repetition and suicide completion • Once a person has self-harmed the likelihood that he or she will die by suicide increases 50-100 times • 1 in 15 dying by suicide within 9 years of the first episode (Kendall and Kapur 2011) • About one in five people who attend an emergency department following self-harm will harm themselves again in the following year (Bergen et al., 2010); • a small minority of people will do so repeatedly (NICE 2011 p17) • There is no good evidence to support the view that people who harm themselves repeatedly, particularly by cutting, are less likely to die by suicide than those who harm themselves in other ways. • Indeed one hospital-based study suggested that self-cutting increased suicide risk (Cooper et al., 2005). (p17) • Repetition of self-harm may occur quickly with up to one in ten repeat episodes occurring within 5 days of the index attempt (Kapur et al., 2005). (p17)

9. Self-harm and suicidal ideation: Young people who ‘might harm themselves’ increase clinician anxieties What are the differences? • Differences between young people who have suicidal ideas and thoughts and those who actually harm themselves: • individuals who had undertaken an act of self-harm were more vulnerable than those who had thoughts (but had not acted on these) • notably through being more exposed to self-harm in familial and peer contexts • and through being more impulsive (O’Connor et al 2012) • Thus, relationshipsand social contexts may be important in distinguishing between ideation and actions Suicidal ideation requires the same processes of assessment as self-harm

10. Children and young people and self-harm • Evidence from self-report surveys show at least 10% of girls and 3% boys have at least one episode of self-harm in their teens • Only 12.6% of those who had harmed themselves had presented to hospital, the vast majority of acts of self-harm being ‘invisible’ to professionals. (NICE 2011 page 17) • Around 30% who begin self-harm in adolescence continue into adulthood (Harrington et al 2006) • The majority therefore begin and end their involvement with self-harm in adolescence, • but knowledge is limited about how and why a young person stops being involved with self-harm – or continues beyond the adolescent years.

11. Service User Perspectives: Experiences of care

12. Service user perspectives on their experiences of care • Evidence from a mainly qualitative research literature • There are mixed attitudes towards ending self-harm and the process of recovery. Some people want to stop, whereas others valued self-harm as a vital coping mechanism. • Service user’s experiences of services are predominantly negative in nature (but with exceptions) • Studies emphasised the importance of the therapeutic relationship; • use of an empathic, non-judgemental approach by practitioners may be associated with a more positive experience of assessment and treatment by service users (Taylor et al 2009; Saunders et al 2011)

13. Service User Perspectives • Self-harm is an indication of underlying difficulties • the reasons for self-harm vary considerably – for different people and for different episodes • For some, self-harm is related to traumatic life events, childhood abuse, psychiatric illness or troubled relationships. • For others, self-harm was an important coping mechanism for dealing with feelings of frustration, loneliness or distress. • It was also described as a cry for help, an escape, or as a means of gaining support. • Others mentioned that they engaged in self-harm in order to feel alive or relieve themselves of dissociation. • The meaning and motivation behind each act may differ considerably from one incident to the next.

14. Every episode and every case is different….principles of care in NICE • During assessment, explore the meaning of self-harm for the person and take into account that: • each person who self-harms does so for individual reasons, and • each episode of self-harm should be treated in its own right and a person’s reasons for self-harm may vary from episode to episode (NICE 2011 p207) • Exploration of self-harm thoughts, intentions and motivations is not dangerous • There is evidence that talking about self-harm does not increase risks • Crawford et al (2011) assessed in 4 GP practices whether screening for risk of suicide, including direct questions about suicidal ideation affected mental health • Patients screened for suicidal ideation did not increase their suicidal feelings compared with group not screened for suicidal ideation

15. Principles of Care Offer an integrated and comprehensive psychosocial assessment of needs and risks to understand and engage people who self-harm and to initiate a therapeutic relationship NICE 2011 p207

16. Risk Factors and Assessment Scales • Risk Factors: • Focus on: episodes of previous self-harm and depression • Risk Scales: • Do not use risk assessment tools and scales to predict future suicide or repetition of self-harm. • Do not use risk assessment tools and scales to determine who should and should not be offered treatment or who should be discharged. • Risk assessment tools may be considered to help structure risk assessments as long as they are part of a holistic psychosocial assessment (NICE 2011 page 208)

17. Current issues in thinking about self-harm and suicide Risk assessments Relational Approaches X X Risk assessment scales Conscious intent Self-harm Repetition Completion of suicide Deliberate self-harm

18. Management and Interventions Short-term therapy or ‘wrap-around’ care?

19. Relating to people who self-harm; professionals should:- • aim to develop a trusting, supportive and engaging relationship • be aware of the stigma and discrimination sometimes associated with self-harm, both in the wider society and the health service, and adopt a non-judgemental approach • ensure that people are fully involved in decision-making about their treatment and care • aim to foster people’s autonomy and independence wherever possible • maintain continuity of therapeutic relationships wherever possible • ensure that information about episodes of self-harm is communicated sensitively to other team members (page 115) • Anticipate that the ending of treatment, services or relationships, as well as transitions from one service to another, can provoke strong feelings and increase the risk of self-harm (p118)

20. Safeguarding • Professionals who work with children and young people who self-harm should consider whether the child’s or young person’s needs should be assessed according to local safeguarding procedures. • use a multi-agency approach, including social care and education, to ensure that different perspectives on the child’s life are considered • if serious concerns are identified, develop a child protection plan. • When working with people who self-harm, consider the risk of domestic or other violence or exploitation and consider local safeguarding procedures for vulnerable adults and children in their care • (NICE 2011 page 286)

21. Working with parents and families • Parents can feel traumatised by the experience of a child’s self-harm or suicide attempt (Rutherford 2005) • e.g one mother took an overdose when she heard of her daughter’s • Parents describe their experiences as a ‘double trauma’ (Buus et al 2013) • the trauma of the suicide attempt(s) and the subsequent psychosocial impact on the family’s well-being. • The pressure on the parents was intense: the unpredictable character of suicide attempts was emphasized. • Parents and family members may struggle to notice signs of self-harm/ suicidal ideation – with consequent guilt/remorse/blame (Owens et al 2011) • “During a suicidal crisis, significant others are required to make a series of highly complex decisions about what is happening and what if anything they should do about it” (p13) • Relatives emotional investment in the relationship (with the suicidal young person) make it difficult to decipher, heed warnings and take appropriate actions (p13)

22. Effectiveness of psychological therapies • Only a small number of good quality trials show effectiveness of an intervention for self-harm • There are limited studies available for adolescent self-harm • No difference between TAU and interventions is a feature of trials for adolescent self-harm (Rossouw and Fonagy 2012) • However, there is some evidence that psychological therapies (in any therapeutic modality) might improve outcomes compared with TAU • Uncertainty stems from variability in population, treatment modalities, comparison arms, heterogeneity of outcomes • Therapies can focus on the behaviour, or take a holistic approach through dealing with relationships, cognitions and social factors (NICE 2011 p201) • The key outcome measure should be reduced episodes/ repetitions of self-harm

23. Examples of research comparing an intervention for self-harm with TAU • Hatcher et al (2011): Problem-solving therapy for people who present to hospital with self-harm • Adults (mean age 34, over 16); 4-9 sessions, problem solving therapy (clinicians trained and supervised) up to 3 months • Results: (a) first time self-harm: no difference (b) repeat self-harm: reduced • Slee N. et al (2008) Cognitive-behavioural intervention for self-harm: • Patients:15- 35 years; 12 sessions manualised CBT, plus 3 follow up, 5.5 months • Results: reduced repetition, 6-12 months; reduced depression; increased problem solving

24. Rossouwand Fonagy (2012) Mentalisation-Based Treatment for Self-Harm in Adolescents: A Randomized Controlled Trial • Adolescents aged 12-17; 1 year weekly MBT (clinicians trained and supervised) • Results: reduced reporting of episodes of self-harm at 12 months

25. Psychological and psychosocial Interventions: NICE recommends • Consider offering 3 to 12 sessions of a psychological intervention that is specifically structured for people who self-harm, with the aim of reducing self-harm • The intervention should be tailored to individual need, and could include cognitive-behavioural, psychodynamic or problem-solving elements • Therapists should be trained and supervised in the therapy they are offering to people who self-harm • Therapists should also be able to work collaboratively with the person to identify the problems causing distress or leading to self-harm • Provide psychological, pharmacological and psychosocial interventions for any associated conditions • i.e refer to NICE CGs for Alcohol-use Disorders, Depression, Schizophrenia, Borderline Personality Disorder, Drug Misuse, Bipolar Disorder

26. Pharmacological Interventions • Do not offer drug treatment as a specific intervention to reduce self-harm. • Provide psychological, pharmacological and psychosocial interventions for any associated conditions, as per NICE CGs • When prescribing drugs for associated mental health conditions to people who self-harm, take into account the toxicity of the prescribed drugs in overdose.

27. Working with relationships and emotions

28. Emotional impact of self-harm on clinician, teams, networks • Powerful impact either of intense feelings or an aspect of the young person’s suicidal struggle • therapist is invested with relational aspects of the suicidal conflict (“Who is hurting whom or what?”) • therapist is drawn into re-enactment of (failed) dyadic relationships • “Suicidal patients frequently draw the therapist into taking responsibility for living and dying” (Campbell 2008) • Fear of suicidal behaviour generates anxious responses • e.g. not feeling able to talk about it with the patient/service-user • Anxiety driven responses • The hostility and violence of suicidal behaviour can be enacted by the clinician/professional • Examples of people who have self-harmed being treated unkindly in services • Dismissing the patient e.g. as ‘attention seeking’

29. 2 key relational themes:(Wright et al 2005) • Intense anxieties • Some young people are painfully depressed, preoccupied with suicidality and ideas of death and dying, generating anxiety in others • Thus intense anxieties are stirred up in therapists, especially at points of separation (end of a session, a break in therapy etc) • Containment of anxieties can lead to reduction of risks, sometimes quickly • Downplaying/negating of feelings/issues • Some young people seem to show no sign of depression, suicidal/ self-harming acts seem impulsive, surprising they seem unaware of risks and dangers • They appear to want others not to see their vulnerabilities, or needs of others • Therapists can feel ‘stupid’ or intrusive for raising these

30. The implications of self-harm • the individual is changed by the act of self-harm. • Thus the focus needs to be placed not only on the factors which precipitate an episode of self-harm, but also on the consequences- or implications –of the attempt • after suicide attempts/ self-harm young people can appear to be traumatised; • in a frozen state, • frightened by the feelings that had been encountered, the ferocity of their own violence • they may display emotions not fitting the events • The need for containment, rather than re-enactment • Organisational ‘spaces’ for ensuring emotional experiences are thought about • Structured therapies which focus on providing sufficient containment • Either time limited (to provide structure) or ‘wrap around’ care for young people, family members

31. References • Bergen H., Hawton, K., Waters, K et al. (2010) Psychosocial assessment and repetition of self-harm: the significance of single and multiple repeat episode analyses, Journal of Affective Disorders, 127, 257-265 • Buus, N. Caspersen, J.,Hansen, R., Stenager E., & Fleischer, E. (2013) Experiences of parents whose sons or daughters have (had) attempted suicide, Journal of Advanced Nursing, online 030813 • Campbell, D. (2008) The father transference in a presuicidal state in S Briggs, A Lemma and W Crouch (eds) Relating to self-harm and suicide: psychoanalytic perspectives on practice, theory and research. (London, Routledge) • Cooper J., Kapur, N., Webb, R. Et al (2005) Suicide after deliberate self-harm a 4 year cohort study, American Journal of Psychiatry, 162, 297-303 • Crawford M., Thana L., Methuen C (2011) Impact of screening for suicide: randomised control trial. British Journal of Psychiatry, 198, 379-84 • Hale, R. (2008) Psychoanalysis and Suicide; Process and Typology in Briggs, S. Lemma, A., Crouch, W. (eds.) Relating to self-harm and suicide: psychoanalytic perspectives on theory, practice and prevention. London, Routledge • Harrington, R.et al (2006) Early adult outcomes of adolescents who deliberately poisoned themselves, J Am Acad Child Adolesc Psychiatry 45, 337-350 • Hatcher S. et al (2011) Self-harm: Zelen randomised controlled trial: Problem-solving therapy for people who present to hospital BJP 2011, 99:310-316

32. References • Hawton, K., Saunders, K and O’Connor, Rl (2012) Self-harm and suicide in adolescence, The Lancet, 379, 2373-82 • KapurN. Cooper, J., et al (2005) Predicting the risk of repetition after self-harm; cohort study. British Medical Journal, 330, 394-395 • Kendall, T. Taylor, C, Bhatti, H. Chan, M., Kapur, N., On behalf of the Guideline Development Group (2011) Longer term management of self-harm: summary of NICE guidance, BMJ 2011;343:d7073 doi: 10.1136/bmj.d7073Bergen et al. (2010) HMG/DH (2012) Preventing suicide in England; A cross-government outcomes strategy to save lives https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216928/Preventing-Suicide-in-England-A-cross-government-outcomes-strategy-to-save-lives.pdf • NICE (2011) Self-harm: longer-term management, (Clinical guideline CG133.) 2011. http://guidance.nice.org.uk/CG133 • O’Connor R. (2012) O’Connor et al (2012) Distinguishing adolescents who think about self-harm from those who engage in self-harm, British Journal of Psychiatry, 200, 330-335 • Owens C et al (2011) Recognising and responding to suicidal crisis within family and social networks: qualitative study British Medical Journal, BMJ 2011;343:d5801

33. References • Rossouw T. and Fonagy P. (2012) Mentalisation-Based Treatment for Self-Harm in Adolescents: A Randomized Controlled Trial, JAACAP, 51,12,1304-1313 • Rutherford, T. (2005) An exploration of the feelings of mothers of adolescent children who have attempted suicide. MA dissertation; University of East London/Tavistock Clinic • Saunders K, Hawton, K, Fortune S. et al (2011) Attitudes and knowledge of clinical staff regarding people who self-harm; systematic review, Journal of Affective Disorders, doi: 10.1016/j.jad.2011.08.024 • Slee N. et al (2008) Cognitive-behavioural intervention for self-harm: randomised controlled trial Br J Psychiatry. 2008 Mar;192(3):202-11 • Taylor, T., Hawton, K, Fortune, S et al (2009) Attitudes towards clinical services among people who self-harm; systematic review, British Journal of Psychiatry 194, 104-110 • Wright, J., Briggs, S., Behringer, J. (2005) Attachment and the body in suicidal adolescents. 2005 Journal of Clinical and Consulting Child Psychology, 10, 4, 477-491

34. Thank you Please contact me at s.briggs@uel.ac.uk www.stephenbriggsconsulting.co.uk