Overall Course Aims

2. Overall Course Aims To increase attendees’ understanding of mental health difficulties To explore issues regarding mental health in the assessment and management of need and risk To promote awareness and discussion of key issues such as jargon, stereotypes, stigma and diversity To increase staff confidence in working with offenders with mental health problems and referring them to local specialist mental health services

3. Overall Course Objectives To provide information regarding the existing legislative framework and potential changes to it To provide information regarding major mental illnesses, learning disabilities, psychopathic disorders, self-harm and suicide, PTSD, eating disorders and depression. To discuss the personal, social and cultural implications of mental health difficulties To provide information and discuss the assessment and management of mental health needs within risk assessment systems e.g. OASys To outline the structure and availability of key local services To explain jargon related to mental health and provide examples of its use To encourage participants to question myths, stigma and stereotypes associated with mental health disorder

4. Session 1: Glossary of Terms Used Session Aim(s): To promote awareness and discussion of key issues such as jargon, stereotypes, stigma and diversity Session Objective(s): To explain jargon related to mental health and provide examples of its use

5. Session 2: Mental Health, and Thinking About Myths, Stigma and Stereotypes Session Aim(s): To promote awareness and discussion of key issues such as jargon, stereotypes, stigma and diversity Session Objective(s): To discuss the personal, social and cultural implications of mental health difficulties To encourage participants to question myths, stigma and stereotypes associated with mental health disorder

6. Continuum of Mental Health and Illness Optimal Mental Wellness Serious Mental Illness

7. Famous People With a History of Mental Illness Winston Churchill Charles Dickens Stephen Fry Kurt Cobain Manic Depression Depression Bi-Polar Disorder/ Depression Manic Depression Also: Spike Milligan, Leo Tolstoy, Abraham Lincoln and others

8. Exercise 1: The Continuum of Mental Health

9. Media Stereotypes Media coverage of mental health issues often involves sensational headlines such as: ‘Cop killer had seen shrinks’ (The Sun, 14.6.07) ‘One person a week ‘killed by a mentally ill patient’’ (The Daily Mail, 3.12.06) ‘Ian’s terror at shooting, nutter guns down wife Jane’ (The Daily Star, 8.10.07) ‘Bloodbath psycho on bail’ (The Sun, 15.9.05)

10. The Impact of Stigma and Stereotypes: Experiences of Discrimination A survey of experiences of discrimination and stigma in relation to mental health found that: 56% of respondents reported discrimination within their own family 51% of respondents reported discrimination from friends 47% of respondents reported discrimination at work (Mental Health Foundation, 2000: 8)

11. The Impact of Stigma and Stereotypes: Disclosure Additionally, the survey showed that: 42% of respondents stated that they could not disclose details about mental distress to some members of their family 22% of respondents stated that they could not disclose details about mental distress to their partners 74% of respondents stated that they could not disclose details about mental distress on application forms 19% of respondents stated that they could not disclose details about mental distress to their GP (Mental Health Foundation, 2000: 12)

12. Exercise 2: Ms Sheila Jenkins

13. Session 3: A Brief Overview of a Range of Mental Health Disorders Session Aim(s): To increase attendees’ understanding of mental health difficulties To promote awareness and discussion of key issues such as jargon, stereotypes, stigma and diversity Session Objective(s): To provide information regarding major mental illnesses, learning disabilities, psychopathic disorders, self-harm and suicide, PTSD, eating disorders and depression To discuss the personal, social and cultural implications of mental health difficulties To explain jargon related to mental health and provide examples of its use To encourage participants to question myths, stigma and stereotypes associated with mental health disorder NACRO Standard 5: Equality and Diversity training to understand the needs of women, people from Black and Minority Ethnic communities, and other disadvantaged groups

14. The Topics Covered in This Section of the Training Mood (affective disorders) Depression Bi-polar affective disorder Eating Disorders Anorexia nervosa Bulimia nervosa Binge eating disorder Personality Disorders Psychotic Disorders Schizophrenia Reaction to severe stress Post-traumatic stress disorder (PTSD) Self-harm and Suicide Additional reading material is also available on learning disabilities

15. Factors Impacting Upon Mental Health Employment Homelessness Poverty Gender Degree of physical activity undertaken Stress Age Past experiences Ethnicity Self-esteem Complexity of mental health need Substance misuse Experiencing traumatic events Social support network/relationships Sexuality Attitudes of others towards the individual Degree of hope and determination that the individual has (Access to) appropriate service provision

16. Exercise 3: Reflecting on your preparatory study

17. Gender Women are more likely than men to be at risk of depression and/or anxiety (Piccinelli and Wilkinson, 2000), self-harm and eating disorders “Mental health problems are far more prevalent among women in prison than in the male prison population or in the general population” (Corston, 2007) “Outside prison men are more likely to commit suicide than women but the position is reversed inside prison” (Corston, 2007)

18. Sexuality A survey conducted by MIND (2003) showed that lesbian, gay and bisexual people reported more psychological distress than heterosexual people

19. Ethnicity “There were 5.6 times as many Black males admitted (to Special Hospitals and Medium Secure Units) than White males…” (Coid et al., 2000) Black Caribbean and Black African people are over-represented in psychiatric hospitals Black Caribbean people are more likely than white people to be diagnosed with schizophrenia Individuals from ethnic minorities are more likely to experience poor outcomes from treatment

20. Substance Misuse Someone who has both mental health problems and substance misuse problems is often labelled as having a ‘dual diagnosis’, and this group of people are particularly at risk of suicide/relapse ‘Co-morbidity’ is when an individual experiences two or more disorders Dual diagnosis can pose barriers to service access There is a direct relationship between some forms of drug misuse and some mental health problems such as drug induced psychosis Individuals who misuse alcohol often report symptoms of anxiety and depression Some people misuse substances as a form of self-medication to alleviate the symptoms of mental health problems

21. Exercise 4: Quiz on your mental health knowledge

22. Exercise 5: Reflection on Knowledge Gained and Future Learning Needs

23. Session 4: The Mental Health Act 1983 Session Aim(s): To explore issues regarding mental health in the assessment and management of need and risk Session Objective(s): To provide information regarding the existing legislative framework and potential changes to it NACRO Standard 5: Knowledge of the Mental Health Act 1983 and Codes of Practice

24. Session 4: Contents Part III of the Act Part II of the Act Related legislation Section 117 Aftercare The Mental Health Review Tribunal The Mental Health Act Commission

25. The Mental Health Act 1983 The act is divided into 10 parts: Part I: Application of the Act Part II: Compulsory Admission to hospital and guardianship (Civil) Part III: Patients concerned in criminal proceedings Part IV: Consent to treatment Part V: Mental Health Review Tribunals Part VI: Removal and return of patients within the UK Part VII: Management of property and affairs of patients Part VIII: Miscellaneous functions of Local Authorities and the Secretary of State Part IX: Offences Part X: Miscellaneous and Supplementary

26. Criteria for Compulsory Detention Patient must be: Suffering from a mental disorder within the meaning of the Act Unwilling for admission or treatment informally Detention must be necessary: To prevent harm to self To prevent harm to others For patient’s health To prevent deterioration in condition (psychopathic disorder only)

27. Sources of Referral for Admission Courts Prisons Special Hospitals General Psychiatric Hospital Wards Medium Secure Units

28. Part III – Section 35: Remand to Hospital for Report on Mental Condition Allows detention for a maximum of 12 weeks – imposed initially for 28 days then renewable for 28 days at a time Crown Court – patient awaiting trial for an imprisonable offence Magistrates Court – patient convicted of an imprisonable offence but not yet sentenced Not subject to consent to treatment provisions under the Act but can be treated with the patient’s consent or under common law Leave and discharge can only be granted by the court

29. Part III – Section 36: Remand to Hospital for Treatment Allows detention for a maximum of 12 weeks – imposed initially for 28 days then renewable for 28 days at a time Crown Court – patient in custody awaiting trial for an offence punishable by imprisonment Consent to Treatment provisions apply – treatment can be given with or without the patient’s consent Leave and discharge can only be granted by the court

30. Part III – Section 38: Interim Hospital Order Allows detention for an initial period of 12 weeks renewable for 28 days at a time but no more than 12 months in total Convicted by a court but not yet sentenced – order made to assess for mental disorder before disposal – usually under section 37 Consent to treatment provisions apply Leave and discharge can only be granted by the Court

31. Part III – Section 37: Hospital Order Allows detention for an initial period of 6 months renewable for a further 6 months and then annually Alternative to prison for offenders found to be suffering from mental disorder at the time of sentencing Consent to treatment provisions apply Leave can be authorised by RMO Discharge can be by RMO, Mental Health Review Tribunal (MHRT) or Hospital Managers

32. Part III – Section 41: Order Restricting Discharge When a Hospital Order is made, an order restricting discharge may be imposed alongside it making it a section 37/41 Grounds for restriction –the Court will consider: Nature of the offence Previous offences and nature of offences Risk of further offences if the person is not detained Protection of the public from harm Duration can be with or without limit of time Leave (outside hospital grounds) and transfer to another mental health facility can be grated by Home Office only Discharge by Home Office and MHRT only

33. Conditionally Discharged Patients Relates to patients detained under section 37/41 only MHRT can discharge the patient ‘conditionally’ and set those conditions – this may include where they must live or where they can or can’t go Section 41 remains to ensure that the patient continues to receive treatment and/or support once discharged The patient will not leave the detaining hospital until the conditions have been met and the MHRT gives approval The MHRT will reconvene in cases where the conditions have not been met The patient can be recalled to hospital if the conditions are broken or the patient is involved in an illegal activity The 37/41 will automatically be reinstated from the date of the original order and the patient will continue to be treated within the hospital setting Within one month of the recall the Home Office will refer the patient for an MHRT to be heard within 8 weeks 12 months after discharge (and then every 2 years) the patient can apply to the MHRT for an absolute discharge

34. Part III – Section 48: Transfer to Hospital of Unsentenced Prisoner The person is suffering from Mental Illness of a nature or degree appropriate for them to be detained in hospital for treatment and that the person is in urgent need of such treatment Duration: will cease once the patient is sentenced or returned to prison Home Office will make a restriction direction under section 49 for people detained in prison or on remand which has the same affect as section 41 On return to Court for final sentencing the order will cease to have effect and would be replaced by a section 37 or 37/41 if appropriate or, if the RMO considers the patient does not require treatment for a mental disorder, the patient would be returned to prison Consent to Treatment provisions apply Discharge, transfer and leave (outside the hospital grounds) can be granted by the Home Office only

35. Part III – Section 47: Transfer to Hospital of Sentenced Prisoner The person is suffering from Mental Illness or Psychopathic Disorder of a nature or degree appropriate for them to be detained in hospital for treatment Duration – could be without limit of time Home Office will make a restriction direction under section 49 for people serving their sentence in prison which has the same effect as section 41 – except where the transfer date is within two weeks of the Earliest Date of Release (EDR) in which case the transfer will be made under section 47 without restrictions and will remain a section 47 until the section is discharged. This is essentially the same as a section 37 or ‘notional’ 37 An Earliest Date of Release may apply at which date the patient would be re-graded to a ‘notional’ 37 – notional in this case simply means without a court order or other paperwork it is automatically re-graded The patient can be returned to prison prior to the EDR Consent to treatment provisions apply Discharge, transfer and leave (restricted cases) can be granted by the Home Office only

36. Part II – Section 3: Admission for Treatment Duration: Up to 6 months, renewable for a further 6 months and then annually Application: Approved Social Worker or nearest relative Criteria: a) mental illness, severe mental impairment, psychopathic disorder or mental impairment of a nature or degree which makes it appropriate for him/her to receive medical treatment, Or, b) in the case of psychopathic disorder or mental impairment such treatment is likely to alleviate or prevent a deterioration of the condition Discharge: Hospital Managers, MHRT or RMO

37. Related Legislation: Criminal Procedures (Insanity) Act 1964, Criminal Procedures (Insanity and Unfitness to Plead) Act 1991 The effect is essentially the same as that of a hospital order under section 37 of the Mental Health Act together with a restriction order under section 41 The patient has not yet stood trial for the offence of which they are accused The patient will remain under this Act until such time as their mental state has recovered sufficiently to attend court, appoint a defence and give evidence Consent to Treatment and appeal rights are the same as for section 37/41 Discharge, transfer and leave by permission of the Home Office only

38. Section 117 (Aftercare) The duty to provide aftercare services for any person to whom this section applies until they are no longer in need of these services Applies to all patients who have been subject to sections 3, 37, 37N, 37/41, 47, 47/49 and 48/49 The aim of a 117 meeting is to agree on aftercare plan based on the patient’s current needs. This will be monitored by the identified link person SW/CPN The meeting should cover the following areas: Housing Finances Relationships/family Employment Social needs Psychology/mental health difficulties Relapse predictors Known risk factors Discharge from a 117 is the joint responsibility of the patient’s health authority and their social services and would be done on the recommendation of the current RMO and multidisciplinary team

39. Mental Health Review Tribunals Independent body Members appointed by Lord Chancellor to review compulsory detention Empowered to: Discharge patients from hospital Recommend leave Decide if discharge should be delayed Impose conditions for discharge Patient/solicitor/Home Office can apply Written and verbal reports required from the RMO, Social Worker (and local authority link person) Date set for hearing (within 8 weeks for unrestricted cases and recalled patients) 3 MHRT members – legal member (chairperson), medical member and lay person Can decide to return the patient to prison to complete their sentence (47/49), await trial (48/49), absolutely discharge, conditionally discharge or not discharge May adjourn to a later date if further information or attendees required

40. Mental Health Act Commission Answerable to the Secretary of State Complies with direction from him/her Established to protect the rights and interests of all detained patients No power of discharge Duties: Review the operation of the Mental Health Act Monitor use of Consent to Treatment Code of Practice Regularly visit hospitals and nursing homes Provide second opinion doctors (SOAD) for patients who can’t or won’t consent to medication Receive complaints regarding the detention and treatment of detained patients Inspect legal documentation Issue practice notes on special issues relating to the Mental Health Act Monitor deaths of detained patients

41. Session 5: A Deeper Introduction to Mental Health Disorder Session Aim(s): To increase attendees’ understanding of mental health difficulties Session Objective(s): To provide information regarding major mental illnesses, learning disabilities, psychopathic disorders, self-harm and suicide, PTSD, eating disorders and depression NACRO Standard 5: Mental health awareness training including learning disability Risk assessment and risk management including risk of suicide and self-harm

42. Bi-Polar Affective Disorder: Session Overview General description of Bi-Polar Affective Disorder The ‘depressive’ element The ‘manic’ element Long term outcomes Treatment

43. General Description: Bi-Polar Affective Disorder Bi-Polar Affective Disorder is a mood-swing condition involving swings of mania (euphoric mood) and severe depression. It used to be known as manic depression, but bi-polar disorder is the preferred term now Symptoms of the disorder may appear ‘out of the blue’ Repeated episodes of mood disorder – sometimes mania, others depression – distinguishes it from recurrent depressive disorder (more common) The pattern of mood swings can vary enormously from person to person – both in type and frequency The term ‘mania’ reserved for more extremes of excitable behaviour, ‘hypomania’ is a more common and milder form The average age of diagnosis used to be 32 years, but is now usually under age 19 years. A recent documentary showed that in America, some Psychiatrists are diagnosing it in children aged less than 10 years There is no current method e.g. brain scan to ‘detect’ the presence of this disorder There is no simple cause of this disorder (such as a ‘bi-polar gene’) but there is some evidence of it association with internal chemical changes to the transmitters of mood to the brain. However, how this happens is not certain

44. Depressive Features Depression is a very common condition, and has a continuum from mild to moderate to severe, where mild depression may simply mean that an individual has to make an extra effort to do the things that they usually do, but severe means that every day activities may be completely impossible Distinctions – reactive – depression in response to life events / stress Endogenous – no obvious external cause Depression can be characterised by: Flattened/low mood Poor appearance – downcast, slow movements, poor dress sense (this may also be a feature of a manic episode), poor hygiene, lack of interest/concern with personal appearance Low energy levels/fatigue Loss of interest/pleasure in activities, reduced libido Disturbed sleep patterns e.g. early morning waking/trouble sleeping Slower speech patterns, reduced capacity to think/concentrate (severe) Low self-esteem/self-confidence up to the point of obsessiveness Suicidal thoughts Agitation, restless but pointless energy Anxiety (Occasionally) – delusions / hallucinations

45. Features of Hypomania Many of the symptoms of hypomania are the opposite of depression: Overactive/excited/euphoric mood Increased motor activity – may feel that you are performing better, which may progress to become chaotic. The individual may also have grandiose thoughts re: their ability – even to the extreme that they believe they are Godlike – may also link to delusions/hallucinations Dis-inhibition (can attract attention) Feeling that others are too ‘slow’ – can lead to irritation/anger with others – can become aggressive/violent May start to make unrealistic plans e.g. to spend lots of money, and may become irritated if these are thwarted Appearance – can be striking – may have dressed quickly and without care and/or have ‘wild eyes’ Hyperactive, unable to sit still / settle – perceive less need for sleep – prolonged activity can cause exhaustion/dehydration Rapid (incoherent) speech, which might be louder than usual

46. Potential Long-Term Outcomes Cumulative effects e.g. debts, arrest can lead to consequences beyond the episode and spark the cycle again Pregnant women with previous Bi-Polar episodes run a strong risk of relapse in/after a future pregnancy Individuals experiencing symptoms of bi-polar affective disorder may feel very frightened by them Estimate that 50% of people with serious and untreated bi-polar affective disorder attempt suicide. 20% of those are successful

47. Treatment Diagnosis of Bi-Polar Affective Disorder has become more sophisticated recently – people may be told that they are bi-polar 1/2/3 now – a reflection of the severity and duration of moods Treatment can be problematic due to the lack of insight that people with the disorder may have into their condition Lithium carbonate (or anti-epileptics) is often used to treat bi-polar affective disorder. This medication stabilises mood swings. Tranquilisers can also be used, and occasionally ECT is used. It is important that those with the disorder are able to recognise the early signs of mood swings, and that they continue to take their medication even though they may feel good during a manic episode. Carers need to ensure that an individual is safe and hydrated during a manic episode, and consider suicide risk during periods of depression.

48. Exercise 6: Ms Sheila Jenkins (Part 2)

49. Schizophrenia: Session Overview General introduction to schizophrenia Causes Symptoms (positive and negative) Phases of Illness Recovery Rates Associated Problems Treatments Schizophrenia and violence Schizophrenia and substance use Consequences of co-morbidity Substitute behaviours

50. General Introduction to Schizophrenia Usually occurs in males during late teens – mid 20s Usually occurs in women during their 20s – 30s 1/100 people under the age of 45 years are affected by schizophrenia worldwide – schizophrenia is found in all cultures in all countries There is a roughly similar gender division

51. Causes There are a number of theories considered as being a cause of schizophrenia: Genetic - if a parent or sibling has a history of schizophrenia Problems during the pregnancy – exposed to viral infection, malnutrition and starved of oxygen during birth Substance Abuse – continuous and long term use of illicit drugs IF you have vulnerabilities to illicit drugs Season of birth Chemistry in the brain going wrong (dopamine) How the brain develops (enlarged ventricles) Stress reaction to life events (already vulnerable)

52. Symptoms: Positive Hallucinations: seeing, hearing or smelling things that are not there e.g. auditory hallucination of voices (which the sufferer may respond to) Delusions: firmly held beliefs which are untrue i.e. you are Jesus or a member of royalty/you are being controlled by an outside force Thought disorder: confused thoughts or speech which do not make any sense (sufferer may be paranoid that someone wants to harm them/their relatives). Sufferer may also use invented words (neologisms)/muddle word order.

53. Symptoms: Negative Decreased motivation Lack of emotion Poor concentration Inability to experience pleasure in things you once enjoyed e.g. golf/socialising Avoiding social situations Reduced speech Neglecting personal appearance A sufferer may not believe that they are ill even when they are behaving strangely.

54. Phases of Illness: Prodromal This is the initial stage and may last for days or months Negative symptoms may emerge either slowly or can appear rapidly: Social withdrawal Poor hygiene – wearing dirty clothes, stop bathing Loss of interest Angry outbursts Decreased motivation Decreased emotions Terror or unreasonable fear of someone or something

55. Phases of Illness: Active/Acute Phase Stressful events, emotional trauma and substance misuse can trigger symptoms of Schizophrenia in those vulnerable to the illness Positive symptoms begin to occur (hallucinations, delusions and thought disorder) Negative symptoms may still be prominent during this stage During this phase, symptoms may fluctuate between severe and stabilized episodes. A person with Schizophrenia usually develops a pattern of illness within the first five years of illness

56. Phases of Illness: Residual Phase Positive symptoms become less intense Regain some social and occupational skills (the later in life you develop Schizophrenia, the more skills you retain) Symptoms become easier to manage Some people may recover fully

57. Recovery Rates Recovery rates vary Relapse signature (prodromal phase)

58. Associated Problems Increased risk of homelessness Increased risk of substance abuse Increased isolation due to thoughts and behaviour Decreased social support Increased interpersonal conflict

59. Treatments The goals of treatment are to eliminate/reduce symptoms, reduce the number of relapses and to reduce the severity of the illness Medication (anti-psychotics) are the most common and effective treatments in psychosis (may be given as a depot injection which releases a drug over several weeks to aid compliance with medication) CBT (Cognitive Behavioural Therapy) teaching the person about their illness, triggering factors which contribute to symptoms, and relapse prevention Social Skills Training, developing communications and coping strategies

60. Schizophrenia and Violence Despite popular belief, people with Schizophrenia are more likely to hurt themselves than others. Violence is NOT a symptom of Schizophrenia 1/3 of Schizophrenic’s will attempt suicide. 1 in 10 will succeed Predicting violence is difficult. However, the following should indicate an increased risk: History of violent behaviour Substance abuse Non-compliance with medication Intense and uncontrollable anger due to command hallucinations or paranoid beliefs

61. Schizophrenia and Substance Use Substance misuse can cause the onset of psychosis and is associated with earlier onset of illness Substance use can alter the clinical presentation of mental illness or exacerbate existing psychotic symptoms Higher rates of re-admission to hospital A clear link between violence/aggression and substance use

62. Consequences of Co-Morbidity Increase of symptoms Increased rates of hospitalisation and longer treatment times Higher rates of relapse Poor physical health (including HIV, Hepatitis A, B and C) Poor medication compliance Increased rates of aggression, violence, crime, DSH and suicide Poor engagement with services

63. Substitute Behaviours Increased smoking Rolling cigarettes in funnels Increased use of medication Increased caffeine intake Listening to related music Self induced euphoria

64. Exercise 7: Mr Alistair Phillips

65. Self-harm and Suicide: Session Overview Definitions Facts and figures At risk groups Why deliberate self-harm? Assessing risk What to do

66. Definitions Suicide: ‘the act of killing oneself/taking one’s own life’ (implies intent) Deliberate Self Harm: a deliberate, single, non-fatal act, which may be a response to psychological pain. NICE definition: ‘self-poisoning or injury, irrespective of the apparent purpose of the act’ (2004: 7)

67. Facts and Figures Approximately 6000 people in the UK killed themselves in 2004 There has been an overall reduction in male suicide rates in the UK since 1998, and female rates have consistently remained lower than male rates From 1998 onwards the highest suicide rates in the UK are males aged 15-44. From 1991-2004, the highest female suicide rates were in elderly women aged 75+ Scotland has the highest UK suicide rate for both sexes – the male rate in Scotland is over 50% higher than the overall UK rate. Similarly, the female suicide rate in Scotland has been consistently higher than that in the UK as a whole There appears to be an association between suicide and deprivation in England and Wales – suicide rates for both sexes in the most deprived areas were double those in the least deprived areas Source: Brock et al., (2006)

68. ‘At Risk’ Groups A Home Office study showed that deaths among ex-prisoners under community supervision mostly occurred soon after release – 25% of deaths had occurred within four weeks of release, and over 50% had occurred by 12 weeks after release. The largest proportion of these deaths was due to accidents (Sattar, 2001: vi) Most suicides occur in young adult males – suicide is the most common cause of death in men aged less than 35 years (DH, 2002) Risks factors also include living alone, having a poor educational /occupational history, being in a low social class, having a history of deliberate self-harm, mental health problems (e.g. command hallucinations) and heavy substance/alcohol misuse (DH, 2002)

69. Why Deliberate Self-Harm? Usually more than one reason Provides a relief from/form of expression of distress Often provides a temporary escape from problems Can be the result of social reinforcement – take me seriously, give me attention, let me control you Form of self-punishment Means of the individual making themselves feel less (sexually) attractive May arise through thought commands (psychosis) Means of re-engaging with reality – people may inflict a sharp pain to bring them ‘down-to-earth’ (disassociation) Form of (male) risk-taking behaviour

70. Assessing Risk Consider: Method of self-harm Minimal physical risk / cosmetic damage – cutting (except neck, stabbing) High risk of non-fatal physical impairment – bleach, weed killer, head-banging High risk of fatality –slow overdoses likely to be fatal, injecting insulin users, lithium, paracetamol, Benzos, Diazepam, anti-depressants (less now but watch for old prescriptions), caustic soda, ligatures Personal Factors High stress levels (staff member) Ethical issues – hard / impossible to have neutral position

71. When undertaking risk assessments… Staff should rely on interviewing and gathering information rather than using written tests: Start with statistical at risk factors – age, gender, time and date, hospital discharge Use observation (look as well as listen), third parties Use a protocol – balance your feelings Interviews – look for statements, hints, observational evidence (co-working of a case may be beneficial) Ask direct questions about the nature of the current crisis, frequency and duration of thoughts, and the individual’s ability to resist them Also ask directly about type of harm, whether this is being actively planned, and investigate what opportunities there are to carry out self-harm/suicidal thoughts (keep this in mind especially if the person is not likely to be in contact with other people for long periods of time)

72. What To Do You will not necessarily be expected to follow all of these points, but some may apply more to certain areas of probation practice than others: Keep calm and try not to feel personally responsible for the distress/safety of the individual – co-work particularly concerning cases if possible, and remember that service-user surveys have shown that individuals who self-harm do not necessarily want professionals that they encounter to have stopping their self-harming behaviour as a goal Consider contacting mental health services/GP for further assessment Limit opportunities and access Practical help e.g. giving local NHS leaflets/discussing possible sources of support for distress e.g. individual’s own social network if appropriate NICE (2004) – guidelines ‘private’ cutting, sharps etc Suggest use of alternatives e.g. ice/elastic bands Problem solving Threats etc deal with minimum interaction, first aid Try to build the individual’s self-esteem Do not criticise/punish (but equally do not encourage) self-harm behaviour – many service users state that they have felt ignored/punished for their behaviour

73. Exercise 8: Mr Phillips (Part 2)