1. longer-term management
Self-harm:
longer-term management
Implementing NICE guidance
ABOUT THIS PRESENTATION:
This presentation has been written to help you raise awareness of the NICE clinical guideline on ‘Self-harm: longer-term management’. This guideline has been written for all health and social care professionals who come into contact with people aged 8 and older who self-harm.
The guideline is available in several formats: the NICE guidance, the full guideline, a NICE pathway, and a version for patients known as ‘Understanding NICE guidance’. The presenter should download a copy of the NICE guideline to refer to if needed during the presentation.
You can add your own organisation’s logo alongside the NICE logo.
We have included notes for presenters, broken down into ‘key points to raise’, which you can highlight in your presentation, and ‘additional information’ that you may want to draw on, such as a rationale or an explanation of the evidence for a recommendation. Where necessary, the recommendation will be given in full.
DISCLAIMER
This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself.
PROMOTING EQUALITY
Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties.
November 2011
NICE clinical guideline 133

2. Related guidance
‘Self-harm: short-term treatment and management’ (NICE clinical guideline 16) covers the treatment of self-harm within the first 48 hours of an incident. Self-harm: longer-term management, clinical guideline 133 , deals with the longer-term psychological treatment and management of both single and recurrent episodes of self-harm. A small number of amendments have been made to CG16 to ensure alignment with the longer-term management guideline.
NOTES FOR PRESENTERS:
This guideline follows on from 'Self-harm: the short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care' (NICE clinical guideline 16) that covered the treatment of self-harm within the first 48 hours of an incident.
This guideline is concerned with the longer-term psychological treatment and management of both single and recurrent episodes of self-harm, and does not include recommendations for the physical treatment of self-harm or for psychosocial management in emergency departments (these can be found in NICE clinical guideline 16).
NICE clinical guideline 16 has had a small number of amendments to ensure it is aligned with the longer-term management guideline.
Other related NICE guidance:
Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. NICE clinical guideline 115 (2011). Available from
Depression: the treatment and management of depression in adults. NICE clinical guideline 90 (2009). Available from
Schizophrenia: core interventions in the treatment and management of schizophrenia in adults in primary and secondary care. NICE clinical guideline 82 (2009). Available from
Borderline personality disorder: treatment and management. NICE clinical guideline 78 (2009). Available from
Drug misuse: opioid detoxification. NICE clinical guideline 52 (2007). Available from
Drug misuse: psychosocial interventions. NICE clinical guideline 51 (2007). Available from
Bipolar disorder: the management of bipolar disorder in adults, children and adolescents, in primary and secondary care. NICE clinical guideline 38 (2006). Available from
Self-harm: the short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care. NICE clinical guideline 16 (2004). Available from

3. What this presentation covers
Definition
Background
Epidemiology
Scope
Key priorities for implementation
Costs and savings
Discussion
NICE Pathway and NHS Evidence
Find out more
NOTES FOR PRESENTERS:
In this presentation we will start by providing some background to the guideline and why it is important.
We will then present the key priorities for implementation. The NICE guideline contains 11 key priorities for implementation, which you can find on pages 7–11 of the NICE guideline.
The key priorities for implementation cover the following areas:
working with people who self-harm
psychosocial assessment
risk assessment
risk assessment tools and scales
care plans
risk management plans
interventions for self-harm
treating associated mental health conditions
Next, we will summarise the costs and savings that are likely to be incurred in implementing the guideline.
Then we will open the meeting up with a list of questions to help prompt a discussion on local issues for incorporating the guidance into practice.
Following this we will look at the NICE pathway for self-harm and the self-harm topic page on NHS Evidence.
Finally, we will end the presentation with further information about the support provided by NICE.

4. Definition
The term self-harm is used in this guideline to refer to any act of self-poisoning or self-injury. This commonly involves self-poisoning with medication or self-injury by cutting. The term self-harm is not intended to cover harm to the self arising from excessive consumption of alcohol or recreational drugs, body piercing, mismanagement of physical health conditions or starvation arising from anorexia nervosa.
NOTES FOR PRESENTERS:
The term self-harm is used in this guideline to refer to any act of self-poisoning or self-injury carried out by an individual irrespective of motivation. This commonly involves self-poisoning with medication or self-injury by cutting. This term is not intended to cover: harm to self arising from excessive consumption of alcohol or recreational drugs, mismanagement of physical health conditions, body piercing or starvation arising from anorexia nervosa.
Additional information:
In the past, various terms have been used including ‘attempted suicide’ and parasuicide (Kreitman 1977). Attempted suicide has been used to describe self-harm in which the primary motivation was to end life. It became clear that motivation is complex and does not fall neatly into these categories. Terms such as ‘non fatal deliberate self-harm’ (Morgan et al. 1975) were preferred because this avoided inferring anything about the motivation behind the behaviour. However, the word ‘deliberate’ has been dropped because this can be considered judgemental and it has been argued that the extent to which the behaviour is ‘deliberate’ or ‘intentional’ is not always clear. Those who harm themselves during a dissociative state often describe diminished or absent awareness of their actions at these times.
References
Kreitman N (1977) Parasuicide. London: Wiley
Morgan HG, Burns-Cox CJ, Pocock H et al. (1975) Deliberate self-harm: clinical and socio-economic characteristics of 368 patients. British Journal of Psychiatry 127: 564–74

5. Background
Self-harm does not often result from the wish to die. Those who self-harm may do so to communicate, to secure help and care or to obtain relief from an overwhelming situation.
Service provision for self-harm is varied. About half of those presenting at an emergency department after an incident of self-harm are assessed by a mental health professional.
NOTES FOR PRESENTERS:
Key points to raise:
Self-harm does not often result from the wish to die. Those who self-harm may do so to communicate with others or influence them to secure help or care. They may self-harm in order to obtain relief from a particular emotional state or overwhelming situation.
One hallmark of service provision for self-harm has been its variability. This variability has been consistent over time. Studies have also suggested under-provision in respect to self- harm services. Possible reasons for poor services include limited resources, lack of an evidence base for treatments, and the unpopularity of this group of service users among some clinical staff.

6. Epidemiology Self-harm is common, especially among younger people
For all age groups, annual prevalence is approximately 0.5%
Self-harm increases the likelihood that the person will eventually die by suicide by between 50 and 100 fold
Psychiatric problems such as borderline personality disorder, depression, bipolar disorder, schizophrenia and drug and alcohol-use disorders are associated with self-harm.
NOTES FOR PRESENTERS:
Key points to raise:
Self-harm is common, especially among younger people. A survey of young people aged 15–16 estimated that more than 10% of girls and more than 3% of boys had self-harmed in the previous year. Self-harm is one of the top-five causes of acute medical admissions for both women and men in the UK (NHS Information Centre 2008).
Self-harm increases the likelihood that the person will eventually die by suicide by between 50 and 100 fold above the rest of the population in a 12-month period.
A wide range of psychiatric problems, such as borderline personality disorder, depression, bipolar disorder, schizophrenia and drug and alcohol-use disorders are associated with self- harm.

7. Scope This guideline covers: all people aged 8 years and older
healthcare professionals who have direct contact with people who self-harm
medium and longer term care management
primary, secondary, tertiary and community care.
NOTES FOR PRESENTERS:
The guideline does not cover people with a neurodevelopmental disorder with repetitive stereotypical self-injurious behaviour, for example head-banging in people with a significant learning disability.
The guideline covers care received in primary, secondary, tertiary and community healthcare settings from healthcare professionals who have direct contact with people who self-harm, and who make decisions about risk assessment, needs assessment, treatment and management of care for people who self-harm.
Additional information:
Clinical issues that the guideline covers:
Medium and longer term care management of people who self-harm.
Ongoing psychosocial assessment for the longer term management of people who have self- harmed. This will include an assessment of needs and risk and how these are integrated.
Psychosocial interventions for the specific treatment of self-harm compared with control groups and other active interventions. For example, but not exclusively, self-help, problem-solving therapy, mentalisation-based treatment, cognitive behavioural therapy, dialectical behaviour therapy, cognitive analytic therapy, psychodynamic psychotherapy and family therapy.
Pharmacological interventions for the specific treatment of self-harm compared with control groups and psychological interventions. For example, antidepressants, anxiolytics and antipsychotics when used as a specific treatment for self-harm.
Safe prescribing for people with a history of self-harm.
Treatment of groups who may have specific care needs. For example, those from black and minority ethnic groups, people who self-injure, young people and older adults.
Harm minimisation and other strategies aimed at reducing the risks and/or harm associated with self-harm. For example, advice on safer cutting, distraction techniques and exploring alternatives to self-harm.
Possible adverse effects associated with treating self-harm.
Training for healthcare professionals treating people who self-harm.
When to refer to other NICE guidelines for the treatment and management of any accompanying or underlying mental health problems.

8. Key priorities for implementation
Working with people who self-harm
Psychosocial assessment
Risk assessment
Risk assessment tools and scales
Care plans
Risk management plans
Interventions for self-harm
Treating associated mental health conditions.
NOTES FOR PRESENTERS:
The NICE guideline contains 57 recommendations about how care can be improved, but the experts who wrote the guideline have chosen key recommendations that they think will have the greatest impact on care and are the most important priorities for implementation. They are divided into eight areas of key priority (KPI) and within these there are 11 recommendations that we will consider in turn.
This slide set also covers some recommendations that are not key priorities. These are highlighted because they form important parts of the care pathway.

9. Working with people who self-harm
Health and social care professionals should:
aim to develop a trusting and supportive relationship
be aware of stigma and discrimination
ensure that people are involved in decision-making about their care
aim to foster people’s autonomy and independence
aim to maintain continuity of therapeutic relationships
ensure that information about episodes of self-harm is communicated sensitively to other team members.
NOTES FOR PRESENTERS:
Recommendation in full:
Health and social care professionals working with people who self-harm should:
-aim to develop a trusting, supportive and engaging relationship with them
-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. [1.1.1]
Related recommendation:
Health and social care professionals who work with people who self-harm should be:
-familiar with local and national resources, as well as organisations and websites that offer information and/or support for people who self-harm, and
-able to discuss and provide advice about access to these resources. [1.1.2]
Additional information:
Reputable national sources of information include: NHS Evidence, Royal college of psychiatry, MIND, Papyrus, Samaritans, Centre for Suicide Prevention at the University of Manchester, and the Centre for Suicide Prevention at the University of Oxford. Health and social care professionals should have a knowledge of local support groups as well as an awareness of websites that are potentially harmful.
NICE is not responsible for the quality or accuracy of, and does not endorse, any information or advice provided by other organisations.

10. Access to services
Children and young people should have access to a full range of treatments and services within child and adolescent mental health services (CAMHS).
Ensure that people from black and minority ethnic groups have the same access to services as other people and that services are culturally appropriate.
People with a mild learning disability should have the same access to services as other people.
NOTES FOR PRESENTERS:
This slide is based on recommendations related to access to services. These are not key priorities for implementation. However access to care is an important part of the care pathway and ensures the continuation of care following the short-term management of self-harm. (for more information on the short-term management of self-harm, please refer to clinical guideline 16.)
Recommendations in full:
Children and young people who self-harm should have access to the full range of treatments and services recommended in this guideline within child and adolescent mental health services (CAMHS). [1.1.3]
Ensure that children, young people and adults from black and minority ethnic groups who self-harm have the same access to services as other people who self-harm based on clinical need and that services are culturally appropriate. [1.1.4]
When language is a barrier to accessing or engaging with services for people who self-harm, provide them with:
-information in their preferred language and in an accessible format
-psychological or other interventions, where needed, in their preferred language
-independent interpreters. [1.1.5]
People with a mild learning disability who self-harm should have access to the same age-appropriate services as other people covered by this guideline. [1.1.6]
When self-harm in people with a mild learning disability is managed jointly by mental health and learning disability services, use the Care Programme Approach (CPA). [1.1.7]
People with a moderate or severe learning disability and a history of self-harm should be referred as a priority for assessment and treatment conducted by a specialist in learning disabilities services. [1.1.8]

11. Training Health and social care professionals should be:
trained in the assessment, treatment and management of self-harm, and
educated about the stigma and discrimination usually associated with self-harm and the need to avoid judgemental attitudes.
Routine access to senior colleagues for supervision, consultation and support should be provided for professionals who work with people who self-harm.
NOTES FOR PRESENTERS:
This slide is based on recommendations related to training for health and social care professionals. These are not key priorities for implementation but are an important part of ensuring quality care is delivered.
Recommendations in full:
Health and social care professionals who work with people who self-harm (including children and young people) should be:
-trained in the assessment, treatment and management of self-harm, and
-educated about the stigma and discrimination usually associated with self-harm and the need to avoid judgemental attitudes. [1.1.9]
Health and social care professionals who provide training about self-harm should:
-involve people who self-harm in the planning and delivery of training
-ensure that training specifically aims to improve the quality and experience of care for people who self-harm
-assess the effectiveness of training using service-user feedback as an outcome measure. [1.1.10]
Routine access to senior colleagues for supervision, consultation and support should be provided for health and social care professionals who work with people who self-harm. Consideration should be given of the emotional impact of self-harm on the professional and their capacity to practice competently and empathically. [1.1.11]

12. Safeguarding
CAMHS professionals should consider whether the child’s or young person’s needs should be assessed. If children or young people are referred to CAMHS under local safeguarding procedures, use a multi-agency approach including social care and education and consider using the Common Assessment Framework. Consider the risk of domestic or other violence and consider local safeguarding procedures for vulnerable adults and children in their care.
NOTES FOR PRESENTERS:
Safeguarding is not a KPI but is an important consideration for this group of patients and thus is covered within this presentation.
Recommendations in full:
CAMHS 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. [1.1.19]
If children or young people who self-harm are referred to CAMHS under 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
-consider using the Common Assessment Framework; advice on this can be sought from the local named lead for safeguarding children.
If serious concerns are identified, develop a child protection plan. [1.1.20]
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. Advice on this can be obtained from the local named lead on safeguarding adults. [1.1.21]
Key point to raise:
For all children and young people presenting with self-harm mental health professionals should consider whether the child / young persons circumstances and / or presentation raise safeguarding concerns and act accordingly.  Any such concerns, whether they require action or not, should be documented in the clinical record.

13. Families, carers and significant others
Ask the person who self-harms whether they would like their family, carers or significant others to be involved in their care.
Subject to the person’s consent and right to confidentiality, encourage the family, carers or significant others to be involved where appropriate.
NOTES FOR PRESENTERS:
This slide is based on recommendations related to families, carers and significant others. These are not key priorities for implementation but are essential to the support network for those who self-harm and are thus included in this presentation.
Recommendations in full:
Ask the person who self-harms whether they would like their family, carers or significant others to be involved in their care. Subject to the person's consent and right to confidentiality, encourage the family, carers or significant others to be involved where appropriate. [1.1.22]
When families, carers or significant others are involved in supporting a person who self-harms:
-offer written and verbal information on self-harm and its management, including how families, carers and significant others can support the person
-offer contact numbers and information about what to do and whom to contact in a crisis
-offer information, including contact details, about family and carer support groups and voluntary organisations, and help families, carers or significant others to access these
-inform them of their right to a formal carer's assessment of their own physical and mental health needs, and how to access this. [1.1.23]
CAMHS professionals who work with young people who self-harm should balance the developing autonomy and capacity of the young person with perceived risks and the responsibilities and views of parents or carers. [1.1.24]

14. Managing endings and supporting transitions
Anticipate that the ending of treatment, services or relationships, as well as transition, can provoke strong feelings and increase the risk of self-harm. Plan in advance changes with the person who self-harms and provide additional support if needed. CAMHS and adult mental health services should work collaboratively to ensure as smooth a transition as possible.
NOTES FOR PRESENTERS:
This slide is not based on key priorities for implementation but has been highlighted as a potential issue and so is covered in this guideline.
Recommendations in full:
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 and:
-Plan in advance these changes with the person who self-harms and provide additional support, if needed, with clear contingency plans should crises occur.
-Record plans for transition to another service and share them with other health and social care professionals involved.
-Give copies to the service user and their family, carers or significant others if this is agreed with the service user. [1.1.25]
CAMHS and adult health and social care professionals should work collaboratively to minimise any potential negative effect of transferring young people from CAMHS to adult services.
-Time the transfer to suit the young person, even if it takes place after they reach the age of 18 years.
-Continue treatment in CAMHS beyond 18 years if there is a realistic possibility that this may avoid the need for referral to adult mental health services. [1.1.26]
Mental health trusts should work with CAMHS to develop local protocols to govern arrangements for the transition of young people from CAMHS to adult services, as described in this guideline. [1.2.27]

15. Primary care
If a person presents in primary care with a history of self-harm and a risk of repetition, consider referring them to community mental health services for assessment. If a person who self-harms is receiving treatment in primary care and secondary care, primary and secondary care and social care professionals should ensure they work cooperatively. Primary care professionals should monitor the physical health of people who self-harm.
NOTES FOR PRESENTERS:
This slide is not based on a KPI. Primary care is covered within this slide set as care for physical health is provided by primary care and is therefore key for people who self-harm. Primary care provide care following attendance at emergency departments and these recommendations follow on from those in the short-term guideline.
Recommendations in full:
If a person presents in primary care with a history of self-harm and a risk of repetition, consider referring them to community mental health services for assessment. If they are under 18 years, consider referring them to CAMHS for assessment. Make referral a priority when:
-levels of distress are rising, high or sustained
-the risk of self-harm is increasing or unresponsive to attempts to help
-the person requests further help from specialist services
-levels of distress in parents or carers of children and young people are rising, high or sustained despite attempts to help. [1.2.1]
If a person who self-harms is receiving treatment or care in primary care as well as secondary care, primary and secondary health and social care professionals should ensure they work cooperatively, routinely sharing up-to-date care and risk management plans. In these circumstances, primary health and social care professionals should attend CPA meetings. [1.2.2]
Primary care professionals should monitor the physical health of people who self-harm. Pay attention to the physical consequences of self-harm as well as other physical healthcare needs. [1.2.3]

16. Psychosocial assessment: 1
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.
During assessment, explore the meaning of self-harm for the person and take into account that each person self-harms for individual reasons. Each episode of self- harm should be treated in its own right.
NOTES FOR PRESENTERS:
Recommendation in full:
Offer an integrated and comprehensive psychosocial assessment of needs (see recommendations 1.3.2–1.3.5 of the NICE guideline) and risks (see recommendations 1.3.6–1.3.8 of the NICE guideline) to understand and engage people who self-harm and to initiate a therapeutic relationship. [1.3.1]
Related recommendation:
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. [1.3.5]
Additional information:
The term ‘Psychosocial assessment’ as used here refers to a comprehensive assessment including an evaluation of risk and needs. The assessment of needs is designed to identify those personal psychological and environmental (social) factors that might explain an act of self-harm. This assessment should lead to a formulation, from which a management plan can be developed.
This assessment should be carried out in a very personal way and professionals should adopt the non-judgemental, supportive manner discussed earlier in this presentation (see slide 9).

17. Psychosocial assessment: 2
All people over 65 years should be assessed by mental health professionals experienced in the assessment of older people who self-harm. Within this age group particular attention should be paid to the potential presence of depression, cognitive impairment and physical ill health.
Follow the same principles as for adults when assessing children and young people.
NOTES FOR PRESENTERS:
This slide is based on recommendations and which are not key priorities for implementation (KPIs) but are related to and which are KPIs and are so covered in this presentation.
Recommendations in full:
All people over 65 years who self-harm should be assessed by mental health professionals experienced in the assessment of older people who self-harm. Assessment should follow the same principles as for working-age adults who self-harm (see recommendations and of the NICE guideline). In addition:
-pay particular attention to the potential presence of depression, cognitive impairment and physical ill health
-include a full assessment of the person's social and home situation, including any role they have as a carer, and
-take into account the higher risks of suicide following self-harm in older people. [1.3.3]
Follow the same principles as for adults when assessing children and young people who self-harm (see recommendations and of the NICE guideline), but also include a full assessment of the person’s family, social situation, and child protection issues. [1.3.4]

18. Personal assessment skills, strengths and assets coping strategies
Assessment of needs should include:
skills, strengths and assets
coping strategies
mental and physical health problems or disorders
social circumstances and problems
psychosocial and occupational functioning, and
vulnerabilities
recent and current life difficulties
the need for intervention and treatment for any associated conditions
the needs of any dependent children.
NOTES FOR PRESENTERS:
Recommendation in full:
Assessment of needs should include:
-skills, strengths and assets
-coping strategies
-mental health problems or disorders
-physical health problems or disorders
-social circumstances and problems
-psychosocial and occupational functioning, and vulnerabilities
-recent and current life difficulties, including personal and financial problems
-the need for psychological intervention, social care and support, occupational rehabilitation, and also drug treatment for any associated conditions
-the needs of any dependent children. [1.3.2]

19. Risk assessment: 1
When assessing the risk of repetition of self-harm or risk of suicide, identify and agree the person’s specific risks, taking into account:
methods and frequency of current and past self-harm
current and past suicidal intent
depressive symptoms
any psychiatric illness
the personal and social context and any other specific factors preceding self-harm.
NOTES FOR PRESENTERS:
Recommendation in full:
When assessing the risk of repetition of self-harm or risk of suicide, identify and agree with the person who self-harms the specific risks for them, taking into account:
-methods and frequency of current and past self-harm
-current and past suicidal intent
-depressive symptoms and their relationship to self-harm
-any psychiatric illness and its relationship to self-harm
-the personal and social context and any other specific factors preceding self-harm, such as specific unpleasant affective states or emotions and changes in relationships
-specific risk factors and protective factors (social, psychological, pharmacological and motivational) that may increase or decrease the risks associated with self-harm
-coping strategies that the person has used to either successfully limit or avert self-harm or to contain the impact of personal, social or other factors preceding episodes of self-harm
-significant relationships that may either be supportive or represent a threat (such as abuse or neglect) and may lead to changes in the level of risk
-immediate and longer-term risks. [1.3.6]
Related information:
A risk assessment is a detailed clinical assessment that includes the evaluation of a wide range of biological, social and psychological factors that are relevant to the individual and, in the judgement of the healthcare professional conducting the assessment, relevant to future risks, including suicide and self-harm.

20. Risk assessment: 2 Also take into account:
specific risk and protective factors that may increase or decrease the risks associated with self-harm
coping strategies
significant relationships that may either be supportive or represent a threat
immediate and longer-term risks.
NOTES FOR PRESENTERS:
Recommendation in full:
When assessing the risk of repetition of self-harm or risk of suicide, identify and agree with the person who self-harms the specific risks for them, taking into account:
-methods and frequency of current and past self-harm
-current and past suicidal intent
-depressive symptoms and their relationship to self-harm
-any psychiatric illness and its relationship to self-harm
-the personal and social context and any other specific factors preceding self-harm, such as specific unpleasant affective states or emotions and changes in relationships
-specific risk factors and protective factors (social, psychological, pharmacological and motivational) that may increase or decrease the risks associated with self-harm
-coping strategies that the person has used to either successfully limit or avert self-harm or to contain the impact of personal, social or other factors preceding episodes of self-harm
-significant relationships that may either be supportive or represent a threat (such as abuse or neglect) and may lead to changes in the level of risk
-immediate and longer-term risks. [1.3.6]
Related recommendations:
Consider the possible presence of other coexisting risk-taking or destructive behaviours, such as engaging in unprotected sexual activity, exposure to unnecessary physical risks, drug misuse or engaging in harmful or hazardous drinking. [1.3.7]
When assessing risk, consider asking the person who self-harms about whether they have access to family members’, carers’ or significant others' medications. [1.3.8]
In the initial management of self-harm in children and young people, advise parents and carers of the need to remove all medications or, where possible, other means of self-harm available to the child or young person. [1.3.9]
Be aware that all acts of self-harm in older people should be taken as evidence of suicidal intent until proven otherwise. [1.3.10]

21. Risk assessment tools and 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 include the areas identified in recommendation on slides 19 and 20.
NOTES FOR PRESENTERS:
Recommendation in full:
Do not use risk assessment tools and scales to predict future suicide or repetition of self-harm. [1.3.11]
Related recommendations:
Do not use risk assessment tools and scales to determine who should and should not be offered treatment or who should be discharged. [1.3.12]
Risk assessment tools may be considered to help structure risk assessments as long as they include the areas identified in recommendation of the NICE guideline and on slides 10 and 11. [1.3.13]
Related information:
Risk assessment tools and scales are usually checklists that can be completed and scored by a clinician or sometimes the service user depending on the nature of the tool or scale. They are designed to give a crude indication of the level of risk (for example, high or low) of a particular outcome, most often suicide.
There is increasing emphasis on the assessment of risk in clinical services. Risk assessment in mental health is a broad concept which covers a judgement of the likelihood of an adverse outcome such as suicide or self-harm but also of violence, risk to children, risk of exploitation and environmental risks such as safety in the home. Risk assessment in the UK is carried out by undertaking a clinical interview and this often includes a checklist of risk factors derived from an assessment scale. In the UK, there is no consistency in the risk assessment tools used by different mental health services. Despite the widespread use of these instruments, there is no clear evidence that their use makes any difference to patient outcome. The usefulness of any particular risk assessment scale for repeated self-harm depends on the ability to correctly distinguish all those who do go on to self-harm from those who do not. Whilst the risk of repeated self-harm is important, healthcare professionals will be most concerned about the risk of suicide. This is more difficult to predict given the relative rarity of suicide even in a population at high risk such as those who have self-harmed.
For recommendations related to developing an integrated care and risk management plan, see recommendations and on page 22 of the NICE guideline.

22. Care plans: 1
Discuss, agree and document the aims of longer-term treatment in the care plan. These aims may be to:
prevent escalation of self-harm
reduce harm arising from self-harm or reduce or stop self-harm
reduce or stop other risk-related behaviour
improve social or occupational functioning
improve quality of life
improve any associated mental health conditions.
Review the care plan with them, and revise it at agreed intervals of not more than 1 year.
NOTES FOR PRESENTERS:
Recommendation in full:
Discuss, agree and document the aims of longer-term treatment in the care plan with the person who self-harms. These aims may be to:
-prevent escalation of self-harm
-reduce harm arising from self-harm or reduce or stop self-harm
-reduce or stop other risk-related behaviour
-improve social or occupational functioning
-improve quality of life
-improve any associated mental health conditions.
Review the person’s care plan with them, including the aims of treatment, and revise it at agreed intervals of not more than 1 year. [1.4.2]

23. Care plans: 2
Care plans should be multidisciplinary and developed collaboratively with the person. Care plans should:
identify realistic and optimistic long-term goals, including education, employment and occupation
identify short-term treatment goals (linked to the long-term goals) and steps to achieve them
identify the roles and responsibilities of any team members and the person who self-harms
include a jointly prepared risk management plan
be shared with the person’s GP.
NOTES FOR PRESENTERS:
Recommendation in full:
Care plans should be multidisciplinary and developed collaboratively with the person who self-harms and, provided the person agrees, with their family, carers or significant others. Care plans should:
-identify realistic and optimistic long-term goals, including education, employment and occupation
-identify short-term treatment goals (linked to the long-term goals) and steps to achieve them
-identify the roles and responsibilities of any team members and the person who self-harms
-include a jointly prepared risk management plan
-be shared with the person’s GP. [1.4.3]

24. Risk management plans: 1
A risk management plan should be a clearly identifiable part of the care plan and should:
address each of the long-term and immediate risks identified in the risk assessment
address the specific factors identified in the assessment as associated with increased risk, with the agreed aim of reducing the risk of repetition of self-harm and/or the risk of suicide.
NOTES FOR PRESENTERS:
Recommendation in full:
A risk management plan should be a clearly identifiable part of the care plan and should:
-address each of the long-term and more immediate risks identified in the risk assessment
-address the specific factors (psychological, pharmacological, social and relational) identified in the assessment as associated with increased risk, with the agreed aim of reducing the risk of repetition of self-harm and/or the risk of suicide
-include a crisis plan outlining self-management strategies and how to access services during a crisis when self-management strategies fail
-ensure that the risk management plan is consistent with the long-term treatment strategy.
Inform the person who self-harms of the limits of confidentiality and that information in the plan may be shared with other professionals. [1.4.4]
Related recommendation:
Update risk management plans regularly for people who continue to be at risk of further self-harm. Monitor changes in risk and specific associated factors for the service user, and evaluate the impact of treatment strategies over time. [1.4.5]

25. Risk management plans: 2
A risk management plan should be a clearly identifiable part of the care plan and should: (continued)
include a crisis plan outlining self-management strategies and how to access services during a crisis
ensure that the risk management plan is consistent with the long-term treatment strategy.
Inform the person who self-harms of the limits of confidentiality and that information in the plan may be shared with other professionals.
NOTES FOR PRESENTERS:
Recommendation in full:
A risk management plan should be a clearly identifiable part of the care plan and should:
-address each of the long-term and more immediate risks identified in the risk assessment
-address the specific factors (psychological, pharmacological, social and relational) identified in the assessment as associated with increased risk, with the agreed aim of reducing the risk of repetition of self-harm and/or the risk of suicide
-include a crisis plan outlining self-management strategies and how to access services during a crisis when self-management strategies fail
-ensure that the risk management plan is consistent with the long-term treatment strategy.
Inform the person who self-harms of the limits of confidentiality and that information in the plan may be shared with other professionals. [1.4.4]
Related recommendation:
Update risk management plans regularly for people who continue to be at risk of further self-harm. Monitor changes in risk and specific associated factors for the service user, and evaluate the impact of treatment strategies over time. [1.4.5]

26. Interventions for self-harm
Do not offer drug treatment as a specific intervention to reduce self-harm.
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. This should be tailored to individual need.
NOTES FOR PRESENTERS:
Recommendation in full:
Do not offer drug treatment as a specific intervention to reduce self-harm. [1.4.9]
Related recommendation:
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. In addition:
-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. [1.4.8]
Additional information:
It is suggested that healthcare professionals provide pharmacological interventions for any associated or underlying conditions as described in the relevant NICE guidelines. When prescribing drugs, toxicity of prescribed drugs in overdose should be taken into consideration. There was recent evidence suggesting TCAs as a drug class were more toxic than SSRIs. When clinicians are considering antidepressants, SSRIs might be preferred in those at risk of suicidal behaviour. In particular, the more toxic TCAs such as dosulepin should be avoided.

27. Harm minimisation
If stopping self-harm is unrealistic in the short term:
consider strategies aimed at harm reduction; reinforce existing coping strategies and develop new strategies as an alternative to self-harm where possible
consider discussing less destructive or harmful methods of self-harm with the service user, their family, carers or significant others, and the wider multidisciplinary team
advise the service user that there is no safe way to self-poison.
NOTES FOR PRESENTERS:
Harm reduction is not a KPI. However this area has been highlighted as an issue and as something that may require a change in current practice. For this reason it is covered within this slide set.
Recommendation in full:
If stopping self-harm is unrealistic in the short term:
-consider strategies aimed at harm reduction; reinforce existing coping strategies and develop new strategies as an alternative to self-harm where possible
-consider discussing less destructive or harmful methods of self-harm with the service user, their family, carers or significant others where this has been agreed with the service user, and the wider multidisciplinary team
-advise the service user that there is no safe way to self-poison. [1.4.10]
Additional information:
The most desirable outcome for the treatment and care of people who self-harm would be to permanently stop self-harming, recover from any underlying psychiatric disorder and to have a good quality of life. For some people not self-harming may not be immediately attainable. Moreover, for some individuals who self-harm, this may not be possible in the medium to long term and there are individuals for whom self-harm functions to prevent suicide. For many people who self-harm, there will be a period in which the aim of treatment will be to reduce harm to the individual, either by reducing the frequency of self-harm, or reducing the harm associated with acts of self-harm.
This approach to harm reduction has been tried with significant success in helping people with substance misuse (including drug, alcohol, and smoking), and in relation to sexual activity (‘safe sex’) to prevent transmission of HIV and other sexually transmitted diseases. Indeed, harm reduction has been an acceptable, secondary aim of treatment in a broad range of chronic medical conditions where cure is either not possible or not immediately attainable. The application of this approach to self-harm has been controversial. The Guideline Development Group nevertheless took the view that harm reduction should be considered in line with the above recommendation.

28. Treating associated mental health conditions
Provide psychological, pharmacological and psychosocial interventions for any associated conditions.
When prescribing drugs for associated mental health conditions to people who self-harm, take into account the toxicity of the prescribed drugs in overdose.
NOTES FOR PRESENTERS:
Recommendation in full:
Provide psychological, pharmacological and psychosocial interventions for any associated conditions, for example those described in the following published NICE guidance:
-Alcohol-use disorders (NICE clinical guideline 115)
-Depression (NICE clinical guideline 90)
-Schizophrenia (NICE clinical guideline 82)
-Borderline personality disorder (NICE clinical guideline 78)
-Drug misuse (psychosocial interventions or opioid detoxification) (NICE clinical guidelines 51 and 52).
-Bipolar disorder (NICE clinical guideline 38). [1.5.1]
Related recommendation:
When prescribing drugs for associated mental health conditions to people who self-harm, take into account the toxicity of the prescribed drugs in overdose. For example, when considering antidepressants, selective serotonin reuptake inhibitors (SSRIs) may be preferred because they are less toxic than other classes of antidepressants. In particular, do not use tricyclic antidepressants, such as dosulepin, because they are more toxic. [1.5.2]

29. Costs per 100,000 population Recommendations with significant costs
(£ per year)
Access to services
800
Psychosocial assessment
19,900
Longer-term treatment and management
10,800
Estimated cost of implementation
31,500
ADAPTING THIS SLIDE FOR LOCAL USE:
We are aware that local factors such as incidence and baseline can vary considerably when compared with the national average. NICE has provided a costing template for you to calculate the financial impact this guideline will have locally. We encourage you to calculate the local impact of this guideline by amending the local variations in the template such as incidence, baseline and uptake. You can then remove the national figures per 100,000 population from the table and replace them with your local figures to present to your colleagues.
NOTES FOR PRESENTERS:
NICE has worked closely with people within and outside the NHS to look at the major costs and savings related to implementing this guideline.
The estimated national annual changes in costs arising from implementing the guideline on Self-harm longer-term management are £16 million. The breakdown of this cost and all assumptions that have been made are detailed in the costing report.
NICE has produced a costing report that provides detailed estimates of the national costs and savings associated with implementing this guideline. NICE has also developed a costing template to calculate the local costs associated with implementing this guideline. The costs per 100,000 population are summarised in the table on this slide.
For further information please refer to the costing template and costing report for this guideline on the NICE website (details on ‘find out more slide’).

30. Savings
Typical costs that could be avoided by implementing the guidance
Description
Reference (national tariff / reference costs)
Non-elective tariff £
A&E attendance
VB07Z and VB08Z
110
Ambulance transfer cost
Reference cost 2009/10
246
Intensive care cost per day
Reference costs 2009/10
XC07Z Adult critical care 0 organs supported
XB05Z Paediatric critical care – intensive care basic
710
2225
Treatment for poisoning
WA11V – major complications
WA11X – intermediate complications
WA11Y – without complications
2200
611
387
Treatment for other wounds or injuries
HD35A – major complications
HD35B – intermediate complications
HD35C – without complications
4231
514
NOTES FOR PRESENTERS:
NICE has found that implementing the guideline on self-harm longer-term management guideline could result in costs avoided by acute and emergency services. Examples of these are given in the table.
Longer-term treatment that may reduce self-harm could have wider economic benefits. The indirect economic costs of self-harming behaviour to an individual and their family are unknown, but are likely to be substantial, especially in terms of days lost from work and other activities, including family responsibilities. There are also significant benefits for individuals because longer-term therapies may assist them to stay in work and improve their quality of life.

31. Discussion
What can we do to help address the stigma and discrimination associated with self-harm?
Do we include within our assessment of needs all that we should? If not, what steps do we need to take?
How can we address the issues associated with the transition from CAMHS to adult services for young people who self-harm?
What is our current practice in terms of using risk assessment tools and scales? How can this be improved?
NOTES FOR PRESENTERS:
These questions are suggestions that have been developed to help provide a prompt for a discussion at the end of your presentation – please edit and adapt these to suit your local situation.

32. Click here to go to NICE Pathways website
The NICE self-harm pathway covers:
planning of services
general principles of care
assessment, treatment and management
longer-term treatment and management.
NOTES FOR PRESENTERS:
NICE Pathways: guidance at your fingertips
Our new online tool provides quick and easy access, topic by topic, to the range of guidance from NICE, including quality standards, technology appraisals, clinical and public health guidance and NICE implementation tools. Simple to navigate, NICE Pathways allows you to explore in increasing detail NICE recommendations and advice, giving you confidence that you are up to date with everything we have recommended.
Click here to go to NICE Pathways website

33. Click here to go to the NHS Evidence website
Visit NHS Evidence for the best available evidence on all aspects of self-harm
Click here to go to the NHS Evidence website
NOTES FOR PRESENTERS:
If you are showing this presentation when connected to the internet, click on the blue button to go straight to the NHS Evidence website topic page for self-harm. For the home page go to

34. Find out more Visit www.nice.org.uk/guidance/CG133 for: the guideline
‘Understanding NICE guidance’
costing report and template
audit support and baseline assessment tool
clinical case scenarios
risk assessment podcast
service user podcast.
NOTES FOR PRESENTERS:
You can download the guidance documents from the NICE website.
The NICE guideline – all the recommendations.
‘Understanding NICE guidance’ – information for patients and carers.
The full guideline – all the recommendations, details of how they were developed, and reviews of the evidence they were based on.
NICE has developed tools to help organisations implement this guideline, which can be found on the NICE website.
Costing tools – a costing report gives the background to the national savings and costs associated with implementation, and a costing template allows you to estimate the local costs and savings involved.
Audit support – for monitoring local practice.
Baseline assessment tool- to help monitor your current practice against the guideline recommendations.
Clinical case scenarios- an educational resource that can be used in individual or group learning situations.
Risk assessment podcast- a discussion with the guideline development group chair about what should and should not be included within a psychosocial assessment with a person who has self-harmed.
Service user podcast- a discussion with a service user about their personal experience of self-harm. This podcast also covers harm minimisation.

35. What do you think?
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NOTES FOR PRESENTERS:
Additional information:
The final slide is not intended to be part of the presentation, it asks for feedback on whether this implementation tool meets your requirements and whether it will help you to put this NICE guidance into practice – your opinion would be appreciated.
To open the links in this slide set right click over the link and choose ‘open link’
To open the links in this slide set right click over the link and choose ‘open link’