Transcript Suicide Risk Assessment: From Theory to Practice

WORKING WITH SUICIDAL
RISKS IN YOUNG PEOPLE:
ASSESSMENT AND
INTERVENTIONS
Professor Stephen Briggs
Centre for Social Work Research
University of East London
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
SUICIDE PREVENTION AND
CLINICAL GUIDELINES:
EVIDENCE FOR PRACTICE
National Suicide Prevention Strategy
Preventing suicide in England: A crossgovernment 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.
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
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)
Suicide, self-harm and suicidal thoughts
self-harm is 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
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)
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, relationships and social contexts may be important in
distinguishing between ideation and actions
Suicidal ideation requires the same processes of assessment as
self-harm
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.
SERVICE USER
PERSPECTIVES:
EXPERIENCES OF CARE
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)
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,
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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.
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
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
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)
Current issues in thinking about self-harm
and suicide
Risk
assessments
Relational
Approaches
Risk assessment scales
Self-harm
Repetition
Deliberate self-harm
Conscious intent
Completion of suicide
MANAGEMENT AND
INTERVENTIONS
Short-term therapy or ‘wrap-around’ care?
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
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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)
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)
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)
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
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
Rossouw and 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
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
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.
WORKING WITH
RELATIONSHIPS AND
EMOTIONS
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’
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
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
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• 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
References
• Bergen H., Hawton, K., Waters, K et al. (2010) Psychosocial assessment and
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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: Problemsolving therapy for people who present to hospital BJP 2011, 99:310-316
References
• Hawton, K., Saunders, K and O’Connor, Rl (2012) Self-harm and suicide in
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adolescence, The Lancet, 379, 2373-82
Kapur N. 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/216
928/Preventing-Suicide-in-England-A-cross-government-outcomes-strategy-tosave-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
References
• Rossouw T. and Fonagy P. (2012) Mentalisation-Based Treatment for
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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
Thank you
Please contact me at [email protected]
www.stephenbriggsconsulting.co.uk