Royal College of Psychiatrists Self-harm, suicide and risk: helping people who self-harm Self-harm, suicide and risk: helping people who self-harm Final report of a working group College Report CR158 © 2010 Royal College of Psychiatrists Cover photograph: © 2010 iStockphoto/Natalya Filimonova College Reports have been approved by a meeting of the Central Policy Coordination Committee and constitute College policy until they are revised or withdrawn. For full details of reports available and how to obtain them, contact the Book Sales Assistant at the Royal College of Psychiatrists, 17 Belgrave Square, London SW1X 8PG (tel. 020 7235 2351, fax 020 7245 1231). Royal College of Psychiatrists The Royal College of Psychiatrists is a charity registered in England and Wales (228636) and in Scotland (SC038369). College Report CR158 Self-harm, suicide and risk: helping people who self-harm Final report of a working group College Report CR158 June 2010 Royal College of Psychiatrists London Approved by Central Policy Coordination Committee: April 2010 Due for review: 2015 DISCLAIMER This guidance (as updated from time to time) is for use by members of the Royal College of Psychiatrists. It sets out guidance, principles and specific recommendations that, in the view of the College, should be followed by members. Nonetheless, members remain responsible for regulating their own conduct in relation to the subject matter of the guidance. Accordingly, to the extent permitted by applicable law, the College excludes all liability of any kind arising as a consequence, directly or indirectly, of the member either following or failing to follow the guidance. Contents Working Group 4 Executive summary 5 Part I: Understanding the problems and the people 1 Background 17 2 What is self-harm? 21 3 Self-harm and mental or physical disorders 25 4 Wider social concerns 29 5 Interventions 37 PART II: The public health agenda 6 The cost of self-harm 45 7 Strategies for the prevention of self-harm and suicide 47 8 A public health approach specifically to address self-harm 50 9 The role of the third sector 55 10 Research 58 Part III: Working with individual people 11 Introduction 63 12 Overarching themes 64 13 What do service users and carers want from services? 68 14 The College Members’ survey: skills and services 72 needed 15 Third-sector providers 95 16 Conclusions 96 Bibliography and references 97 Appendix I: Online survey of College Members 107 Appendix II: People who gave evidence to the Working Group 133 Appendix III: Pathways to suicide behaviour 135 Royal College of Psychiatrists 3 Working Group CHAIR John, Lord Alderdice Consultant Psychiatrist in Psychotherapy, Northern Ireland HONORARY SECRETARY Dr John Morgan Consultant Psychiatrist, Leeds MEMBERS Ms Janey Antoniou Service User Dr Jim Bolton Consultant Psychiatrist, South West London and St George’s Dr Tom Brown Consultant Psychiatrist, former Chair of the Royal College of Psychiatrists, Scotland Division Dr Cathal Cassidy Chair of the Royal College of Psychiatrists, Northern Ireland Division Dr Rowena Daw Head of Policy, Royal College of Psychiatrists Dr Mick Dennis Consultant in Liaison Psychiatry for Older People, Reader in Psychiatry, Swansea Dr Kimmett Edgar Head of Research, Prison Reform Trust Mr Joe Ferns Director of Policy, Research and Development, Samaritans Mr Adrian Fisher Service User Professor Keith Hawton Oxford University Centre for Suicide Research Ms Veronica Kamerling Carer Professor Rory O’Connor British Psychological Society Ms Lucy Palmer Programme Manager, Royal College of Psychiatrists, College Research and Training Unit Dr Gemma Trainor Psychiatric Nurse and Child and Adolescent Mental Health Expert Ms Melba Wilson* National Programme Lead, Mental Health Equalities, National Mental Health Development Unit *Ms Sue Waterhouse, Deputy National Programme Lead, Mental Health Equalities, National Mental Health Development Unit was a substitute for Ms Melba Wilson at most meetings and is an expert in her own right. 4 http://www.rcpsych.ac.uk Executive summary Self-harm is poorly understood in society even among those who in their working lives as school teachers, pastors, social workers, housing officers, police, prison officers and even nurses and doctors encounter people who harm themselves. People who harm themselves are subject to stigma and hostility. In contrast to the trends in completed suicide, the incidence of self- harm has continued to rise in the UK over the past 20 years and, for young people at least, is said to be among the highest in Europe. This high level of self-harm among different age and social groups is a worrying feature of our society. The focus of this report is to enquire into and report on why people harm and kill themselves and to consider the role (including the limits of the role) that psychiatrists and other mental healthcare professionals play in their care and treatment. The experiences and views of people who harm themselves as well as those of their carers, health professionals and third-sector workers are central to this enquiry. As there is much policy and guidance on self-harm and suicide prevention, the report does not attempt to retrace this same ground but rather examines the evidence of practice on the ground, including the implementation of the National Institute for Health and Clinical Excellence (NICE) guidelines on self-harm (National Collaborating Centre for Mental Health, 2004). This report is the second in the Royal College of Psychiatrists’ programme of work on the broad issue of risk. The College report Rethinking Risk to Others was published in July 2008 (Royal College of Psychiatrists, 2008a) and a new Working Group was set up under the chairmanship of John, Lord Alderdice, to examine risk, self-harm and suicide. This clinical issue is an integral part of the role of the psychiatrist in ensuring the good care and treatment of patients. Our central theme is that the needs, care, well-being and individual human dilemma of the person who harms themselves should be at the heart of what we as clinicians do. Public health policy has a vital role to play and psychiatrists must be involved and not leave these crucial political and managerial decisions to those who are not professionally equipped to appreciate the complexities of self-harm and suicide. But we must never forget that we are not just dealing with social phenomena but with people who are often at, and beyond the limit of what they can emotionally endure. Their aggressive acts towards themselves can be difficult to understand and frustrating to address, but this is precisely why psychiatrists need to be involved to bring clarity to the differing causes for the self-destructive ways in which people act and to assist in managing the problems for the people concerned, including family, friends and professional carers, who sometimes find themselves at the end of their tether in the face of such puzzling and destructive behaviour. Royal College of Psychiatrists 5 College Report CR158 The report is divided into three parts. In Part I, we give some background information on self-harm in the UK and on understanding why people harm themselves. In Part II, we examine some of the public health policy issues, and in Part III we concentrate on the practice of healthcare professionals and others who work with people who have harmed themselves and are at risk of harming themselves, as evidenced particularly by a survey and consultations with College Members and Faculties. The important role of the third sector is also examined. PART I: UN D ERSTAN D ING THE P ROBLEMS AN D THE P EO P LE For the purpose of this report we define self-harm as an intentional act of self-poisoning or self-injury irrespective of the type of motivation or degree of suicidal intent. Thus it includes suicide attempts as well as acts where little or no suicidal intent is involved (e.g. where people harm themselves to reduce internal tension, distract themselves from intolerable situations, as a form of interpersonal communication of distress or other difficult feelings, or to punish themselves.) An act of self-harm is a not necessarily an attempt or even indicator of suicide, indeed it can sometimes be a bizarre form of self-preservation. Nevertheless it covers a wide spectrum of behaviour, with harmful physical effects, and a person who repeatedly self-harms is at a higher risk of suicide. Self-harm is a behaviour, a manifestation of emotional distress. It is an indication that something is wrong rather than a primary disorder. For each person the contributing circumstances are individual. However, commonly they include difficult personal circumstances, past trauma (including abuse, neglect or loss), or social or economic deprivation together with some level of mental disorder. A person’s self–harming behaviour may often be associated with the misuse of drugs or alcohol. The rate of self-harm is higher among women and girls than among men and boys, although completed suicide is more prevalent among men and boys. People of all ages and from all social and cultural backgrounds may harm themselves but some groups are especially vulnerable because of life experiences, personal or social circumstances, physical factors or a combination of these elements. There is a higher incidence of self-harm among prisoners, asylum seekers, veterans from the armed forces, people bereaved by suicide, some cultural minority groups and people from sexual minorities. The assessment and management of a person who has harmed themselves therefore requires a biopsychosocial approach which assesses their problems, needs and in so far as is possible understands the risks of further harm to this individual and provides a person-centred management plan. Helping this person address their current and ongoing problems with whatever help can be made available to them in their context should be the key principle informing the care and treatment of the individual.