Tackling selfharm: challenges of needs assessment

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Tackling self-harmchallenges of needs assessment

• Stephen PlattRUHBC, University of Edinburgh
• Lanarkshire self-harm health needs assessment
  stakeholder consultation meetingHamilton, 16
  July 2008

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Content of presentation

• What is self-harm?
• How does self-harm differ from suicide and
  attempted suicide?
• Epidemiology of self-harm
• Choose Life and self-harm
• Services for people who self-harm
• Towards a framework for assessing need among
  people who self-harm

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Definition of self-harm

• Self-harm is non-accidental self-poisoning or
  self-injury, irrespective of the apparent purpose
  of the act
• NICE National Clinical Practice Guideline Number
  16, 2004

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Common terms used to describe self-harm (NICE)

• Deliberate self-harm
• Intentional self-harm
• Parasuicide
• Attempted suicide
• Non-fatal suicidal behaviour
• Self-inflicted violence

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Types of self-harm

• Self-poisoning and self-injury
• Self-injury also referred to as self-mutilation,
  self-injurious behaviour, non-suicidal
  self-injury, parasuicide
• Self-injury is intentional harm to the outside of
  the body, often by cutting with a sharp object
  (most common)
• also by burning, biting, hitting/punching,
  banging (head), scratching, jumping from height,
  swallowing objects

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Suicide, suicide attempt, self-harm whats in a
name? (1)

• Suicide an intentional (i.e. non-accidental) and
  fatal act of self-harm
• Some of these acts will have been intended to
  result in death, with high suicidal intent
  (suicide attempt)
• But some deaths classified as suicide may result
  from acts which were not intended to cause death
  or where the motivation (suicidal intent) was
  equivocal
• Likewise, some acts of self-harm may be intended
  to result in death but are foiled by, e.g.,
  timely intervention (rescue) from others,
  imperfect knowledge, choice of method or some
  other reason

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Suicide, suicide attempt, self-harm whats in a
name? (2)

• Many (most?) acts of self-harm are not intended
  to end a persons life (not suicide attempt)
• Thus, not all self-harming behaviour should be
  considered suicidal behaviour
• However, people who harm themselves are at
  increased risk of completing suicide on some
  subsequent occasion
• Nevertheless, the vast majority of people who
  self-harm do not go on to take their own life

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Epidemiology of self-harm (1)

• Major source of information is hospital
  admission/ discharge data
• 80-85 of presentations to AE following
  self-harm are self-poisoning
• However, people who self-poison are more likely
  to seek help than those who self-injure
• Episodes of self-harm leading to hospital
  admission are probably only a minority of all
  such episodes
• Studies of people who attend AE paint a
  different picture about the prevalence of
  self-poisoning versus self-injury from studies of
  the general population
• Self-injury is more common than self-poisoning in
  the population, perhaps by a ratio of 21 among
  teenagers

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Hospital admissions due to intentional self-harm
(Scotland, 2006)

• 4205 males (crude rate 170/100,000)
• 5560 females (crude rate 210/100,000)
• (Discharges from non-obstetric and
  non-psychiatric hospitals. Excludes AE
  attendances that do not result in admission)

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Epidemiology of self-harm (2)

• A national interview survey suggests that between
  4.6 and 6.6 of people in Great Britain have
  self-harmed (lifetime prevalence)
• However, even this may be an underestimate
• In a school-based survey of 15/16 yr olds,
  lifetime prevalence of self-harm was 13 and
  annual prevalence was 7
• Overall, women more likely to self-harm than men.
  Gender difference most pronounced in adolescence
  girls may be three times more likely to self-harm
  than boys
• Self-harm can occur at any age but is most common
  in adolescence and young adulthood

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Choose Life and self-harm (1)

• This strategy includes only those aspects of
  self-harming behaviour which might be considered
  as an indication of risk of suicide. It is
  recognised that there are other dimensions and
  manifestations of deliberate self-harm that are
  not covered within the strategys scope.
• Choose Life strategy, page 12

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Choose Life and self-harm (2)

• Objective 1 (early prevention and intervention)
  increasing the awareness of suicide, deliberate
  self-harm and suicidal risk factors
• Objective 7 (knowing what works) establishing
  indicators on suicidal behaviour, the incidence
  of completed suicides, self-harm and other at
  risk factors
• NIST will evaluate the National Strategy and
  Action Plan monitoring trends in suicide and
  self-harm.
• By March 2006 national capacity for collection
  of data on suicide and self-harm will be
  established
• Perceived neglect of the complex issue of
  deliberate self-harm (DSH) in the consultation
  document.
• Respondents identified the need to distinguish
  more clearly between suicide sic and DSH.

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Choose Life and self-harm (3)

• Possible interventions in relation to children
  and young people might include
• actions to equip teachers and other children and
  young peoples workers with the knowledge, skills
  and training to enable them to talk openly about
  suicide and deliberate self-harm
• ensuring that those who deal with young people
  who self-harm (e.g. in AE) are good at
  recognising those at risk of further self-harm

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Services for people who self-harm Penumbra

• Penumbra provides range of person-centred support
  services for people with mental health problems
  across Scotland
• One of main organisations in Scotland working in
  field of self-harm, especially 16-25 age group
• User-led support services to young people who
  self-harm also explore training and support
  needs of parents, carers and professionals
• Aberdeen
• Edinburgh
• West Lothian (Hawthorn Project)
• North Ayrshire
• Fife (early response service to people aged 18
  who have been involved in recent self-harm
  incident)

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Other self-harm projects

• The Corner (Dundee) offers wide range of health
  and information services to young people (11-25)
  address/investigate factors leading to mental
  health problems, self-harm and suicide in young
  people
• Hazardous drinking screening in AE (Highland)
  identifies people with hazardous drinking habits
  and provide timely support, especially when
  associated with self-harm
• Lifelink (Glasgow) crisis intervention service
  for people aged 12 who self-harm and/or are at
  risk of suicide immediate front-line support,
  effective referral and thorough aftercare
• Life coaching project (Glasgow) peer support to
  vulnerable adults released from prison, with a
  view to reducing risk of suicide, attempted
  suicide and self-harm

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Defining need

• Many definitions of 'need' have been developed
• It may be an illusion to suppose that there
  might ever be a consensus about the meaning of
  needs
• Culyer A. Need - is a consensus possible? J Med
  Ethics 1998247780

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Bradshaws typology of need

• Normative need which is identified according to
  a norm (or standard), usually set by experts
• Example social security benefit levels
• Comparative problems which emerge by comparison
  with others
• Example comparison of social problems in
  different areas in order to determine which areas
  are most deprived
• Felt need which people feel - that is, need from
  the perspective of the people who have it
• Expressed need which people say they have
• People can feel need which they do not express
  and they can express needs they do not feel
• Bradshaw J. A taxonomy of social need. New
  Society 1972 640-3.

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Assessing self-harm needs (based on Bradshaws
typology) challenges

• Normative what evidence will be used to
  establish norm?
• Comparative which are the appropriate comparison
  groups?
• Felt how to measure felt need which is not
  expressed?
• Expressed how to distinguish real from
  artificial needs?

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Which areas of need should be measured?

• Medical (aftermath of self-harm)
• Physical ill-health
• Psychiatric (e.g. untreated or inadequately
  treated mental illness)
• Dependence on alcohol/drugs
• Social (e.g. interpersonal loss, severe life
  events)
• Socio-economic (e.g. worklessness, low income)
• Living environment (socio-economic deprivation,
  poor housing conditions)

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Different intervention approaches

• Universal targets the general population or a
  population group (not identified on basis of
  risk)
• Selective strategies target at-risk groups that
  have greater probability of becoming suicidal,
  aiming to prevent onset of suicidal behaviour
• Indicated strategies target specific high-risk
  individuals who show early signs of suicidal
  potential

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Needs in relation to different intervention
approaches

• General population (especially young people)
  universal interventions to strengthen
  resilience/protective processes, enhance
  knowledge, remove barriers to treatment/services,
  improve knowledge and understanding (e.g. in
  schools)
• At risk groups selective interventions to help
  reduce risk of self-harm among those in
  crisis/especially vulnerable (e.g. homeless,
  suffering abuse)
• Vulnerable individuals indicated interventions
  to reduce risk of chronic self-harm (e.g.
  preventing repetition)

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Key questions/challenges

• How is self-harm to be defined (especially in
  operational terms)?
• Which people or groups are to be targeted?
• Universal, selected or indicated approaches?
• Promotion, prevention or treatment?
• How are needs to be established?
• What about felt needs that are not expressed
  (among those at risk of self-harm as well as
  those who have self-harmed)?
• Formal services deal only with expressed need
  (but not all such need)
• Some need expressed to informal sources of
  support (e.g. peers, family) or self-help groups
• What procedures will be used to measure need?
• What types of need will be covered?

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Focus of needs assessment filling the gaps