New NICE guidelines on self-harm: show it’s not possible to hit three targets simultaneously
Writers of NICE guidelines have to take on three tasks. They have to marshal the evidence and integrate new findings into the existing guidance. They have to present their findings in different formats to suit different audiences. And they have to ensure that any guidance can reasonably be taken up, by taking into account such research as there is on barriers to implementation.
In the context of self-harm these tasks are more than usually demanding. Most obviously there just isn’t that much new evidence – a symptom of underfunding as much as it is of researcher indifference or incompetence. And such research as there is may be based upon populations far removed from the typical UK patient seen in ED or primary care. Much practice is therefore consensus or opinion based and new guidance cannot simply take the form – now modify treatment regime A by substitution or replacement to make Regime B.
Second, much self-harm is seen initially by practitioners who have no great depth of knowledge of self-harm theory or research; even when working in mental health services they are often generalists rather than part of a specialist self-harm team. Guidance therefore needs to take the form of clear and specific pointers to action, of a sort that does not rely on implicit knowledge.
And third, existing culture could not be described as conducive to dispassionate evidence-based practice. Influential and unhelpful ideas about personality disorder, non-suicidal self-harm or emotional instability exert a dismaying amount of influence.
It strikes me that these three demands are impossible to reconcile into a single document, as the latest NICE guidelines on the management of self-harm illustrate.
In an effort to stay based upon evidence the review recommends only two psychological treatments, neither with advice about how the recommendations will be read and implemented: CBT-informed therapy the definition of which does not take account of interpersonal factors and which will therefore be interpreted as “CBT-lite” by most people, and DBT for young people with “significant emotional dysregulation” without indicating how that will be determined in routine clinical practice or what happens to all the other young people who aren’t getting a label of emerging borderline personality.
Some of the advice to non-specialists is unhelpfully vague – I don’t think the average GP needs to be advised to refer to mental health services if they are concerned after assessment in primary care, and I don’t know that school staff will know without some specifics how to meet the recommendation that they identify “self-harm behaviours”. On the other hand some key questions – about the role of diagnosis in management decisions, how to get to the meaning of suicidal thinking with a patient, the important differences between one-off presentations in crisis and long-standing repeated self-harm, the origins and response to professional stigmatising – are hardly touched on.
Implementation challenges don’t get much of a look in. To give one example: it’s impossible to discuss how to improve self-harm services if we don’t acknowledge that aftercare is likely to require referral to CMHT who can’t/won’t see people without a “serious mental illness” or clinical psychology who won’t see suicidal people or who will if they’ll sit on a months-long waiting list.
I don’t think the problem here is primarily down to the expertise of the guideline group, which contained some experienced and sensible clinicians. A major problem resides in remit. This is a three-in-one document: a (short!) document giving a synthesis of what’s new in research; an assessment and treatment manual written with specific readers in mind (so actually a series of manuals) and a trouble-shooting guide to tackling current problems in service provision. NICE guidance just isn’t set up to meet such diverse aims and I wouldn’t therefore expect these latest guidelines to make much difference to the grim reality of service provision for people who present after self-harm.