Stories about self-harm are everywhere. One of the recurring features of these stories is that they include calls for more mental health services – especially for young people. A few suggest that self-harm is something to which we should all be able to respond. For example, 3rd sector organisations such as Young Minds and Samaritans recommend being open to talking with people who self-harm – surely that’s right if up to a quarter of young people are affected.
There’s nothing wrong with this advice except that it doesn’t come with much help to guide people in what they should actually say.
Here for example is
what BBC say
at the bottom of a typical news item about self-harm:
What adults can do to help a child who is self-harming:
Show you understand
Talk it over
Discover the triggers
Build their confidence
Show you trust them
Choose who you tell carefully
Help them find new ways to cope
Difficult to disagree with, but how does it help a worried parent or friend who can’t show they understand because they don’t understand, or doesn’t know what “talk it over” means or how to “help them find new ways to cope”?
After a look around
for sources specific advice, I decided that some direct simple and specific
advice was needed and so I wrote my book Understanding
and Responding to Self Harm, just published by Profile
Books. The book offers practical suggestions:
For a person who self-harms [1] planning to disclose to friends or family [2] planning to talk to your GP [3] managing contact with a hospital emergency department [4] getting help from the mental health services
For
a close friend or family [1] how to respond if you learn somebody you know is
self-harming [2] what you can do that helps practically.
Coverage of self-harm
in our national mainstream media is unhelpfully unbalanced. News stories
almost always report that there’s a massive crisis/epidemic of self-harm in
young people underway. There does seem to have been an increase but the
coverage rarely says exactly what it is that’s increasing. The accompanying
story is pretty much always about a young woman with a long history of
self-cutting with the implication that’s what it’s about. See for example this BBC news item.
To balance up a bit…
A
recent report in Lancet
Psychiatry, based on 2014 results from the Adult
Psychiatric Morbidity Survey, which is published
by NHS Digital, was widely covered as showing this dramatic rise in self-harm
in young people. It did indeed report on a marked increase in young people but
it also showed that people of all ages and both genders report higher rates
than they did a decade ago. Self-harm is presented in the media as almost
entirely a problem for young women but 5% of all men say they have self-harmed at
some time. Self-harm is also
presented as almost entirely affecting teenagers but 5% of those over 35 say
they have self-harmed at some time. UK
figures show that a quarter of those who go to hospital Emergency Department
after self-harm are aged 40-59 years.
Self-harm
is presented as almost always about cutting, but when asked in the Adult
Psychiatric Morbidity Survey more than half people
who say they have self-harmed say they have swallowed something or done
something else other than cut themselves. Similar findings emerge in the
Millennium Cohort Study, widely publicised by the Children’s
Society.
Social
media use is presented as clearly a cause but studies show that people can find
it helpful and supportive, a non-judgemental environment in which to discuss
worries about eg social or sexual identity. Important when something like a
third of people who self-harm don’t confide in anybody they know.
The truth is that we won’t help people with
self-harm until we start taking a more balanced approach to discussing the real
issues. “What’s fuelling the terrifying rise in self-harmers?” screams Mail
Online 6 March. That’s not a great way to start a conversation, nor indeed a
great way to label people who self-harm.
The Government White Paper: Online Harms has been out for consultation for the past three months. Its main proposal is to establish a regulator charged with ensuring that a duty of care is exercised by all those who produce, host or distribute potentially harmful online material.
This sounds like an idea with which few could disagree, and the consultation questions are mainly about how to make it work properly. There are however some real problems raised by the inclusion of online content about self-harm. The other topics covered by the White Paper include incitement to terrorist activities, dissemination of child pornography, and drug dealing in the dark web. While it’s difficult to imagine a socially desirable component to the online presence of any of these activities, the same doesn’t apply to self-harm. Here’s my own reply to the consultation’s Question 8…
Q8: What further steps could be taken to ensure the regulator will act in a targeted and proportionate manner?
In
relation to self-harm, the main need is for a clear and specific definition of
the nature of harmful content. It is
responsible management of such content that constitutes the duty of care to be
imposed on those who make self-harm content available online. The White Paper
talks about “content and behaviour which encourages suicide and self-harm” (para
7.32) and “content that provides graphic details of suicide methods and
self-harming” (para 7.34). Neither definition is specific enough to inform
practice and without a tighter definition the regulator is at risk of
idiosyncratic or inconsistent intervention.
What is
the challenge in coming up with a workable definition of harmful self-harm
content?
There are
three issues here:
Examination of online material about self-harm reveals substantial diversity in form and content. Those who post and those who respond to posts are engaged in conversations not just about the manifest topic of self-harm and suicide, even when the relevant posts are explicitly tagged as self-harm: content is also about emotional problems more generally, about relationships, fitting in or belonging, and about attractiveness, sexuality and body image. The mixture of textual and visual messaging leads to communication the ambiguity and irony of which can be missed by reading one without the other.
Much
of this is regarded as helpful by those who access it, and that includes
direct communication about self-harm including images of self-injury. Such
images can help an isolated person (anything up to a half of people who self-harm
don’t confide the fact to anybody in their personal life) feel less alone. The
images may come with messages about self-care or harm minimisation. It is
reasonable to conclude that content some people find unhelpful is found helpful
by others, and that whether a particular content is found to be helpful or
unhelpful by a particular individual depends upon the immediate circumstances
in which it is accessed.
It
isn’t clear what the pathway to harm is, following exposure to self-harm
material online. Words like graphic, explicit or glamorising are in themselves
not tightly defined but they imply that the underlying mechanism is an
invitation to copy the behaviour. Linking this argument to suicidal behaviour
is problematic – for example most online images of self-harm are of self-injury
(cutting or burning) and yet these are extremely rare methods of suicide,
especially in young people. If the putative pathway to suicide isn’t copying
then presumably it is by exposure leading to low mood and hopelessness – in
which case it isn’t clear that images of self-injury are more problematic than
other mood-influencing content.
What is
the risk of disproportionate or untargeted action?
For much
of the content covered by the White Paper, there really isn’t much doubt about
what’s bad and needs to be suppressed – drug dealing, distributing child
pornography, inciting terrorism. In the case of self-harm however there are
risks of going too far in suppressing content. Those risks reside in the
diversity of material that comes under the online rubric of self-harm; the
likelihood of blocking access to material experienced as beneficial by isolated
and unhappy people, and the uncertainty about what’s genuinely harmful in
self-harm form and content. Clumsy, excessive or inconsistent intervention – in
the name of reducing harmful exposure and (by implication) habituation or normalization
– may have the unintended damaging consequence of increasing the sense of
disconnectedness and burdensomeness experienced by people with mental health
problems who self-harm.
What
steps to take?
There are
two steps:
If the
White Paper is to include action on self-harm content then the regulator needs
expert and specific advice on what content should be regulated and limited
immediately – even taking into account the considerably uncertainty outlined
above. That is, the advice should identify that material for which we can be
confident that harm is likely to accrue from accessing it and the risk of harm
obviously outweighs the possibility of benefit. This advice should be provided by an expert
panel that consults a diverse range of academics and mental health specialists.
Its recommendations should be for limited immediate action given how little we
know about harms.
As a
second step, the regulator should seek regular reports on emerging research
findings that support changes to its practice – to ensure that practice is
evidence-based rather than opinion-based.
Liaison psychiatry involves clinical practice, teaching and
research in psychiatry that takes place in non-psychiatric settings. In the UK that has meant mainly in acute
(general) hospitals or in specialist settings such as neurology centres,
although there have been small scale attempts to practice liaison psychiatry in
primary care (general practice). The rationale for liaison psychiatry is that
people with mental health problems don’t get the best care if they are being
seen in a non-psychiatric setting, unless there is a specialist team available
to see them where they are.
The main areas of activity in liaison psychiatry are:
Mental health problems that co-exist with
physical disease, which is sometimes called co-morbidity or multi-morbidity.
Each condition tends to complicate the treatment of the other and can lead to
poor outcomes for the patient.
Medically unexplained symptoms such as pain,
chronic fatigue, weakness or loss of bodily feeling. These conditions often
have a psychological component, although it upsets some people to say so.
Psychiatric emergencies such as suicidal
behaviour, acute psychosis, or delirium – all of which are seen in acute
hospitals.
Liaison psychiatrists can work in the emergency department,
on acute inpatient wards, in specialist hospital departments, and in their own
specialist outpatient clinics.
Discussions about services for people with co-existent physical
and mental health problems usually start with a brief account of how common that
state of affairs is, and how important it is.
Fair enough, but there’s another step in the discussion: how do you
decide who is best placed to respond to the needs of the people affected? Of course clinicians who specialise in
physical health should know something about mental health and vice versa: my
question is what to do when help is needed from specialists in this so-called
co-morbidity? And more specifically, what’s the role of liaison psychiatry?
To begin at the beginning…
Below is a schematic representation of a clinical service,
pictured as a simple care pathway. It acknowledges that at each stage some
people will not be referred on or will refuse referral, some accept referral
and do not attend, and some attend but drop out early. Also at each stage there
are some who complete treatment at each level but do not improve. These groups
are represented on the right.
The pathway also acknowledges, in line with standard thinking
about stepped
care, that some people present with such severe and complex needs that they
should be referred directly to a special service.
In the UK, brief psychological therapies are usually delivered in
primary care through a service known universally by the acronym IPAT (pr. eye apt)
and in secondary care by a range of services, most typically clinical health
psychology, or psychiatric nurse therapists working in liaison mental health
services.
The numbers who move along the branches of this pathway into the
complex/severe end are huge. To take one
example – figures
from NHS Digital indicate that only about a third of those referred to IAPT
for a talking therapy complete the course of treatment and of these only just
over a half have “moved to recovery” by the end of treatment. We know from
other research that relapse rates after brief therapies are high – up to 50%
over the next 1-2 years.
So…the pathway above is right to indicate the need for a
specialist service for complex and severe cases. What are the features of such cases?
The answer is – no two cases are the same.
Here’s a list of some of the features of complex and severe problems.
1. Diagnostic complexity (physical health)
Multiple or persistent severe symptoms that don’t fit standard
diagnostic categories (including don’t fit standard MUS categories like
fibromyalgia, CFS)
or encompass multiple diagnostic categories
Multiple drug treatments including opioid or equivalent analgesia
Multiple physical diagnoses, including some validated (so both
significant LTC and MUS)
Erroneous physical diagnosis assigned in past or by 3rd
parties
Disability out of proportion to physical disease severity
Major
non-adherence or misuse of therapeutic regime, including induced illness, with
serious physical consequences
2. Diagnostic complexity (mental health)
Illness conviction, especially non-affective – can sometimes have
a delusional quality, sometimes shared by close others
Suicidal and related thinking, self-harm history or current risk
3. Organisational complexity (healthcare)
Frequent unscheduled attendance – GP surgery; ED; other healthcare
Recurrent unscheduled acute admission
Recurrent unwarranted physical investigation
Multiple
healthcare providers
Drop
out from or failure to respond to first line treatment, with persistent
problems
4. Organisational complexity (social care)
Receipt of benefits dependent upon non-recovery
Various forms of assisted living for functional disabilities
5. Social complexity
Wider social dysfunction – tension or conflict with others,
impoverished illness-centred social network – having an impact on health or healthcare
that acts as a barrier to effective brief psychological therapies
Children or others as enmeshed carers
Involvement in long-running and contested litigation or complaints related to health or
healthcare
The origin of liaison psychiatry and the fuel for
its growth in the UK (until recent years) was the demand for expertise in the
management of such cases.
However, not only does a comprehensive service need
a component to deal with chronicity/complexity/severity, it also needs to be
able to offer integrated care – across primary and secondary care and between
the various components of mental health care. So…what are the characteristics
of integrated care? Here’s another list.
All this points to a (to my mind) relatively
obvious conclusion. Liaison
psychiatry services have an important role in the care of people with mental
and physical co-morbidity and, at least in secondary care, it would be best if
services were arranged so that IAPT, clinical health psychology and liaison
psychiatry were brought together in a genuinely-integrated multidisciplinary
service. There are barriers to that development – professional resistance is
one, and in my experience mainly from clinical psychology; in recent times
liaison psychiatry services have been swamped by the acute/urgent component of
liaison work, not least because of NHS England policy; manpower shortages and
funding limitations consequent on government policy – all play a part. It would
be great to see this practical and basically cost-free improvement to care
adopted as a national strategic priority by all the key interested parties.
