Self-harm is a sign of distress usually involving a person injuring or poisoning themselves, regardless of motivation. Self-harm in young people is common; one survey of young people aged 15-16 years found more than 10% of girls and more than 3% of boys had self-harmed in the past year. Self-harm is associated with a 50- to 100-fold increased risk of suicide in a 12-month period.
Multiple mental health conditions are associated with self-harm including depression, borderline personality disorder, bipolar disorder, and schizophrenia. About half of people who present to emergency departments with self-harm have visited their GP in the previous month, and a similar number attend primary care in the 2 months following.
This Guidelines summary provides recommendations for:
- communicating with people who self-harm
- undertaking assessments for further self-harm or risk of suicide
- advice for developing risk management plans
- recommended treatment for self-harm and associated mental health conditions.
This guideline partially replaces CG16, and is the basis of QS189. This guideline follows on from NICE's associated guideline on Self-harm in over 8s: short-term management and prevention of recurrence.
Working with people who self-harm
- Health and social care professionals working with people who self-harm should:
- aim to develop a trusting, supportive and engaging relationship with them
- be aware of the stigma and discrimination sometimes associated 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.
- 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.
- Assessment of needs should include:
- skills, strengths and assets
- coping strategies
- mental health problems or disorders
- physical health problems or disorders
- social circumstances and problems
- psychosocial and occupational functioning, and vulnerabilities
- recent and current life difficulties, including personal and financial problems
- the need for psychological intervention, social care and support, occupational rehabilitation, and also drug treatment for any associated conditions
- the needs of any dependent children.
- When assessing the risk of repetition of self-harm or risk of suicide, identify and agree with the person who self-harms the specific risks for them, taking into account:
- methods and frequency of current and past self-harm
- current and past suicidal intent
- depressive symptoms and their relationship to self-harm
- any psychiatric illness and its relationship to self-harm
- the personal and social context and any other specific factors preceding self-harm, such as specific unpleasant affective states or emotions and changes in relationships
- specific risk factors and protective factors (social, psychological, pharmacological and motivational) that may increase or decrease the risks associated with self-harm
- coping strategies that the person has used to either successfully limit or avert self-harm or to contain the impact of personal, social or other factors preceding episodes of self-harm
- significant relationships that may either be supportive or represent a threat (such as abuse or neglect) and may lead to changes in the level of risk
- immediate and longer-term risks.
Risk assessment tools and scales
- Do not use risk assessment tools and scales to predict future suicide or repetition of self-harm.
- Discuss, agree and document the aims of longer-term treatment in the care plan with the person who self-harms. These aims may be to:
- prevent escalation of self-harm
- reduce harm arising from self-harm or reduce or stop self-harm
- reduce or stop other risk-related behaviour
- improve social or occupational functioning
- improve quality of life
- improve any associated mental health conditions.
- Review the person's care plan with them, including the aims of treatment, and revise it at agreed intervals of not more than 1 year.
- Care plans should be multidisciplinary and developed collaboratively with the person who self-harms and, provided the person agrees, with their family, carers or significant others[A]. Care plans should:
- identify realistic and optimistic long-term goals, including education, employment and occupation
- identify short-term treatment goals (linked to the long-term goals) and steps to achieve them
- identify the roles and responsibilities of any team members and the person who self-harms
- include a jointly prepared risk management plan (see the recommendation in the section, Risk management plans)
- be shared with the person's GP.
[A] 'Significant other' refers not just to a partner but also to friends and any person the service user considers to be important to them.
Risk management plans
- A risk management plan should be a clearly identifiable part of the care plan and should:
- address each of the long-term and more immediate risks identified in the risk assessment
- address the specific factors (psychological, pharmacological, social and relational) identified in the assessment as associated with increased risk, with the agreed aim of reducing the risk of repetition of self-harm and/or the risk of suicide
- include a crisis plan outlining self-management strategies and how to access services during a crisis when self-management strategies fail
- ensure that the risk management plan is consistent with the long-term treatment strategy.
- Inform the person who self-harms of the limits of confidentiality and that information in the plan may be shared with other professionals.
Interventions for self-harm
- 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. In addition:
- 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.
- Do not offer drug treatment as a specific intervention to reduce self-harm.
Treating associated mental health conditions
- Provide psychological, pharmacological and psychosocial interventions for any associated conditions, for example those described in the following published NICE guidance:
- Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence (NICE clinical guideline 115).
- Depression (NICE clinical guideline 90).
- Psychosis and schizophrenia (NICE clinical guideline 178).
- Borderline personality disorder (NICE clinical guideline 78).
- Drug misuse (psychosocial interventions or opioid detoxification) (NICE clinical guidelines 51 and 52).
- Bipolar disorder (NICE clinical guideline 185).
- When prescribing drugs for associated mental health conditions to people who self-harm, take into account the toxicity of the prescribed drugs in overdose. For example, when considering antidepressants, selective serotonin reuptake inhibitors (SSRIs) may be preferred because they are less toxic than other classes of antidepressants. In particular, do not use tricyclic antidepressants, such as dosulepin, because they are more toxic.
- If a person presents in primary care with a history of self-harm and a risk of repetition, consider referring them to community mental health services for assessment. If they are under 18 years, consider referring them to Child and Adolescent Mental Health Services (CAMHS) for assessment. Make referral a priority when:
- levels of distress are rising, high or sustained
- the risk of self-harm is increasing or unresponsive to attempts to help
- the person requests further help from specialist services
- levels of distress in parents or carers of children and young people are rising, high or sustained despite attempts to help.
- If a person who self-harms is receiving treatment or care in primary care as well as secondary care, primary and secondary health and social care professionals should ensure they work cooperatively, routinely sharing up-to-date care and risk management plans. In these circumstances, primary health and social care professionals should attend care programme approach (CPA) meetings.
- Primary care professionals should monitor the physical health of people who self-harm. Pay attention to the physical consequences of self-harm as well as other physical healthcare needs.
NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.
Published date: 23 November 2011 (amended March 2020).
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