Self-harm: Assessment, Management and Preventing Recurrence

Overview

This guideline covers assessment, management, and preventing recurrence for children, young people, and adults who have self-harmed. It includes those with a mental health problem, neurodevelopmental disorder, or learning disability.

In this guideline, self-harm is defined as intentional self-poisoning or injury, irrespective of the apparent purpose. The guideline does not cover repetitive, stereotypical self-injurious behaviour, such as head banging.

This guideline updates and replaces NICE guideline CG16 (published July 2004) and NICE guideline CG133 (published November 2011).

This Guidelines summary is relevant for healthcare professionals working in primary care settings, and therefore does not include recommendations from the full guideline on psychosocial assessment and care by mental health professionals, non-primary care health professionals, and professionals from other sectors; risk assessment tools and scales; supporting people to be safe after self-harm; and training and supervision for staff who work with people who self-harm. For the complete set of recommendations, refer to the full guideline.

The recommendations apply to all people who have self-harmed, unless a recommendation specifically states that it is for adults or children and young people only.

Reflecting on your Learnings

Reflection is important for continuous learning and development, and a critical part of the revalidation process for UK healthcare professionals. Click here to access the Guidelines Reflection Record.

Information and Support

• Provide information and support for people who have self-harmed. Share information with family members or carers (as appropriate). Topics to discuss include:
  • what self-harm is
  • why people self-harm and, where possible, the specific circumstances of the person
  • support and treatments available
  • self-care (also see recommendation 1.11.12 in the section on harm minimisation in the full guideline), including when to seek help
  • how to deal with injuries
  • how to manage scars
  • care plans and safety plans, and what they involve
  • the impact of encountering stigma around self-harm
  • who will be involved in their care and how to get in touch with them
  • where appointments will take place
  • what to do if they have any concerns
  • what do to in an emergency
  • local services and how to get in touch with them, including out-of-hours
  • local peer support groups, online forums, local and national charities, and how to get in touch with them.
• Provide information and support for the family members or carers (as appropriate) of the person who has self-harmed. Topics to discuss include:
  • the emotional impact on the person and their family members or carers
  • advice on how to cope when supporting someone who self-harms
  • what to do if the person self-harms again
  • how to seek help for the physical consequences of self-harm
  • how to assist and support the person
  • how to recognise signs that the person may self-harm
  • steps to reduce the likelihood of self-harm in the future
  • support for families and carers and how to access it
  • the impact of encountering stigma around self-harm
  • local services and how to get in touch with them, including out-of-hours
  • local peer support groups, online forums, local and national charities, and how to get in touch with them
  • their right to a formal assessment of their own needs including their physical and mental health (known as a ‘carer’s assessment’), and how to access this (see the NICE guideline on supporting adult carers).
• Information for people who have self-harmed and their family members or carers should be:
  • tailored to their individual needs and circumstances, taking into account, for example, whether this is a first presentation or repeat self-harm, the severity and type of self-harm, and if the person has any coexisting health conditions, neurodevelopmental conditions or a learning disability
  • provided throughout their care
  • sensitive and empathetic
  • supportive and respectful
  • consistent with their care plan, if there is one in place
  • conveyed in the spirit of hope and optimism.

For more guidance on communication, providing information (including different formats) and shared decision making, see the NICE guidelines on shared decision making, service user experience in adult mental health, patient experience in adult NHS services and babies, children and young people’s experience of healthcare.

• Recognise that support and information may need to be adapted for people who may be subject to discrimination, for example, people who are physically disabled, people with neurodevelopmental conditions or a learning disability, people from underserved groups, people from Black, Asian and minority ethnic backgrounds and people who are LGBTQ+.

Consent and Confidentiality

• Healthcare professionals and social care practitioners who have contact with people who self-harm should be able to:
  • understand when and how to apply the principles of the Mental Capacity Act 2005 and its Code of Practice, the Mental Health Act 2007 and its Code of Practice, and the Care Act 2014 and the Care Act 2014 statutory guidance
  • assess mental capacity
  • make decisions about when treatment and care can be given without consent
  • understand when and how to seek further guidance about consent to care
  • direct people to independent mental capacity advocates (IMCAs).

Also see the NICE guidelines on decision making and mental capacity, service user experience in adult mental health, and babies, children and young people’s experience of healthcare, and the Department of Health and Social Care’s consensus statement on information sharing and suicide prevention.

• Healthcare professionals and social care practitioners who have contact with children and young people who self-harm should also be able to:
  • understand how to apply the principles of the Children Act 1989 and the Children and Families Act 2014 in relation to competence, capacity and confidentiality and the scope of parental responsibility
  • understand how to apply the principles of the Mental Health Act 2007 to young people
  • understand how issues of capacity and competence to consent apply to children and young people of different ages
  • assess the young person’s capacity to consent (including Gillick competence).
• If staff working with people who self-harm need to discuss issues relating to capacity and consent, they should have access to:
  • specialist advice (for example, liaison psychiatry) at all times and
  • legal advice as needed.
• Staff working with people who self-harm should be familiar with the limits of confidentiality with regard to information about a person’s treatment and care.
• Staff working with people who self-harm should be aware of the benefits of involving the person’s family and carers and sharing information, and should recognise the need to seek consent from the person as early as possible. Also see the Department of Health and Social Care’s consensus statement on information sharing and suicide prevention.
• Staff working with people who self-harm should recognise that if it is necessary to breach confidentiality, they should ensure that the person who has self-harmed is still involved in decisions about their care and, where possible, is informed about the breach of confidentiality.

Safeguarding

• All staff who have contact with people who self-harm should:
  • understand when and how to apply the safeguarding principles of the Care Act 2014, the Children Act 1989, and the Children and Families Act 2014
  • ask about safeguarding concerns, for example, domestic abuse, violence or exploitation at the earliest opportunity and, if appropriate, when the person is alone
  • explore whether the person’s needs should be assessed and documented according to local safeguarding procedures
  • be aware of local safeguarding procedures for vulnerable adults and children in their care, and seek advice from the local named lead on safeguarding if needed.

Also see the NICE guidelines on domestic violence and abuse, looked-after children and young people, child abuse and neglect and child maltreatment.

• If people who self-harm are referred to local health and social care services under local safeguarding procedures, use a multi-agency approach, including education and/or third sector services, to ensure that different areas of the person’s life are taken into account when assessing and planning for their needs.

Involving Family Members and Carers

• Ask the person who has self-harmed whether and how they would like their family or carers to be involved in their care, taking into account the factors in the recommendation directly following, and review this regularly. If the person agrees, share information with family members or carers (as appropriate), and encourage them to be involved.
• When thinking about involving family members or carers in supporting a person who has self-harmed, take into account issues such as:
  • whether the person has consented for information to be shared and, if so, if the consent is limited to certain aspects of their care
  • any safeguarding concerns
  • the person’s mental capacity, age and competence to make decisions
  • the person’s right to confidentiality and autonomy in decision making
  • the balance between autonomy (in children and young people, their developing independence and maturity) and the need to involve family members or carers
  • the balance between the possible benefits and risks of involving family members of carers and the rights of the person.

Also see the NICE guidelines on decision making and mental capacity, service user experience in adult mental health, and babies, children and young people’s experience of healthcare.

• When involving family members or carers in supporting a person who has self-harmed:
  • encourage a collaborative approach to:
    • empower and support the person who has self-harmed
    • minimise the person’s self-harm behaviours and
    • support the person’s recovery to prevent recurrence
  • give them opportunities to be involved in decision making, care planning and developing safety plans to support the person beyond the initial self-harm episode, and through their care pathway
  • ensure that there is ongoing and timely communication with the family or carers
  • regularly review whether the person who has self-harmed still wants their family or carers to be involved in their care, and ensure that they know they can withdraw consent to share information at any time.
• Be aware that even if the person has not consented to involving their family or carers in their care, family members or carers can still provide information about the person.
• If the person who has self-harmed finds it difficult to vocalise their distress when they are in need of care, support the person and their family members or carers (as appropriate) in trying alternative methods of communication (such as non-verbal language, letters, emotional wellbeing passports, and using agreed safe words, phrases or emojis).

Assessment and Care by Healthcare Professionals and Social Care Practitioners

Principles for Assessment and Care by Healthcare Professionals and Social Care Practitioners

• When a person presents to a healthcare professional or social care practitioner following an episode of self-harm, the professional should:
  • treat the person with respect, dignity and compassion, with an awareness of cultural sensitivity
  • establish the means of self-harm and, if accessible to the person, discuss removing this with therapeutic collaboration or negotiation, to keep the person safe
  • assess whether there are concerns about capacity, competence, consent or duty of care, and seek advice from a senior colleague or appropriate clinical support if necessary; be aware and accept that the person may have a different view and this needs to be taken into account
  • seek consent to liaise with those involved in the person’s care (including family members and carers, as appropriate) to gather information to understand the context of and reasons for the self-harm
  • discuss with the person and their families or carers (as appropriate), their current support network, any safety plan or coping strategies.
• When a person presents to a healthcare professional or social care practitioner following an episode of self-harm, the professional should establish the following as soon as possible:
  • the severity of the injury and how urgently medical treatment is needed
  • the person’s emotional and mental state, and level of distress
  • whether there is immediate concern about the person’s safety
  • whether there are any safeguarding concerns
  • whether the person has a care plan
  • if there is a need to refer the person to a specialist mental health service for assessment.
• Carry out concurrent physical healthcare and the psychosocial assessment as soon as possible after a self-harm episode.
• For immediate first aid for self-poisoning, see the BNF’s guidance on poisoning, emergency treatment, TOXBASE and the National Poisons Information Service.
• Do not use aversive treatment, punitive approaches or criminal justice approaches such as community protection notices, criminal behaviour orders or prosecution for high service use as an intervention for frequent self-harm episodes.

Assessment and Care in Primary Care

• When a person presents in primary care after an episode of self-harm, consider referring them to mental health or social care services for a psychosocial assessment or informing their existing mental health team, with consent from the person and their family members or carers (as appropriate).
• Make referral to mental health professionals a priority when:
  • the person’s levels of concern or distress are rising, high or sustained
  • the frequency or degree of self-harm or suicidal intent is increasing
  • the person providing assessment in primary care is concerned
  • the person asks for further support from mental health services
  • levels of distress in family members or carers of children, young people and adults are rising, high or sustained, despite attempts to help.
• If the person who has self-harmed is being supported and given care in primary care, their GP should ensure that the person has:
  • regular appointments with their GP for review of self-harm
  • a medicines review
  • information about available social care, voluntary and non-NHS sector support and self-help resources care for any coexisting mental health problems, including referral to mental health services as appropriate.

For recommendations on assessment and care by ambulance staff and paramedics, by non-mental health emergency department professionals, in general hospital and social care settings, and by professionals from other sectors, refer to the full guideline.

Admission to and Discharge from Hospital

• Consider admission to a general hospital after an episode of self-harm if:
  • there are concerns about the safety of the person (for example, the person is at risk of violence, abuse or exploitation) and psychiatric admission is not indicated
  • safeguarding planning needs to be completed and psychiatric admission is not indicated
  • the person is unable to engage in a psychosocial assessment (for example, because they are too distressed or intoxicated).
• If a 16- or 17-year-old is admitted to a general hospital, ensure that it is to a ward that can meet the needs of young people.
• For arrangements for initial aftercare for people who have been admitted to a general hospital after they have self-harmed, see the section on initial aftercare after an episode of self-harm.
• Do not delay carrying out a psychosocial assessment or offering mental health treatment if the person is admitted to hospital or needs treatment for physical injuries.

For further recommendations on self-harming during hospital admission and pre-discharge planning, refer to the full guideline.

Initial Aftercare After an Episode of Self-harm

• After an episode of self-harm, discuss and agree with the person, and their family members and carers (as appropriate), the purpose, format and frequency of initial aftercare and which services will be involved in their care. Record this in the person’s care plan and ensure that the person and their family members and carers have a copy of the plan and contact details for the team providing the aftercare.
• If there are ongoing safety concerns for the person after an episode of self-harm, the mental health team, GP, team who carried out the psychosocial assessment or the team responsible for their care should provide initial aftercare within 48 hours of the psychosocial assessment.

Interventions for Self-harm

• When planning treatment following self-harm, take into account any associated coexisting conditions and the psychosocial assessment.
• For guidance on how to treat coexisting conditions that may be related to self-harm, also see the NICE guidelines on:
  • Alcohol-use disorders
  • Autism spectrum disorder in adults
  • Autism spectrum disorder in under 19s
  • Bipolar disorder
  • Borderline personality disorder
  • Care and support of people growing older with learning disabilities
  • Challenging behaviour and learning disabilities
  • Depression in adults
  • Depression in children and young people
  • Drug misuse in over 16s: opioid detoxification
  • Drug misuse in over 16s: psychosocial interventions
  • Eating disorders
  • Generalised anxiety disorder and panic disorder in adults
  • Learning disabilities and behaviour that challenges
  • Mental health problems in people with learning disabilities
  • Obsessive–compulsive disorder and body dysmorphic disorder
  • Psychosis and schizophrenia in adults
  • Post-traumatic stress disorder.
• Offer a structured, person-centred, cognitive behavioural therapy (CBT)-informed psychological intervention (for example, CBT or problem-solving therapy) that is specifically tailored for adults who self-harm. Ensure that the intervention:
  • starts as soon as possible
  • is typically between 4 and 10 sessions; more sessions may be needed depending on individual needs
  • is tailored to the person’s needs and preferences.
• For children and young people with significant emotional dysregulation difficulties who have frequent episodes of self-harm, consider dialectical behaviour therapy adapted for adolescents (DBT-A). Take into account the age of the child or young person and any planned transition between services.
• Healthcare staff should be appropriately trained and supervised in the therapy they are offering to people who self-harm.
• Work collaboratively with the person, using a strengths-based approach to identify solutions to reduce their distress that leads to self-harm.
• Consider developing a safety plan in partnership with people who have self-harmed. Safety plans should be used to:
  • establish the means of self-harm
  • recognise the triggers and warning signs of increased distress, further self-harm or a suicidal crisis
  • identify individualised coping strategies, including problem solving any factors that may act as a barrier
  • identify social contacts and social settings as a means of distraction from suicidal thoughts or escalating crisis
  • identify family members or friends to provide support and/or help resolve the crisis
  • include contact details for the mental health service, including out-of-hours services and emergency contact details
  • keep the environment safe by working collaboratively to remove or restrict lethal means of suicide.
• The safety plan should be in an accessible format and:
  • be developed collaboratively and compassionately between the person who has self-harmed and the professional involved in their care using shared decision making (see the NICE guideline on shared decision making)
  • be developed in collaboration with family and carers, as appropriate
  • use a problem-solving approach
  • be held by the person
  • be shared with the family, carers and relevant professionals and practitioners as decided by the person
  • be accessible to the person and the professionals and practitioners involved in their care at times of crisis.
• Do not use diagnosis, age, substance misuse or coexisting conditions as reasons to withhold psychological interventions for self-harm.
• Do not offer drug treatment as a specific intervention to reduce self-harm.

Therapeutic Risk Taking

Therapeutic risk taking should only be used after a psychosocial assessment (see the section on psychosocial assessment and care by mental health professionals). For recommendations on therapeutic risk taking, refer to the full guideline.

For recommendations on supporting people to be safe after self-harm, refer to the full guideline.

Safer Prescribing and Dispensing

• When prescribing medicines to someone who has previously self-harmed or who may self-harm in the future, healthcare professionals should take into account:
  • the toxicity of the prescribed medicines for people at risk of overdose (for example, opiate-containing painkillers and tricyclic antidepressants)
  • their recreational drug and alcohol consumption, the risk of misuse, and possible interaction with prescribed medicines
  • the person’s wider access to medicines prescribed for themselves or others
  • the need for effective communication where multiple prescribers are involved.

Also see the section on reducing access to methods of suicide in the NICE guideline on preventing suicide in community and custodial settings.

• Use shared decision making to discuss limiting the quantity of medicines supplied to people with a history of self-harm (for example, weekly prescriptions), and ask them to return unwanted medicines for safe disposal. Also see the NICE guideline on shared decision making.
• Consider carrying out a medicines review after an episode of self-harm. Take into account the pharmacokinetic properties of medicines, for example, half-life, risk of toxicity and the concurrent use of medicines such as benzodiazepines and opiates. If necessary, contact the National Poisons Information Service for further advice. Also see the NICE guideline on medicines optimisation. For people with learning disabilities or autism or both, the NHS England STOMP-STAMP principles may be useful.
• Community pharmacy staff should be aware of warning signs relating to self-harm, such as identifying people who are in acute distress, buying large amounts of over-the-counter medicines or who have access to large amounts of medicines.
• Healthcare professionals, including GPs and community pharmacy staff, should use consultations and medicines reviews as an opportunity to assess self-harm if appropriate, for example, asking about thoughts of self-harm or suicide, actual self-harm, and access to substances that might be taken in overdose (including prescribed, over-the-counter medicines, herbal remedies and recreational drugs).

For recommendations on psychosocial assessment and care by mental health professionals, non-primary care health professionals, and professionals from other sectors; risk assessment tools and scales; supporting people to be safe after self-harm; and training and supervision for staff who work with people who self-harm, refer to the full guideline.