Self-Harm in Young People: A Therapeutic Assessment Manual PDF

Preface

The idea of Therapeutic Assessment was conceived several years ago when I was a second-year trainee psychiatrist assessing a young person while on call (I'll call her Meg). She presented to an inner-city hospital emergency department following a massive overdose and her life was in severe danger. I saw Meg after she was medically "cleared", that is to say her physical health was stable. The psychiatric history was very difficult to take – Meg had experienced multiple traumas and could not speak about them because of the unmanageable feelings her story was likely to evoke. At one stage she started crying uncontrollably and it took me a long time to soothe her. On the basis of what little information was available, I gradually started to form the view that Meg was suffering from severe depression.

At the time I was studying the principles of several psychological therapies. It was obvious, however, that the techniques I was learning were geared towards longer-term treatment and I felt powerless in the face of an acute crisis. Meg was admitted to a psychiatric unit under a section of the Mental Health Act – she had very negative memories of a previous admission but the risk of suicide seemed overwhelming. When I came to say goodbye, she was crying and told me I was another person who had made her go through "this hell" again.

Several ideas emerged from this experience. Firstly, it was clear that self-harm presentation represents a crisis but also a time of therapeutic opportunity – except the therapeutic opportunity is frequently missed. Secondly, the process of self-harm assessment might well be an alienating rather than a therapeutic experience for many young people. The assessment may sometimes be little more than a clinician asking a young person lots of difficult questions in order to make up his or her mind whether the young person is safe to go home or not. The questions may of course increase levels of distress, which the assessor then may not know how to handle adequately. Thirdly, it seemed obvious that even if some kind of therapeutic intervention was used, it was unlikely that a single technique would work with all young people. Finally, it was also clear that no matter how effective our interventions for managing self-harming behaviour are or will become in the future, they are all pretty much useless unless we can engage young people in the therapeutic process.

Therapeutic Assessment is an attempt to address, to a degree, these problems. Its main tenets are as follows. Firstly, a therapeutic intervention at the time of distress, compared to standard psychosocial history and risk assessment, appears to improve young people's satisfaction and their willingness to engage with further therapeutic work. Secondly, Therapeutic Assessment draws on a vast range of evidence-based interventions to create a therapeutic "toolkit" that individual practitioners can use. Thirdly, Therapeutic Assessment is simple and easy to learn and is designed for use by all mental health professionals who assess young people following an episode of self-harm.

This book consists of two parts. Part I is called "The Framework" and Part II is called "The Tools".

Part I is about facts – the building blocks of the framework Therapeutic Assessment is based on. There are three key questions addressed in Part I: 1."What is self-harm?" 2. "What are the key facts about self-harm?" 3. "What is the rationale for Therapeutic Assessment?"

Part II is about tools – the building blocks of Therapeutic Assessment practice.

There are three key questions addressed in Part II: 1. "How to help patients understand self-harm?" 2. "How to motivate and instil hope?" 3. "How to explore alternatives to self-harm?" Therapeutic Assessment provides clinicians with a set of tools to achieve these goals. The readers of this manual may well already be using a form of assessment that has some therapeutic elements. The authors of this manual would not claim that the techniques described here are necessarily better than whatever techniques work for individual, experienced practitioners. Moreover, if these techniques were evidence based we would like to incorporate them into the future development of Therapeutic Assessment. There is no limit to the number of tools in the TA "toolkit" and we hope that even the most experienced therapists may find some of the ideas useful.