Depression and risk of self-harm - assessment tools

Here are references relating to different types of therapeutic interventions we can offer and different types of mental health issues, developmental disorders and other presenting problems.
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Depression and risk of self-harm - assessment tools

Post by miriam »

Paul Wicks has written a useful wikipedia page on the BDI here

Other tools for measuring depression include:

For adults:
The CORE-OM assesses risk, anxiety and depression
HADS - Hospital Anxiety and Depression Scale
MDI - Major Depression Inventory
BHI - Beck Hopelessness Inventory

For children:
CDI - Childhood Depression Inventory
Beck Youth Inventories
SDQ - Strengths and Difficulties Questionnaire (widely used, but rather non-specific)

Assessing risk of self-harm

1) Clarification. Talk to the person, encourage them to go into more detail + seek clarification - e.g. are they just suicidal thoughts, or is there suicidal intent? Does the person have plans? If it is a concern that another person (e.g. child) may be at risk, seek clarification on the things the person has said that concern you in a non confrontational manner.

It can be useful to ask:

How do you feel about the future?
Have you ever felt life isnt worth carrying on with?
If so, have you made any definite plans?
What are these plans?
How recently have you considered carrying them out?
What has stopped you from harming yourself so far?

It is also worth considering the practicalities - how much time is the person alone, how much access do they have to their means of self-harm (eg tablets, knives, etc), when are the worst times.

2) Communication. I think it would be useful to outline your concerns to the person involved talk to them about what you might have to do + reassure the person whilst talking about what you might have to do if you feel the person is at risk. Similarly, if is about anything else - communicate your concerns + see what they think. You can also make a contract with a person not to self-harm before the next appointment, and provide lots of information and places to call if they feel low (eg Samaritans, local emergency team, GP, etc).

This might be more difficult when another person is involved (e.g. child/adult protection issues), as a slightly more covert approach may be needed if you feel another person/party may be at risk.

3) Supervision + note taking. Seek supervision on the issues you have concerns about. Ensure everything you have gone through is documented in the person's notes. Your supervisor should be able to give advice + guidance on what procedures/ steps are or aren't needed.

4) If a client seems suicidal or has talked about self-harm or thoughts of self-harm, your organisation should have a procedure to follow.

Why do people self-harm?

In general it is forumlated as being a combination of some of the following reasons:

1) A way of regulating affect: That is a way to manage painful or upsetting emotions and distress due to ego deficits. Self harm is an effective (although self-defeating) way of dissociating the self from painful emotions ("I makes the pain go away"), or grounding the self from dissociative experiences ("It makes me feel real")

2) A way of punishing the self out of anger, frustration and hate. I see this as defensive in nature, arising from a primary identification with punitive and subjugating caregivers. Basically self-directed anger and rage.

3) It could also be for control. If the individual feels they have no control over the rest of their life, or part of it, they can take control by self harming, for example, controlling the amount they hurt themselves, how often etc.

4) Reinforcing, and hence addictive, because of its functional aspects in relation to the above, and because of the dissociating and numbing effect of the endorphins the body releases.

Don't forget that self-harm may not be related to a wish to die, or to enduring depression (and that a lot of suicides may be accidental deaths). There is evidence that a lot of self-harm is impulsive and not in the context of an enduring clinical depression. Many people self-harm (and risk death) to gain some physical sensations (for example pain as self-punishment, or as more manageable than emotional pain), bio-chemical consequences (endorphins can give a sense of detatchment and blot out worries or guilt temporarily) or social consequences (to show people they feel bad or unsafe, that they need nurture, or are "ill") rather than because they want to die or have chronic depression.

References and Reading

There is some reading about this subject on the BPS website. article on self harm aimed at members of public. You can find the NICE guidelines for self harm here

A fab website that deals with self harm is as is

Rory O'connor's website has some good stuff on it. Klonsky (2006) published a review on self-harm in Clinical Psychology Review 27. It might be a good starting place to get some references etc. There was also an article on self-harm on the students page of the psychologist in April 2007, and the samaritans published some useful information (and their website is also good).

Gratz, K.L., Conrad, S.D., & Roemer, L. (2002). Risk Factors for Deliberate Self-Harm Among College Students. American Journal of Orthopsychiatry. 72(1):128-140.

Chapman, A.L.. Gratz, K.L. & Brown, M.Z. (2006). Solving the puzzle of deliberate self-harm: The experiential avoidance model. Behaviour Research & Therapy. 44(3); pp 371-394.

Kay Redfield Jamison wrote a book called 'Night Falls Fast: Understanding Suicide" and there is also one about self-harm called "cutting it out" by Caroline Smith and "hidden self harm" by Maggie Turp. "Bodies under Siege: Self-mutilation and Body Modification in Culture and Psychiatry" by Favazza is worth a look too.

Links updated Feb 2009. JoanneR

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