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Shift from crisis to prevention needed in self-harm services

There should be a system shift away from the current reliance on crisis interventions in tackling self-harm towards a more preventative model of support is the overriding message from the All-Party Parliamentary Group on Suicide and Self-Harm Prevention.

Respondents to their inquiry made clear that the single most impactful change to improve the support available to young people who self-harm would be this systemic change. In order to facilitate this long term aim, planned investment in NHS mental health support for young people should be increased and brought forward more quickly than currently planned. Investment in community-based preventative services, often delivered by the third sector, will also be key.

“For some young people who self-harm, specialist mental health support will be the best option from the outset. For many, though, a lower-level community-based intervention which arrives earlier and addresses the wider drivers of their self-harm would be most effective. Self-harm should be understood as the presenting behaviour for a set of underlying social or emotional problems or traumas to be addressed,” the inquiry report said.

Flipped on its head

At the end of 2017 the government committed to ‘earlier intervention and prevention’ in mental health support for young people. However, almost three years later, evidence received by the inquiry shows there is still much progress to be made in this regard. Young people need to receive support much sooner than they currently do, before their mental health needs escalate and their self-harming behaviour is more likely to become habitual.

Respondents told the inquiry that the current system of support should be flipped on its head. Rather than providing specialist mental health support only once a young person reaches crisis point, the government should focus long-term investment in early intervention provided by wider community-based services specifically for self-harm. This shift must take place alongside and in addition to investment into specialist mental health support such as CAMHS and IAPT in order to reduce waiting times, lower thresholds and increase specialist knowledge and support around self-harm, the inquiry adds.

Rates of self-harm are increasing among every age group and across both genders. This increase has been more pronounced in young people and particularly young women. As rates increase and the evidence base for the link between self-harm and suicide becomes clearer, greater prominence has been given to tackling self-harm in local and national suicide prevention plans.

Demand increased exponentially

There have also been a number of important commitments by NHS England in recent years in terms of supporting young people who self-harm. This includes investment to increase the capacity of specialist mental health services and improving mental health crisis support as outlined in the NHS Long Term Plan.

Recent government investment in preventative mental health support in schools and colleges through the introduction of Mental Health Support Teams (MHSTs) was widely welcomed by respondents to the inquiry. Despite recent policy advancements, changes are not consistently being translated into effective support ‘on the ground’.

Budgets for preventative interventions have been significantly reduced in recent years, yet demand for specialist NHS mental health services such as CAMHS and IAPT has increased exponentially, outstripping investment and exacerbating workforce issues.

This has resulted in longer waiting lists, higher thresholds and, as a result, more refused referrals of young people who self-harm. The government’s target of 35% of young people who need mental health support receiving it by 2020/21 still leaves two thirds without help. The inquiry heard that these problems are likely to be exacerbated by the Covid-19 pandemic, which began mid-way through the inquiry and greatly impacted the provision of mental health services, which have had to quickly adapt to provide support remotely.

Stigma 'a powerful force'

Referrals of young people to NHS mental health services reduced significantly during lockdown and are starting to increase again. Professionals working in self-harm expressed grave concern regarding the demand that is likely to be placed on the system post-lockdown, its ability to cope with this demand, and the impact that this will have on some of the most vulnerable young people in our society.

Demand for mental health services outstripping capacity predates the Covid-19 pandemic and has led to the exclusion of young people from those services on the basis of their self-harming behaviour. Particular groups of young people, including young people from ethnic minorities, those who identify as LGBT, or are autistic, who particularly struggle to access support due to problems with service outreach and design. Much more needs to be understood about the specific interventions which work to help young people when they are self-harming, particularly for those who are most at risk and currently disproportionately struggle to access support.

There is a lot of promising work going on around facilitated peer support, both online and in person. More evidence is needed around how this can be undertaken most effectively and safely for a range of young people. Stigma remains a powerful and problematic force, which continues to inhibit help seeking and negatively impacts the effective design and delivery of services. To combat this, education around self-harm remains of paramount importance at all levels of society.

Postcode lottery

“Anyone who requires specialist mental health support should receive it when they need it. Evidence to the inquiry, however, made clear that not all young people will require such care. For some, a lower-level community-based solution arriving earlier, before needs become more severe, would be more appropriate. The current system of support has developed to compensate for years of underfunding to focus on crisis-interventions, but this can and should be changed. There is both a human and financial case for early intervention, with one study estimating the overall annual cost of general hospital management of self-harm at £162 million per year,” said the report.

The report says that it became clear through the course of the inquiry that voluntary organisations and charities play a crucial role in providing support for young people who self-harm, filling the gaps in statutory services and also providing alternatives to them. Despite this, it was also noted in evidence that the sector’s reach and responsiveness is limited by capacity issues, exacerbating regional discrepancies in care. Young people who self-harm struggle to navigate the complex patchwork of services which vary greatly in their offer and impact, entrenching a postcode lottery for support.

Government support for the third sector, which is facing unprecedented challenges due to the Covid-19 pandemic, must be increased so that charities and voluntary organisations not only survive the difficulties of the next 18 months, but are better placed to offer high quality support alongside specialist NHS mental health services than before the pandemic. Youth services and sports clubs should have money invested as they play a crucial role to play in supporting young people earlier than is currently the case, before mental health needs escalate.

A move away from crisis support, towards a system of early intervention, should be underpinned by an understanding of self-harm through the lens of trauma as the presenting behaviour for a set of underlying social or emotional problems to be addressed.

The inquiry makes a number if recommendations including:

- The government should implement a new system of early intervention to support young people who self-harm.

- DHSC should use the forthcoming funding settlement to increase and accelerate planned investment in existing mental health services for young people.

- DfE should provide schools and colleges with increased mental health resource sooner to roll out Mental Health Support Teams more widely so that they are able to undertake preventative interventions around self-harm more consistently.

- NHSE/I, DfE, DCMS should ensure any frontline professional likely to come into contact with a young person who self-harms receives appropriate training on how best to support them.

- DHSC and NHSE should work together to ensure that safe peer-support models are promoted.

For the full recommendations and the report
Inquiry into the support available for young people who self-harm
A report by the All-Party Parliamentary Group on Suicide and Self-Harm Prevention
Inquiry_into_the_support_available_for_young_people_who_self-harm.pdf (samaritans.org)

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