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www.npjournal.org The Journal for Nurse Practitioners - JNP
299
Deliberate self-harm (DSH) is a widespreadproblem among
young people. In a commu-nity sample report, at least 1 episode
of non-
suicidal self-injury (NSSI) was found among one third to
one half of all United States adolescents.1 In a random
sample of undergraduate and graduate students identified
via an internet survey, “The lifetime prevalence rate of � 1
self-injurious behavior incident was 17.0%. Seventy-five
percent of those students engaged in self-injurious behav-
iors more than once.”2
A wide range in prevalence data is attributed to the fact
that many who self-injure do not seek medical assistance.
The gender difference in DSH prevalence is slightly higher
in younger females but evens out in adulthood.
Self-injury is defined in various ways in the literature,
but for this article, the term deliberate self-harm is used to
describe “intentional destruction of body tissue without
suicidal intent and for purposes not socially sanctioned.”3
It is important to recognize that a percentage of persons
who self-harm eventually do attempt suicide. Hawton
and Harriss4 found that, in a sample of 4,843 young peo-
ple followed in a 20-year cohort, 1.7% had committed
suicide. It is crucial to note that 90% of these individuals
had used overdosing to self-harm.

Various terms are used to label DSH, including self-
injurious behavior, intentional self-injury, nonsuicidal
self-injury, and self-mutilation. DSH occurs in various
forms, with the most common including cutting, brand-
ing or burning, picking at skin or reopening wounds
(dermatillomania), pulling hair (trichotillomania), hitting
or punching, and head banging.5
DSH is often regarded as a chronic condition associated
with such sequelae as physical injury, scarring, cosmetics
impairment, and unintended death.6 DSH assessment and
identification in young people in the primary care setting
poses particular challenges to primary care providers (PCPs).
BACKGROUND AND SIGNIFICANCE
There is little information on PCP involvement in DSH
assessment and identification. This lack is a result of both
ABSTRACT
Deliberate self-harm is a major public health concern among
young people age
12-24 years old. Health care providers lack basic knowledge
regarding the assess-
ment and identification of deliberate self-harm, thus delaying
recognition. Given
the time restrictions and knowledge deficit of health care
providers, a detailed
physical, psychological, and psychosocial assessment is often
excluded during well
and acute visits. Using the evidence, this article outlines some
guidelines to fur-
ther providers’ understanding of the essential components of
assessment, which
can enhance the identification of deliberate self-harm in the
primary care setting.

Keywords: adolescent, assessment, deliberate self-harm, risk,
young adult
© 2012 American College of Nurse Practitioners
Assessment and
Identification of Deliberate
Self-Harm in Adolescents
and Young Adults
Courtney Brooks Catledge, FNP-BC,
Kathleen Scharer, PMHCSN-BC,
and Sara Fuller, PNP
300 The Journal for Nurse Practitioners - JNP Volume 8, Issue
4, April 2012
the acceptability of self-harm behavior throughout time7
and such practice barriers as inadequate training, screen-
ing tools, reimbursement, and mental health resources for
referrals.8 Recent literature reflects an advancement in
understanding that DSH behaviors serve as affect regula-
tion, self-punishment, interpersonal influence and
boundaries, antidissociation, or sensation seeking.1
Literature on treatment has been limited to suicidal risk
and treating injuries in emergency departments.9 Despite
the availability of suicide risk assessments and emergency
treatment guidelines for acute care settings, there continues
to be inconsistent assessment and management of young
adult patients in the primary care setting. Many PCPs are
excluding both the physical and psychosocial assessment
needed to identify and prevent DSH.8

ONSET IN ADOLESCENT AND YOUNG ADULTS
DSH occurs across the lifespan, yet young people are
seen as participating in the behavior at disproportion-
ately higher rates.10 The Center for Suicide Preven -
tion11 found that the behaviors usually start in early
adolescence, then increase between ages 16 to 25.
DSH has been rare in those under 12.12 Thus the
focus of this article is the young adult population
ranging in age from 12 to 24.
Skegg identified various risk factors that contribute
to young people’s risk of participating in DSH.12 The
demographic factors include age, gender, and socioeco-
nomic status. Psychosocial factors that affect DHS partic-
ipation incorporate childhood experiences such as child
abuse and other forms of family dysfunction.
Lastly, the presence of or a family history of psychi-
atric illness, especially anxiety, depression, and personality
disorders, is a strong precursor to young adult participa-
tion in DSH. More females than males tend to self-harm.
Skegg12 found low socioeconomic status, education level,
and income and living in poverty to be associated with
increased risk of DSH, yet the literature overall lacks
consistency on this topic.
FUNCTIONS OF PARTICIPATING IN DSH BEHAVIOR
The literature clearly supports DSH as a behavior without
the intentional desire to die.13 The terminology itself is rec-
ognized as the intent to harm without having fatal out-
comes.12 DSH serves as a mechanism to regulate effect in
stressful situations; communicate distress to others; coerce or
compete with other self-injurers; resolve conflicts; release
anger, tension, or emotional pain; provide a sense of secu-

rity or control; punish oneself; generate intimacy; and serve
as suicide alternative.13,14 Harris’ study reported that 1 par-
ticipant said, “The purpose of some acts of self-harm is to
preserve life… professionals sometimes find this a difficult
concept to understand.”15 This quotation reinforces the
idea that DSH is used as a coping mechanism that may
seem to be the only option. Harris recognizes that those
who repeatedly self-harm may demonstrate variations in
methods, as well as differing intention and motive.15
FACTORS ASSOCIATED WITH DSH
Factors associated with DSH include sexual abuse, family
dysfunction, psychosocial factors, and psychological fac-
tors.3,10,12 In addition, childhood sexual abuse is thought
to contribute to early initiation of DSH as a method to
remedy psychological issues such as the depression and
anxiety typically associated with both abuse and DHS.16
Fliege and colleagues10 correlated stressful, traumatic
experiences in childhood to DSH.
Evidence supports a strong correlation between
psychological factors and DSH. Anxiety, depression,
hopelessness, anger, and impulsivity were the most
prevalent in the literature.10,17 Problems with friends,
boy/girlfriends, schoolwork, alcohol and drug use, and
bullying were some additional psychosocial factors in
the literature that were shown to have an impact on
both behavior and risk for DSH.18
PRACTICE AND KNOWLEDGE ASSESSMENT OF DSH IN
PRIMARY CARE
Morey et al’s study found that only 49.8% of those
engaging in DSH sought help after the event and the
assistance included mainly friends or family members,
with only 11.3% presenting to the hospital.16 Ozer and

colleagues19 found that approximately one third of ado-
lescents seen in primary care said they were asked about
their emotional health. Multiple reasons for underutiliza-
tion of screening opportunities in the primary care set-
ting were noted, including physician lack of confidence
to treat such illness as depression and lack of integrated
systems for both screening and management.19 Of those
patients seeking services for DSH, many acknowledged
negative experiences, with a perceived lack of patient
involvement in management decisions, hostile staff
behavior, lack of staff knowledge, and the need for better
after-care arrangements.20,21
301
RECOMMENDATIONS
PCPs of young people should assess for evidence of and
risk for DSH. Providers need to be educated to enhance
their ability to identify, assess, and manage DSH in pri-
mary care using current evidence. Assessing young people
for DSH can impact the prevention and reoccurrence of
those behaviors. Ozer and colleagues19 found that PCPs
should include a screening for emotional distress as a
standard part of young adult care. A timely assessment is
important, especially during the early teen years, which
have been found to be an important life phase in the
prevention and early identification for self-harm.9,22,23
THERAPEUTIC RELATIONSHIP
PCPs of young adults need to create a trusting, private
environment without family or caregivers present initially
to ensure patient safety and accurate assessment data.
Establishing a therapeutic relationship with young people

in the primary care setting is essential to demonstrate trust,
respect, and rapport.3,13 A matter-of-fact approach that is
neither critical nor overly sympathetic works best. It is
critical to establish a working
relationship to promote joint
clinical decision making based
on the foundational elements of
understanding and compassion.
Skegg noted the impor-
tance of providers guarding
against a reaction of horror,
while recognizing that assess-
ment should work towards
identifying the functions of the
behavior in a non-judgmental
way.12 Walsh noted that self-
injury can produce extreme
reactions in caregivers including shock, disgust, recoil,
judgment, anxiety, fear, anger, and confusion; therefore,
PCPs should examine their behaviors and reactions so
as not to compromise the therapeutic relationship.13
Confidentiality and privacy should be emphasized with
the caveat that certain types of behaviors such as child
abuse or current suicidal intention must be reported.
Purcell et al24 identified that a large portion of HCPs
do not interview their patients in private. Given the
correlation that DSH has with family dysfunction and
abuse, the initial interview should be in private to
reduce the risk of rebound abuse by a perpetrator.
Strong communication skills on the part of the PCP are
important to both establish a relationship and collect
the information needed for a comprehensive assessment.

PHYSICAL ASSESSMENT
Behavioral clues to participating in DSH include dress-
ing in long sleeves and pants even in warm weather,
wearing wrist bands or bulky bracelets, avoidance of
activity where the person has to change clothes or
expose skin such as physical education class. These
behaviors may indicate the need for a comprehensive
skin examination even if the presenting problems might
not require it. A comprehensive skin assessment should
included normally clothed areas such as breasts, entire
arms, legs, upper and inner thighs, and abdomen.
Considering the number of young adults who deliber-
ately self-harm, a skin assessment should be conducted
annually. Evidence of scratches, burns, lacerations, objects
felt under the skin by palpation, or multiple scars with-
out reasonable explanations may be signs of self-harm.
Scars will vary greatly in appearance, depending upon
their age and depth of cutting
and what is used to cut. Razor
blades are quite commonly
used but other objects such as
nail clippers or scissors may be
used. Sometimes the skin is
gouged, perhaps with a flat
blade screw driver. Many who
cut choose to cut over and over
again in the same spot so that
there may only be a single line.
But cross-hatched wounds or
even words may be carved into
the skin. The number of cuts
also will vary widely from 1 or 2 to more than 100.25
Objects can be embedded under the skin, such as nee-

dles or glass pieces. Burns are often from cigarettes but
candle flames, lighters or matches may also be used.
Walsh noted that most individuals who self-harm cut the
extremities and abdomen, not the neck.13 Proper assess-
ment of wounds can provide objective information
about the frequency and level of physical damage.
Additional clues may consist of signs of anger, sadness,
and anxiety expressed through acts of defiance or with-
drawal, and low self-esteem. 25 Documentation should
include location of the evidence of self-harm, type of
It is critical to establish a
working relationship to
promote joint clinical
decision making based on
the foundational elements
of understanding and
compassion.
4, April 2012
injury, size, and stage of healing for later comparison
since it is common for the same sites to be reused.
Self-Injury Risk Assessment
Health care providers, when providing either acute or
preventative care services, should include a self-injury
risk assessment. Assessment should be specific to the
patient presentation at the time of the encounter and
take into account gender variations, previous behavior,
and any comorbidity. Functions and characteristics of

self-harm vary greatly between patients and DSH
episodes so it is important to assess each episode sepa-
rately.26 Young adults who self-harm should be taken
seriously by PCPs.27 A comprehensive self-injury risk
assessment guides the PCP on appropriate care and fol-
low-up.3,9,17,25 According to Peterson and colleagues,1
Walsh,13 and Spender,28 the self-injury risk assessment
should include the items listed in Table 1.
Psychosocial and Psychological Risk Assessment
PCPs should complete a psychosocial and a psychological
risk assessment, including suicide risk assessment based on
individual circumstances. Consideration should be given
to interviewing family and other key people while main-
taining patient confidentiality and with patient consent. A
preliminary psychosocial assessment should be completed
at initial presentation to determine the individual’s men-
tal capacity, level of distress, and presence of mental ill-
ness.26 All who have self-harmed should be assessed for
clinical and demographic characteristics known to be
associated with risk of further self-harm or suicide.
PCPs must identify the key psychological characteristics
associated with risk, such as depression, hopelessness, and
suicidal intent.26 Assessment of suicide risk, history of physi-
cal and sexual abuse, substance abuse history, evaluation of
family functioning, and identification of comorbid psychi-
atric illness should all be included in the assessment.1,29
Unless the person is suicidal, a self-harm contract is gener-
ally not effective. However, if the individual reports some
suicidal ideation, check for a plan and then determine if fur-
ther intervention is needed immediately.
The vast majority of DSH is through cutting, which

by itself rarely causes death. However, the use of alcohol
can increase the risk of suicide in patients who self-
harm.4 Whitlock and Knox,30 in a random sample of col-
lege students, looked at the relationship between DSH
and suicidality, with the results showing that as DSH
episodes increase, so does suicide attempt. Some self-
injurers will move from a low lethality method to higher
lethality, thereby increasing suicide risk. Clinicians work-
ing with persons with DSH need to monitor over time
whether their clients are also experiencing suicidal
ideation, planning, and behaviour, with the priority to
respond to the suicidal crisis first.13
PCPs need to monitor patient motivation for self-
injury and specifics of the act. In response to a DSH
act, the PCP needs to address the patient’s psychosocial
needs, poor problem solving, and impulsivity to prevent
further acts. This may require a referral to a mental
health professional.23
While various instruments to measure self-harm have
been developed for research, 2 measures have been devel-
oped for clinicians. The Self-Harm Inventory31 is a 22-
item self-report questionnaire that includes questions
about high-risk behaviors of overdosing or attempted
suicides, self-harm, and 3 items that deal with eating-dis-
order behaviors. This free paper measure is easy to use
and has reasonable validity and reliability. It is available in
the cited paper.
Diamond and colleagues8 have been developing a
computer-based behavioral health assessment tool that
takes about 13 minutes to complete. The assessment is
scored by the computer so that results are immediately
available to the provider. This screen includes important
issues relating to DSH, including self-harm questions, and

has good psychometric data.
PCPs should remember the correlation DSH has
with abuse, family tension/stressors, and other underlying
Table 1. Self-Injury Risk Assessment Criteria
• History (age at onset, type of self-injury, functions,
wounds per episode, duration per episode, duration of
the problem, body area[s], extent of physical damage,
other forms of self-harm)
• Details of recent self-injury (types, functions, number of
wounds, temporal dimensions, extent of physical
damage, body areas, patterns, use of a tool, physical
location, social context)
• Antecedents (historical, environmental, biological,
cognitive, affective, and behavioral triggers)
• Consequences/aftermath (emotional relief, attention
from others, and environmental, biological, cognitive,
affective, behavioral results)
• Other details2,14,29
303
mental disorders.10,25,27 Compared with those who do
not self-harm, those who do experience more frequent
negative and unstable emotions, including anxiety,
depression, aggressiveness, and impulsivity in their daily
lives.10 When working with the family, it is important to

know if problems within the household have led to the
patient’s DSH,10 since the approach to the family would
have to be modified if it would likely increase the risk of
further DSH or suicide. The duty to share information
with parents is limited to generalities, and providers must
be cautious about what is shared, protecting the patient’s
confidences while ensuring safety.
EVIDENCE-BASED MANAGEMENT AND FOLLOW-UP
PCPs should provide evidence-based management and
follow-up. Treatment for the patient exhibiting DSH or
risk should include a management plan3 developed in
conjunction with the patient. Initial treatment for the
patient who participates in DSH should include treat-
ment for physical consequences of self-harm.26 Skegg12
identified general principles of care after self-harm (Table
2). Youth who engage in DSH do grow into adults who
may continue to self-harm, or they may cease the behav-
iour, only to have it restart in adulthood under severe
stress. Alternately, some individuals who engage in DSH
may gradually escalate the type or intensity of their DSH
behaviors and eventually attempt suicide if their coping
attempts are unsuccessful in regulating their affect or dis-
tress increases significantly.30 Therefore, the individual
plan should identify coping skills and deficits with a plan
to increase those skills.
Psychoeducation for the patient and family, cognitive
problem-solving skills, family therapy, and dialectical
behavior therapy (DBT) are often appropriate, depending
on patient needs.1 Spender found that treatment may
include alternative forms of communication, including
writing in a diary or blog, composing poetry or music,
drawing or painting, chatting on a messaging network, or
talking more to friends or family members.28

PCP EDUCATION
PCPs of young adults with DSH should be educated on
the characteristics, signs and symptoms, incidence and
etiology, and sequelae. They also should know commu-
nity referral resources and practice recommendations,
including comprehensive target physical assessment and
psychosocial assessment. Ozer and colleagues19 reported
that when clinicians have the training and tools needed
to provide primary care, the result is improved clinician
self-efficacy, thus increased rates of screening and coun-
seling of adolescents for risky health behaviors.
PRACTICE IMPLICATIONS
Deliberate self-harm has existed for centuries and has
taken on a variety of forms, yet there are few practice
guidelines available specific to the best practice stan-
dards of assessment and identification of young adults in
the primary care setting. The above assessment recom-
mendation was created to assist primary PCPs in offer-
ing best practice care to young adults with DSH. This
recommendation is quite important, given both the
increasing numbers of young adults participating in
DSH and the lack of PCPs with knowledge, skill, and
resources to provide care. Using a targeted assessment in
this population will lead to an improved likelihood of
identifying DSH. As a result, improvement can be made
to provide best practice treatment that reduces repeat
episodes and long-term sequelae.
The guideline recognizes the importance of establish-
ing a therapeutic relationship with the realization that
PCPs are stretched to their limits when it comes to time
and resources. As a result, the guideline should be imple-
mented over several visits. Within the context of the ini-

tial visit, priority should be given to creating a safe and
therapeutic environment for assessment, so that with
Table 2. Evidence-Based Management and Follow-Up13
• Monitor patient for further suicidal or self-harm
thoughts
• Identify support available in a crisis
• Come to a shared understanding of the meaning of the
behavior and the patient’s needs
• Treat psychiatric illness vigorously
• Attend to substance abuse
• Help patient to identify and work toward solving
problems and improve coping skills
• Enlist support of family and friends where possible
• Encourage adaptive expression of emotion
• Avoid prescribing quantities of medicine that could be
lethal in overdose
• Assertive follow-up in an empathic relationship
• Affirm the values of hope and of caring for oneself
4, April 2012

additional encounters, more detailed assessment findings
can be gathered. This assessment can be effectively car-
ried out only in an environment perceived to be safe by
the patient.
The initial assessment must include a physical, suicide
risk, and psychosocial and psychological risk assessments
to ensure young people are not a serious threat to them-
selves or others, as well as ensure there is no imminent
danger in the home, work, or other personal environ-
ment. This also identifies their mental competence and
the need for treatment of physical injury and any identi-
fied psychological disorders.
During follow-up encounters, PCPs can complete the
assessments to improve understanding of the DSH behav-
ior and collaborate with patients to establish a comprehen-
sive treatment plan. Subsequent encounters may also
provide insight into the need for additional referral and
follow-up. It is important to find ways to reduce and elim-
inate the health care barriers encountered by young adults.
Understanding and addressing the barriers that prevent
them from seeking help must be dealt with, rather than
waiting for young adults to seek out PCPs.32
NURSING EDUCATION IMPLICATIONS
A major problem in the care of adolescents who self-harm
or are suicidal is that PCPs may have difficulty dealing with
these intentional acts.33-35 The intentional nature of the
behavior can be difficult for providers to understand and to
accept when they are dealing with potentially life-threaten-
ing problems of other clients or when their own anxieties
about the behavior interfere with providing compassionate
care. The education of all health professionals needs to
include opportunities to examine feelings about DSH
behaviors, gain some understanding about the factors that

influence these behaviors, and receive education about
appropriate responses for the level of care they will be pro-
viding. Assessment, identification, and treatment of DSH in
the adolescent and adult population need to be included.
Student nurses and NPs need to understand the issue
of DSH and should be taught how DSH presents, the
underlying risk factors, and the evidence-based manage-
ment strategies. Student nurses should also be taught spe-
cific red flags for to look for when assessing the young
adult that would better equip them to identify and coun-
sel patients exhibiting the risk or behaviors of DSH.
Finally, they need to be taught how and when to refer
DSH patients for further care.
At the graduate level, advanced practice nurses need
detailed information on the assessment, psychosocial fac-
tors, psychological factors, peer association, and evi-
dence-based management strategies to properly provide
comprehensive primary care. A good understanding of
child abuse, anxiety and depressive disorders, stress-related
illness, and peer association cues should be part of the
advanced practice curriculum.
Neville and Poustie6 recognized the need for greater
training and support for all members of the primary health
care team as part of continuing education. Taylor et al20
noted that PCPs need improved knowledge, communica-
tion, and follow-up, thus compounding the need for further
assessment of the educational and health care system to
identify where knowledge and experience could be attained.
CONCLUSION
Every young adult who engages in DSH should be taken
seriously by the health care team. Providers need to take

an active role in improving outcomes for those who are
at risk for or participating in DSH. It must start with a
thorough and comprehensive assessment.
References
1. Peterson J, Freedenthal S, Sheldon C, Andersen R.
Nonsuicidal self-injury in
adolescents. Psychiatry (Edgmont). 2008;5(11):20-26.
2. Whitlock J, Eckenrode J, Silverman D. Self-injurious
behaviors in a college
population. Pediatrics. 2006;117:1939-1948.
3. Klonsky ED, Muehlenkamp JJ. Self-injury: A research review
for the
practitioner. J Clin Psychol. 2007;63(11):1045-1056.
4. Hawton K, Harriss L. Deliberate self-harm in young people:
characteristics
and subsequent mortality in a 20-year cohort of patients
presenting to
hospital. J Clin Psychiatry. 2007;68(10):1574-1583.
5. Smith M, Segal J. Self injury help, support, and treatment.
2008. Last
updated January 2012.
http://www.helpguide.org/mental/self_injury.htm.
6. Neville R, Poustie A. Deliberate self-harm cases: a primary
care perspective.
Nurs Standard. 2004;18(48):33-36.
7. Timofeyev A, Sharff K, Burns N, Outterson R. Timeline: self
mutilation in
history. 2002.

http://wso.williams.edu/�atimofey/self_mutilation/History/
index.html. Accessed February 10, 2012.
8. Diamond G, Levy S, Bevans KB, et al. Development,
validation, and utility of
internet-based, behavioral health screen for adolescents.
Pediatrics.
2010;126(1):e163-e170.
9. Australasian College for Emergency Medicine and The Royal
Australian and
New Zealand College of Psychiatrists. Guidelines for the
management of
deliberate self-harm in young people.
www.acem.org.au/media/publications/
youthsuicide.pdf. Accessed February 10, 2012.
10. Fliege H, Lee JR, Grimm A, Klapp BF. Risk factors and
correlates of
deliberate self-harm behavior: a systematic review. J
Psychosomatic Res.
2009;66(6):477-493.
11. Centre for Suicide Prevention. A closer look at self-harm.
http://www.docstoc.
com/docs/31961943/A-Closer-Look-at-Self-Harm. Accessed
February 10, 2012.
12. Skegg K. Self-harm. The Lancet. 2005;366(9495):1471-
1483.
13. Walsh B. Clinical assesment of self-injury: a practical
guide. J Clin Psychol.
2007;63(11):1057-1068.
14. Lloyd-Richardson EE, Perrine N, Dierker L, Kelley ML.
Characteristics and

functions of non-suicidal self-injury in a community sample of
adolescents.
Psychol Med. 2007;37(08):1183-1192.
15. Harris J. Self-harm: cutting the bad out of me. Qual Health
Res.
2000;10(2):164-173.
www.psy.dmu.ac.uk/brown/selfinjury/harris.pdf.
Accessed February 10, 2012.
16. Klonsky E, Moyer A. Childhood sexual abuse and non-
suicidal self injury:
meta-analysis. Br J Psychiatry. 2008;192:166-170.
http://www.helpguide.org/mental/self_injury.htm
http://wso.williams.edu/~atimofey/self_mutilation/History/index
.html
http://www.acem.org.au/media/publications/youthsuicide.pdf
http://www.docstoc.com/docs/31961943/A-Closer-Look-at-Self-
Harm
http://www.psy.dmu.ac.uk/brown/selfinjury/harris.pdf
http://wso.williams.edu/~atimofey/self_mutilation/History/index
.html
http://www.acem.org.au/media/publications/youthsuicide.pdf
http://www.docstoc.com/docs/31961943/A-Closer-Look-at-Self-
Harm
305
17. Cleaver K. Characteristics and trends of self-harming
behavior in young
people. Br J Nurs. 2007;16(3):148-152.

18. de Kloet L, Starling J, Hainsworth C, Berntsen E, Chapman
L, Hancock K.
Risk factors for self-harm in children and adolescents admitted
to a mental
health inpatient unit. Aust N Z J Psychiatry. 2011;45(9):749-
755.
19. Ozer EM, Zahnd EG, Adams SH, et al. Are adolescents
being screened for
emotional distress in primary care? J Adolesc Health.
2009;44(6):520-527.
20. Taylor T, Hawton K, Fortune S, Kapur N. Attitudes toward
clinical services
among people who self-harm: systematic review. Br J
Psychiatry.
2009;194:104-110.
21. Houston K, Haw C, Townsend E, Hawton K. General
practitioner contacts
with patients before and after deliberate self-harm. Br J Gen
Pract.
2003;53(490):365-370.
22. Patton G, Hemphill S, Beyers J, et al. Pubertal stage and
deliberate self-
harm in adolescents. J Am Acad Child Adolesc Psychiatry.
2007;46(4):508-
514.
23. Webb L. Deliberate self-harm in adolescence: a systematic
review of
psychological and psychosocial factors. J Adv Nurs.
2002;38(3):235-244.
24. Purcell J, Hergenroeder A, Kozinetz C, Smith E, Hill R.

Interviewing
techniques with adolescents in primary care. J Adolesc Health.
1997(20):300-305.
25. Hicks M, Hinck S. Best-practice intervention for care of
clients who self-
mutilate. J Am Acad Nurs Pract. 2009;21:430-436.
26. NICE. Self-harm. The short-term physical and psychological
management
and secondary prevention of self-harm in primary and secondary
care:
summary of management and treatment.
www.nice.org.uk/nicemedia/pdf/
CG016NICEguideline.pdf. Accessed February 10, 2012.
27. Ystgaard M, Arensman E, Hawton K, et al. Deliberate self-
harm in
adolescents: comparison between those who receive help
following self-
harm and those who do not. J Adolesc. 2009(32):875-891.
28. Spender Q. Assessment of adolescent self-harm. Paediatrics
Child Health.
2007;17(11):448-453.
29. Sourander A, Aromaa M, Pihlakoski L, et al. Early
predictors of deliberate
self-harm among adolescents. A prospective follow-up study
from age 3 to
age 15. J Affect Disord. 2006(93):87-96.
30. Whitlock J, Knox KL. The relationship between self-
injurious behavior and
suicide in a young adult population. Arch Pediatr Adolesc Med.
2007;161(7):634-640.

31. Sansone RA, Wiederman MW, Sansone LA. The self‐harm
inventory (SHI):
development of a scale for identifying self‐destructive
behaviors and
borderline personality disorder. J Clin Psychol. 1998;54(7):973-
983.
32. Morey C, Corcoran P, Arensman E, Perry I. The prevalence
of self-reported
deliberate self-harm in Irish adolescents. BMC Public Health.
2008;8:79-85.
33. Patterson P, Whittington R, Bogg J. Measuring nurse
attitudes toward
deliberate self-harm: the Self-Harm Antipathy Scale (SHAS). J
Psychiatr
Ment Health Nurs. 2007;14(5):438-445.
34. Mackay N, Barrowclough C. Accident and emergency staff’s
perceptions of
deliberate self-harm: Attributions, emotions and willingness to
help. Br J
Clin Psychol. 2005;44(2):255-267.
35. McAllister M, Creedy D, Moyle W, Farrugia C. Nurses’
attitudes towards
clients who self‐harm. J Adv Nurs. 2002;40(5):578-586.
Courtney B. Catledge, DNP, MPH, MSN, APRN, FNP-BC,
is an instructor at the University of South Carolina in
Lancaster and can be reached at [email protected]
Kathleen M. Scharer, PhD, RN, PMHCNS-BC, FAAN, is a
professor, and Sara Fuller, PhD, APRN, BC, PNP, FAAN, is a
professor (retired), both at the University of South Carolina,
Columbia. In compliance with national ethical guidelines, the

authors report no relationships with business or industry that
would pose a conflict of interest.
1555-4155/12/$ see front matter
© 2012 American College of Nurse Practitioners
doi: 10.1016/j.nurpra.2012.02.004
http://www.nice.org.uk/nicemedia/pdf/CG016NICEguideline.pdf
mailto:[email protected]
http://www.nice.org.uk/nicemedia/pdf/CG016NICEguideline.pdf
Assessment and Identification of Deliberate Self-Harm in
Adolescents and Young AdultsBACKGROUND AND
SIGNIFICANCEONSET IN ADOLESCENT AND YOUNG
ADULTSFUNCTIONS OF PARTICIPATING IN DSH
BEHAVIORFACTORS ASSOCIATED WITH DSHPRACTICE
AND KNOWLEDGE ASSESSMENT OF DSH IN PRIMARY
CARERECOMMENDATIONSTHERAPEUTIC
RELATIONSHIPPHYSICAL ASSESSMENTSelf-Injury Risk
AssessmentPsychosocial and Psychological Risk
AssessmentEVIDENCE-BASED MANAGEMENT AND
FOLLOW-UPPCP EDUCATIONPRACTICE
IMPLICATIONSNURSING EDUCATION
IMPLICATIONSCONCLUSIONReferences
1. O(True) or X(False)
(
) 1. A trade-off is a principle for market activities.
(
) 2. A manager's salary is the opportunity cost.
(
) 3. A trade provides a division of labor.
(

) 4. The market failure always results in the negative
externality.
(
) 5. An analysis on Trump’s tax policy is the normative
analysis.
(
) 6. The demand change due to a related commodity price
change is a demand law.
(
) 7. The supply change due to that input price change is a
supply law.
(
) 8. The right demand shift results into an increase in
equilibrium price.
(
) 9. The price down of necessity goods results in increases of
both demand and total revenue.
(
) 10. The price down for long-run results in increases of both
demand and total revenue.
(
) 11. A control of gasoline price results in more demand for
gasolines than supply.
(
) 12. An indifference curve is a curve of 2 goods purchase not
related to satisfaction.
(

) 13. A budget line is a line of 2 goods purchase with a given
budget not related to prices.
(
) 14. A budget line shifts leftt as a budget increases.
(
) 15. The substitution effect of price change is always an
inverse relationship.
(
) 16. The income effect of price change is always a positive
relationship.
(
) 17. A consumer surplus is the surplus of consumption which a
consumer spends for.
(
) 18. A producer surplus is the surplus of producer above the
price.
(
) 19. The cost equation is not related to output prices.
(
) 20. The revenue function is related to output..
(
) 21. The export results in extra gain, while the import does not
result in extra gain.
(
) 22. The Giffen goods are those whose demand decreases due
to price change.
(
) 23. The labor marginal product is the labor productivity.

(
) 24. As the average product decreases, the marginal product
decreases always.
(
) 25. The average product and marginal product do not cross
each other.
(
) 26. When price elasticity of demand is less than 1, production
increase increases revenue.
(
) 27. When price elasticity of demand is greater than 1,
production decrease decreases revenue.
2. Summarize
(1) Marginal Principle
(2) Circular Flow Model
(3) Externalities
(4) Demand Elasticity for Price, Income, and Cross-Price
(5) Consumer Optimization Rule
(6) Price Change Effects on Demand in the Short-Run and
Long-Run

(7) Substitution effects and income effects
(8) Total Product, Average Product, and Marginal Product
(9) Indifference curve
(10) Isoquant curve
(11) Production Possibility Frontier
(12) Consumer Surplus
Teaching Therapeutic Assessment for self-harm
in adolescents: Training outcomes
Dennis Ougrin1∗ , Tobias Zundel2, Audrey V. Ng3,
Batsheva Habel2 and Saqib Latif4
1King’s College London, Institute of Psychiatry, Child and
Adolescent Psychiatry, UK
2Tavistock and Portman NHS Foundation Trust, London, UK
3Central and North West London NHS Foundation Trust, UK
4South London and Mudsley NHS Foundation Trust, UK
Objectives. To describe the teaching programme of Therapeutic
Assessment (TA),
a brief intervention at the point of initial assessment for
adolescents with self-harm; to
describe trainees’ preferences and choices regarding their use of
specific aspects of TA.

Design. This is a comparative study investigating the
differences in the TA skills before
and after training. This design was chosen to establish whether
or not TA training is
efficacious.
Methods. Twenty-four clinicians volunteered to participate in
five half-day TA training
sessions. Their scores on the Therapeutic Assessment Quality
Assurance Tool (TAQAT,
primary outcome measure) were compared before and after
training. Satisfaction with
training and therapeutic strategy choices as well as ability to
perform TA in an RCT
were investigated.
Results. Clinicians who participated in TA training had
significantly increased scores
on TAQAT after training. The clinicians who achieved the
required quality of TA post
assessments were likely to be able to carry out TA in an RCT
with high fidelity. In addition,
prior to training, significant differences in the quality of
assessments as measured by
TAQAT were identified depending on the experience of the
clinician. This discrepancy
was no longer present post training. Therapeutic strategy based
on solution-focused
brief therapy (SFBT) was the option of choice post training.
Conclusions. TA training is feasible and associated with
improved quality of self-harm
assessment.
Practitioner points

• TA is a brief intervention associated with improved treatment
engagement.
• TA training is feasible and is associated with improved quality
of self-harm assess-
ment.
• SFBT-based exit is the most commonly used strategy in TA.
∗ Correspondence should be addressed to Dennis Ougrin, Child
and Adolescent Psychiatry, Institute of Psychiatry, PO 85,
King’s College London SE5 8AF, UK (e-mail:
[email protected]).
DOI:10.1111/j.2044-8341.2011.02047.x
Psychology and Psychotherapy: Theory, Research and Practice
(2013), 86, 70–85
© 2011 The British Psychological Society
www.wileyonlinelibrary.com
70
Suicide is the third- or the second-leading cause of death in
adolescents in most Western
countries (Biddle, Brock, Brookes, & Gunnell, 2008; CDC,
2008; Office for National
Statistics, 2005). It remains a significant public health problem
in the United Kingdom
(Ougrin, Banarsee, Dunn-Toroosian, & Majeed, 2011). Self-
harm is the strongest predictor
of eventual death by suicide in adolescence, increasing the risk
up to 10-fold (Hawton

& Harriss, 2007). Self-harm is common; approximately, 1 in 10
adolescents will have
self-harmed by the time they are 16-year old (Hawton, Rodham,
Evans, & Weatherall,
2002).
The current literature on self-harm treatment is limited and no
interventions show
conclusive evidence for effectiveness against self-harm in
adolescents, hence the need
for more research (Ougrin, Tranah, Leigh, Taylor, & Asarnow,
in press).
Increasing numbers of brief interventions appear to be
efficacious in adolescents
presenting with a range of psychiatric problems (Colby et al.,
2005; Spirito et al., 2004)
and potentially self-harm (Rotheram-Borus, Piacentini,
Cantwell, Belin, & Song, 2000;
Spirito, Boergers, Donaldson, Bishop, & Lewander, 2002).
Psychosocial assessment itself
appears to have a significant beneficial impact (Poston &
Hanson, 2010) on the patients
presenting to mental health services. There is also increasing
evidence that educational
interventions might be effective in changing clinicians’
attitudes towards the patients
who self-harm (Krawitz, 2004; Treloar, 2009), improving their
knowledge and self-
efficacy (Shim & Compton, 2009) and lead to better patient
outcomes with regards to
depression and suicidality (Mann et al., 2005).
Despite these advances, poor adherence to follow-up is a major
obstacle in providing
practical help to adolescents who self-harm. A total of 50–77%

of these adolescents
are non-adherent with outpatient treatment (Groholt & Ekeberg,
2009; Haw, Houston,
Townsend, & Hawton, 2002; Trautman, Stewart, & Morishima,
1993) and around 50%
are likely to attend four or fewer outpatient follow-up sessions
(Groholt & Ekeberg,
2009; Spirito et al., 1992). Around 25–50% of the adolescents
who engage in self-harm
are likely not to attend any follow-up sessions (Granboulan,
Roudot-Thoraval, Lemerle,
& Alvin, 2001; Taylor & Stansfeld, 1984). In addition, there is
no evidence that offering
young people a structured psychological therapy increases
engagement with treatment
(Ougrin & Latif, 2011).
The young people’s treatment in emergency departments was
highlighted as an
important predictor of further engagement. Time delays between
the initial and the
follow-up appointments (Clarke, 1988), delayed initial
evaluation (Wilder, Plutchnik, &
Conte, 1977), and the attitude of emergency department staff
(Rotheram-Borus et al.,
1996), all seem to influence engagement with treatment.
One approach that has been shown to improve engagement with
aftercare in
adolescents presenting with self-harm is TA, a brief
intervention based on cognitive
analytic therapy (Ougrin, Ng, & Low, 2008; Ougrin et al.,
2011).
A pilot study (Ougrin et al., 2008) showed that TA versus
assessment as usual

might lead to better adherence to the first follow-up
appointment, as required by
the National Institute for Health and Clinical Excellence
guidelines (NICE, 2004) and
better engagement with community follow-up. The results were
replicated in a random
allocation study (Ougrin et al., 2011), the Trial of Therapeutic
Assessment in London
(TOTAL).
In the TOTAL, TA was compared to usual assessment. The
study involved 70
adolescents in two groups, those in the TA group were
significantly more likely to attend
the first follow-up appointment: odds ratio 5.12, 95% CI (1.49,
17.55), p < .01. During a
3-month period of naturalistic follow-up, participants in the TA
group were more likely
Teaching Therapeutic Assessment 71
than those in the control group to attend four or more treatment
sessions: odds ratio
5.19, 95% CI (2.22, 12.10) and more likely to attend more
treatment sessions overall (p <
.001). At 3-month follow-up, there were no statistically
significant differences between
the groups on the total score of the Strengths and Difficulties
Questionnaire or the
Children’s Global Assessment Scale score. There was a
statistically significant difference
in the proportion of the young people who had at least one
session of a structured
psychotherapy (cognitive behaviour therapy, family therapy,

motivational interview
based therapy, or mentalization-based psychotherapy) versus
case management alone
in the TA group.
There are very few studies describing the process of teaching
clinicians the proposed
brief interventions. Training mental health professionals in self-
harm assessment and
treatment has been found to be inadequate (Rudd, Cukrowicz, &
Bryan, 2008).
Broadly speaking, self-harm teaching interventions that focus
on professionals can be
divided into the following three categories depending on the
practitioners’ professional
background:
(1) Primary-care training focused on recognition and
management of depression (Rutz,
2001; Szanto, Kalmar, Hendin, Rihmer, & Mann, 2007).
(2) Training for gatekeepers and helpers (teachers, social
workers, care workers etc.),
often focused on recognition, appropriate referrals, and
immediate problem solving
(Chagnon, Houle, Marcoux, & Renaud, 2007).
(3) Training for mental health professionals focused on
assessment and treatment of
self-harm (Oordt, Jobes, Fonseca, & Schmidt, 2009).
As far as the form of training is concerned, the following
options exist:
(1) Reading textbooks, guidelines, treatment manuals and

journals.
(2) Workshops.
(3) Train-the-trainer (T4T) teaching.
(4) Multi-component training.
A recent systematic review (Herschell, Kolko, Baumann, &
Davis, 2010) identified
only two studies evaluating professionals’ training in the field
of self-harm (Chagnon
et al., 2007; Oordt et al., 2009). Only one of the studies focused
on training mental
health professionals (Oordt et al., 2009).
In the study by Oordt et al. (2009), a 12-h programme covering
assessment and
treatment of suicidal behaviour was delivered to 82 air force
mental health professionals.
The intervention included presentations, role-play, and panel
discussion; it was based on
a manual and involved instructions from two experts in the
field. Participants’ confidence
in dealing with suicidal behaviour and their beliefs about the
use of hospitalization were
designated as outcome measures. Both outcomes were measured
using non-validated
questionnaires. In addition, the participants were asked to
assess the presence and the
quality of suicidal behaviour policies and procedures at their
places of work. Only 50% of
the participants returned the questionnaires, there was no
intention to teach analysis and
there was no individualized video feedback. Nonetheless, the
authors reported increased
confidence and a favourable impact on trainees’ practice both
immediately after the end
of the training and especially at 6-month follow-up.

A literature search uncovered further two major self-harm
training programmes. The
STORM (Skills-based Training on Risk Management)
programme has been evaluated in
72 Dennis Ougrin et al.
the last decade (Appleby et al., 2000; Gask, Dixon, Morriss,
Appleby, & Green, 2006;
Gask, Lever-Green, & Hays, 2008; Hayes, Shaw, Lever-Green,
Parker, & Gask, 2008).
The STORM was not designed specifically for mental health
professionals. It is a package
originally developed by the University of Manchester, UK. The
content of the intervention
reflects established assessment and management methods for
patients with suicidal
ideation and/or feelings of hopelessness. The course has four
modules: assessment, crisis
management, problem solving, and crisis prevention. It is
delivered in a 4-day format. The
training consists of brief lectures on background knowledge and
the skills to be acquired,
focused group discussion, video demonstration of skills by
health care professionals, role-
play (rehearsal of skills) in trios (professional–client–observer)
and pairs (professional–
client) using pre-prepared scripts to facilitate the practice of
specific skills. There is also
video feedback in small group settings of recorded role-played
interviews carried out
by course participants. These activities are followed by group
discussion to consolidate

learning. An important part of the discussion is how to translate
the skills learnt into
practice.
The training is associated with high trainee satisfaction,
improved skills, and confi-
dence. There is evidence of the early gains not being sustained
over time (Gask et al.,
2006) and no evidence of the impact of the STORM training on
suicide prevalence
(Morriss et al., 2005).
Another programme that has not yet been fully evaluated is the
Applied Suicide
Intervention Skills Training (ASIST) developed in Canada. It is
also not specific to
mental health professionals and is aimed at front-line caregivers
from all disciplines and
occupational groups (formal and informal). It involves a 2-day
intensive, interactive, and
practice-dominated course designed to help caregivers recognize
risk and learn how to
intervene to prevent suicide. ASIST workshops cover five
learning modules: introduction,
attitudes, risk estimation, intervention/skills, and
resourcing/networking. The structure
of the workshops is fixed and participants must attend both days
consecutively. The
programme is disseminated by local trainers, who have attended
a 5-day ‘T4T’ workshop.
There are some preliminary positive reports of the impact of
ASIST on the trainees’
satisfaction and confidence (McAuliffe & Perry, 2007) but no
further evaluation is
available.

A literature review did not reveal any published studies
evaluating training interven-
tions for mental health professionals who work with adolescents
who self-harm.
In this study, we summarize the results and describe the process
of the first three
teaching cycles for TA. We discuss the clinicians’ preferences
and choices regarding
the use of specific aspects of TA after training and describe the
Therapeutic Assessment
Quality Assurance Tool (TAQAT), a scale designed to evaluate
the quality of TA. We also
report clinicians’ fidelity to TA in a recently completed
TOTAL.
In addition to the above exploratory aims, we set out to test
these three specific
hypotheses:
(1) Clinicians will have significantly higher scores on the
TAQAT after the TA training
in comparison to their pre-training baseline.
(2) Clinicians with up to and including 2 years of mental health
experience will score
significantly lower than the clinicians with over 2 years of
mental health experience
on the TAQAT both before and after the TA training.
(3) Clinicians participating in the TOTAL will demonstrate
adequate adherence to the
TA protocol and will score above a pre-determined quality
threshold on the TAQAT
in at least nine out of 10 randomly selected audio-taped TAs.

Method
Eligibility criteria for participants
All Child and Adolescent Mental Health Service (CAMHS)
clinicians from the South
London and Maudsley NHS Foundation Trust were eligible to
take part in TA training
provided they could report being competent in basic self-harm
assessment. An adver-
tisement for free training in TA for adolescents with self-harm
was circulated by email
within the Trust. In addition, TA training was advertised in two
other London Mental
Health Trusts and the eligibility criteria were the same. The
volunteers were enrolled
in two research projects (a pilot study of TA and the TOTAL
study) and all agreed to
undergo a full evaluation before and after TA training. The
research projects received
ethical approval from the Joint South London and Maudsley and
the Institute of Psychiatry
Research Ethics Committee on 20 November 2006 (ref.
06/Q0706/99) and the Camden
and Islington Community Local Research Ethics Committee on
23 October 2007 (ref.
07/H0722/66), respectively.
The settings and locations where the data were collected
All TA training courses were held at the South London and
Maudsley NHS Foundation
Trust.
Therapeutic Assessment

TA is a brief, manualized intervention based on cognitive
analytic therapy, which can
be delivered in different settings by professionals from a range
of disciplines (Ougrin,
Zundel, & Ng, 2009).
The major components of the TA are as follows:
(1) Standard psychosocial history and risk assessment.
(2) A 10-min break to review the information gathered and to
prepare for the rest of the
session.
(3) Joint construction of a diagram (based on the cognitive
analytic therapy paradigm)
consisting of three elements: reciprocal roles, ‘core pain’, and
maladaptive proce-
dures (see Ryle & Kerr, 2002 for a review).
(4) Identifying the target problem.
(5) Considering and enhancing motivation for change.
(6) Searching for potential ‘exits’ (i.e., ways of breaking the
vicious cycles identified)
facilitated by one or more of the following: examining the
influence and control of
the target problem on the young person, his or her family and
social network; looking
for exits tried in the past and exploring the options at present;
using future-oriented
reflexive questioning; using problem-solving techniques;
exploring alternative views
of ‘core pain’; and behavioural techniques including relaxation.
(7) Summarizing the issues discussed in an ‘understanding

letter’; this includes a
summary of the diagram as well as the possible exits identified
and usually contained
an invitation for further exploration.
Training
The training consisted of five half-day teaching sessions over 5
weeks. The first session
focused on how to create a TA diagram with a young person and
the subsequent four
sessions covered a range of ‘exit’ interventions (cognitive
behaviour therapy, systemic–
narrative therapy, motivational interviewing and solution-
focused brief therapy [SFBT]).
Before attending the first training session, each clinician
attended an Objective
Structured Clinical Examination (OSCE) with an actor playing
the role of a young person
presenting with self-harm. The clinician was given the written
background history to
‘the case’ prior to the meeting. The purpose of the OSCE was to
allow the clinician to
role-play what they would do to summarize and conclude the
assessment process, thus
providing a specific opportunity to explore any implemented
therapeutic strategies or
approaches to building an alliance and engaging the young
person. The OSCE did not
involve actually taking the history, mental state or risk
assessment de novo. Each of these
interviews was filmed.

After each OSCE was completed, the TAQAT questionnaire was
scored by the clinician
and the actor. In addition, an independent assessor watched each
OSCE on videotape
and also completed the TAQAT questionnaires for each
interview.
This process was then repeated after the 5-week training cycle
was concluded. The
second round of OSCEs with an actor was based on a modified
case history but followed
the same principle. It was scored using the TAQAT in the same
way.
Following the completion of the training, clinicians were
offered monthly supervision
sessions. Those clinicians involved in the pilot study and the
TOTAL were required
to audiotape their assessments, and a random sample of the
tapes was subsequently
evaluated.
Primary outcomes
Therapeutic Assessment quality assurance tool (TAQAT)
The TAQAT (Appendix) is a five-item scale. Each item
corresponds to the five main aims
of TA derived from a study of young people’s hopes and
expectations from self-harm
assessment (Ougrin & Zundel, 2009).
(1) Developing understanding of the difficulties leading to self-
harm.
(2) Enhancing motivation for change.
(3) Instilling hope.

(4) Exploring alternatives to self-harm.
(5) Setting targets and goals for future work.
Each item is scored on a 10-point Likert scale ranging from 0
(the aim was not
achieved at all) to 10 (the aim was fully achieved). Three
different raters (the person
being assessed, the assessing clinician, and an independent
evaluator) each complete
a version of the TAQAT. The three scores are then added and
the TAQAT total score
therefore ranges from 0 to 150.
The objectivity of the assessment evaluation was maximized by
triangulating the
TAQAT scores of one subjective (interviewer) and two
objective (independent observer
and interviewee) ratings. Validity and reliability of the TAQAT
have not been established
in any earlier studies.
In order to qualify for participation in the research, the trainees
had to achieve a
score of 33 or more on the objective rating of the TAQAT.
Trainee satisfaction
This was measured using the following six items:
(1) This training was well presented.
(2) The material presented was easy to understand.
(3) The material presented was clinically relevant.

(4) The material covered will help me implement TA.
(5) The practical exercises were chosen well.
(6) I would recommend this course to a friend.
Each item was scored on a continuous 0- to 10-point scale,
where 0 = strongly
disagree and 10 = strongly agree. The satisfaction
questionnaires were anonymous and
it was not possible to link them with specific TAQAT scores.
Secondary outcomes
(1) Proportion of the clinicians who chose
Solution
Focused Brief Therapy (SFBT),
Cognitive Behaviour Therapy (CBT), Motivational Interviewing
(MI), and Family
Therapy (FT) exits post training.
(2) Proportion of clinicians who considered SFBT, CBT, MI,
and FT exits, respectively,
as the best ones to use in TA.
(3) Proportion of the assessments in the TOTAL study where
clinicians attained a score
of 33 or more on the objective TAQAT rating.

Statistical analysis
The data were analysed using SPSS for Windows. Continuous
variables were compared
using the t-test and dichotomous variables using the � 2-test.
All tests were two-tailed. In
order to investigate the effect of participants’ experience on the
outcome, a repeated
measures ANOVA was undertaken with time as a within-subject
and experience as a
between-subject variable. In order to account for those
clinicians who did not complete
the training in the intent to train analysis, we assumed that their
score on TAQAT
remained unchanged. These scores were entered into the final
analysis.
Results
Twenty-four clinicians received training in TA, seven in 2006,
eight in 2007, and nine in
2009. The first seven professionals took part in the TA pilot
study. All were trained in TA.
Three were allocated to carry out TA and four continued to
provide assessment as usual.
The eight professionals trained in 2007 represented those

professionals who agreed to
participate in the TOTAL and were randomized into the TA
group. The nine professionals
trained in 2009 included those professionals who provided
control interventions in the
TOTAL on the understanding that they will be trained in TA
following the completion
of the TOTAL study.
One clinician did not attend the final post-training assessment
and one clinician
attended fewer than four training sessions and was not eligible
for the post-training
assessment. The TAQAT scores of the two clinicians who did
not complete the final
assessment were assumed not to have changed (in line with the
intention to teach
design).
Clinicians’ background and experience characteristics
The characteristics of the clinicians’ background and experience
are presented in Table 1.
TAQAT baseline scores
The pre-training OSCE results are described in Tables 2 and 3.

There were significant
differences in the TAQAT scores depending on the experience
of the clinicians.
Table 1. Clinicians characteristics
Characteristic Number (percentage) Mean (SD)
Average age in years 34.1 (7.16)
Years of mental health experience 7.1 (5.5)
Years of CAMHS experience 3.1 (3.3)
Female sex ethnicity 14 (58%)
White British 6 (25%)
White other 10 (42%)
Asian or Asian British 5 (21%)
Black or Black British 3 (13%)
Professional background
Doctors (all) 10 (41%)

Consultant psychiatrists 1 (4%)
Specialist registrars 4 (17%)
Senior house officers 5 (21%)
Psychologists 4 (17%)
Social workers 3 (13%)
Nurses 7 (30%)
0–1 years of CAMHS experience 11 (46%)
2–3 years of CAMHS experience 5 (21%)
4 + years of CAMHS experience 8 (33%)
Number of first self-harm assessments in previous 6 months
0 6 (25%)
1–6 11 (46%)
7 + 7 (29%)
Preferred therapeutic modality for self-harm assessments
None 10 (42%)
CBT 8 (33%)
Family therapy 2 (8%)

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