OBJECTIVES:While rates of self-harm are rising in the United Kingdom, people who self-harm can often struggle to access appropriate treatment. This study sought to explore adult stakeholders' perspectives and experiences of the barriers to, and facilitators of, accessing support for self-harm and also how services could be better tailored to meet needs. DESIGN:A cross-sectional qualitative study. METHODS:Semi-structured interviews were conducted remotely with 19 participants in the United Kingdom, including 10 individuals with lived experience of self-harm and nine mental health professionals that worked with people who self-harm. Reflexive thematic analysis was used to analyse the data. Normalisation Process Theory (NPT) was used as a guiding framework throughout the study. RESULTS:Both stakeholder groups felt that services did not offer appropriate support; there were system-level challenges and a sense of associated powerlessness. It was important to understand the person behind the behaviour, as a lack of understanding was reported to increase feelings of shame. Services that prioritise person-centred care, expert-by-experience involvement and early intervention were valued. Professionals outlined the positives of brief interventions, while individuals who self-harm held concerns about whether briefer interventions addressed complex difficulties. CONCLUSIONS:Findings highlight important organisational barriers and potential facilitators that individuals who self-harm may face when accessing psychological interventions. Results prompt the need for inclusive and easily accessible services.

OBJECTIVES:Defining target problems (TPs) and associated target problem procedures (TPPs) is a key competency of cognitive analytic therapy (CAT). This study sought to categorize types of TPPs identified, assess the acceptability of TP/TPP sessional tracking, assess whether changes in TP/TPP recognition and revision occurred and also whether change in TP/TPPs predicted severity of self-injury urges and psychological distress. METHODS:As part of the RELATE clinical trial, N = 31 participants were allocated to eight-session CAT. TPs/TPPs were rated for recognition and revision at every session in a nested ABC plus follow-up single case design. The competency of therapists was assessed. TPPs were coded as to whether they were a snag, trap of a dilemma. Linear mixed-effects models tested whether TP/TPPs changed over time and according to phase of CAT. Change in TPs/TPPs were used to predict self-injury urges and psychological distress (i.e., research follow-up measures taken by blinded researchers). RESULTS:There was strong interrater agreement on whether the TPP was a snag, trap or dilemma. The sessional rating of TPs/TPPs appeared acceptable, as during 97.68% of treatment sessions and 82.60% of follow-up sessions, tracking occurred. Compared to the reformulation phase, awareness and then therapeutic change of TPs/TPPs significantly increased during the recognition and revision phases. Recognition and revision of TPs/TPPs during CAT in the revision phase did not predict self-injury urges and psychological distress at research follow-up. CONCLUSION:Early definition and sessional tracking of TPs/TPPs appear acceptable and changes to awareness and ability to change TPs/TPPs appears linear. CAT therapists should routinely integrate sessional tracking of TP/TPPs into their work.

Self-harm is a major health concern amongst young people that is increasing in prevalence. Cognitive analytic therapy (CAT) is a relational, integrative psychotherapy that is theoretically consistent with our growing understanding of self-harm. The aim of this study was to ascertain the feasibility and acceptability of evaluating brief CAT in young people aged 13–17 who self-harm using a randomised controlled trial (RCT) design. Sixty young people with experiences of self-harm will be recruited from child and adolescent mental health services. Participants will be randomly allocated (1:1 ratio) to brief CAT plus treatment as usual (TAU) or TAU alone. Assessors will be blind to treatment allocation. Assessments will occur at baseline, 8, 16, and 20 weeks after randomisation. A qualitative process evaluation will investigate experiences of the therapy and trial procedures. The primary outcome for this study is feasibility, judged against a priori progression criteria relating to recruitment, retention, adherence to therapy, and missing data. Brief CAT may help young people struggling with self-harm, but research is needed. In order to undertake a definitive RCT, it is first necessary to resolve a number of feasibility uncertainties. The planned feasibility trial will help inform a larger definitive trial focused on the efficacy of brief CAT for young people who self-harm. The trial was pre-registered (01/08/25) on ISR CTN (ISRCTN code: ISRCTN11505839).

Objective To explore the acceptability of the Community Outpatient Psychotherapy Engagement Service for Self-harm (COPESS) intervention and trial procedures for participants.Design A mixed-method approach and a single-blind randomised controlled trial design with 1:1 allocation to either COPESS plus treatment as usual or treatment as usual alone.Setting Primary care.Participants Fifteen semistructured interviews were conducted with participants in the COPESS trial; eight were randomised to the intervention arm, and seven were randomised to the treatment-as-usual arm. Interviews lasted 30–60 min.Intervention COPESS is a brief, relational psychotherapy delivered over 4 weekly sessions plus a follow-up, focusing on understanding difficult emotional states and their links to self-harm through here-and-now relational and emotional processes.Analysis Thematic analysis allowed exploration of themes important to participants in their experiences in the COPESS trial and their experiences of care for self-harm more generally.Findings Five themes were identified as associated with the acceptability of the COPESS intervention and trial: self-harm as a primary problem, what I needed when I needed it, being heard and understood, online delivery of the intervention and lasting impacts. Participants generally expressed positive views about the intervention, citing a need for services that specifically target self-harm and an appreciation of the rapid access to help. Strong relationships with the therapist were highly valued and not diminished by online delivery of the intervention. Positive impacts continued post therapy sessions.Conclusions These results support the acceptability of the COPESS intervention, the need for self-harm specific services and support moving forward to a full trial.Trial registration Pre-registered on clinicaltrials.gov (NCT04191122) on 9 December 2019.

INTRODUCTION:Self-harm in adults is a complex and highly prevalent problem. The Relational Approach to Treating Self-Harm (RELATE, ISRCTN code: ISRCTN75661422) trial investigated the feasibility, acceptability and safety of 8-session cognitive analytic therapy (CAT) for self-harm, compared with treatment as usual. This qualitative evaluation explored participants' experiences of study processes and of brief CAT. METHOD:Semi-structured one-to-one interviews were carried out with N = 24 participants and reflexive thematic analysis explored participants' experiences. RESULTS:Five themes were identified supporting the perceived acceptability of the trial and the therapy. Being responsible to accept uncertainty was the concern prior to and at the start of the CAT and centred on a sense of vulnerability during the therapy itself. Self-acceptance through more understanding and taking ownership illustrated understandings of how CAT worked. Living with urges was seen as the impact of the CAT on impulsivity, and being prepared for the end of treatment was a key factor in the overall view of brief CAT. CONCLUSIONS:Brief CAT for self-harm appears acceptable in terms of intervention coherence, self-efficacy and perceived effectiveness. Anticipation of increased vulnerability (i.e., affective attitudes) and the energy required (i.e., burden) in talking through difficulties and trauma suggest a need to manage patient expectations before brief CAT is started.

When cognitive analytic therapy (CAT) is used to help people that self-harm, then patients are typically allocated to the 24-session version. RELATE (relational approaches to self-harm) was a National Institute for Health Research (NIHR) funded feasibility randomised controlled trial; it evaluated delivering 8-session CAT compared to treatment as usual for patients that were self-harming. This is a co-produced case study with Jade who was a participant in the RELATE trial. The aims were: (a) to describe the treatment protocol, (b) demonstrate protocol fidelity, (c) index therapeutic competency, (d) evaluate nomothetic clinical outcomes, (e) evaluate of change in the idiographic target problems and (f) for Jade to provide a description of her experience of the tools, phases and approach of CAT. Results show that the CAT was competently delivered with high fidelity to the protocol. Self-harm reduced and non-overlap analyses found that improvements to recognition and revision of two of the three target problems occurred (and these would be coded as being evidence of a 'highly effective' intervention). Improvements were maintained at follow-up. Jade had low expectations before starting therapy, felt that the tools of CAT were helpful, building and maintaining trust in the therapeutic relationship was an important contributor to change and follow-up was useful. The conclusion is that it is possible to deliver brief CAT that is focal to self-harm with high treatment integrity. Guidance on how therapists can best utilise the brief CAT approach are provided.

Binge Eating Disorder (BED) and self-harm often co-occur and cause great distress. BED is often poorly understood and under-represented in research, despite high prevalence. It is unclear how self-harm in BED populations compares to rates of self-harm in other eating disorder populations or control groups. A systematic review and meta-analysis were undertaken with the aim of investigating how often self-harm occurs along with BED compared to other eating disorders and control groups. The protocol for this review was pre-registered (PROSPERO reference: CRD42023466201). Online databases, PsycINFO, MEDLINE and Web of Science, were searched using key terms relating to BED and self-harm, for publications dating up to February 2025. Inclusion criteria were studies that measured BED and self-harm. Titles, abstracts and full texts were screened by independent screeners. Sixteen studies were identified. Meta-analyses were completed to determine the odds of self-harm in BED groups compared to other eating disorders and non-clinical control groups. Risk of bias and publication bias were assessed. There was no difference in rate of self-harm between people experiencing BED compared to those experiencing Anorexia Nervosa (Odds Ratio [OR] = 0.7, 95

Although empirical support for the International Statistical Classification of Diseases and Related Health Problems (11th ed.; ICD-11) distinction between posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) is growing, research into the ICD-11 CPTSD model in prison staff is lacking. This study used latent profile analysis (LPA) to (a) determine if there are distinct groups of trauma-exposed prison governors (i.e., "wardens" in the United States and Canada) who have symptom profiles consistent with the distinction between PTSD and CPTSD and (b) identify predictors and posttraumatic maladaptive beliefs associated with the latent profiles. Trauma-exposed prison governors (N = 385) completed the International Trauma Questionnaire (ITQ) and a measure of traumatic life events. LPA was used to extract profiles using the six ITQ symptom clusters and revealed four profiles: CPTSD (8.4%), PTSD (14.4%), disturbances in self-organization (DSO; 11.0%), and low symptoms (66.3%). Membership in the CPTSD and DSO profiles was associated with cumulative traumatization, odds ratios (OR) = 1.42 and OR = 1.26, respectively, and poorer health, OR = 2.84 and OR = 1.64, respectively, relative to the low symptom profile, and membership in the PTSD profile was associated with younger age, OR = 0.91, relative to the low symptom profile. The CPTSD profile showed the highest level of posttraumatic maladaptive beliefs. This study yields empirical support for the ICD-11 CPTSD model in prison staff. The results provide additional support for the validity of ITQ measurement of PTSD and CPTSD.

Background Co-occurring self-harm and aggression (dual harm) is particularly prevalent among forensic mental health service (FMHS) patients. There is limited understanding of why this population engages in dual harm. Aims This work aims to explore FMHS patients’ experiences of dual harm and how they make sense of this behaviour, with a focus on the role of emotions. Method Participants were identified from their participation in a previous study. Sixteen FMHS patients with a lifetime history of dual harm were recruited from two hospitals. Individuals participated in one-to-one, semi-structured interviews where they reflected on past and/or current self-harm and aggression. Interview transcripts were analysed using reflexive thematic analysis. Results Six themes were generated: self-harm and aggression as emotional regulation strategies, the consequences of witnessing harmful behaviours, relationships with others and the self, trapped within the criminal justice system, the convergence and divergence of self-harm and aggression, and moving forward as an FMHS patient. Themes highlighted shared risk factors of dual harm across participants, including emotional dysregulation, perceived lack of social support and witnessing harmful behaviours. Participants underlined the duality of their self-harm and aggression, primarily utilising both to regulate negative emotions. These behaviours also fulfilled distinct purposes at times (e.g. self-harm as punishment, aggression as defence). The impact of contextual factors within FMHSs, including restrictive practices and institutionalisation, were emphasised. Conclusions Findings provide recommendations that can help address dual harm within forensic settings, including (a) transdiagnostic, individualised approaches that consider the duality of self-harm and aggression; and (b) cultural and organisational focus on recovery-centred practice.

Background: This study explored how health professionals construct clinical and psychological meaning based on the location of self-injury on the body, particularly in relation to concealed or visible injuries and how they might inform attributions about risk, self-injury functions, and distress. Methods: This study used qualitative thematic analysis of semi-structured interviews with 19 health professionals with experience working with self-injury, exploring perceptions and attributions about self-injury in different body locations. Results: Seven themes emerged. In some cases, staff’s attributions aligned with the findings from studies of those who self-injure, such as injuries to areas such as the neck are higher risk. Location was one factor among others, such as injury severity, that staff considered when assessing the risk of infection or suicide. Staff often viewed visible injuries as less risky and attributed them to interpersonal communicative functions, and concealed injuries to intrapersonal factors, though not all staff shared these perspectives. Some staff considered other potential drivers of injury location, including past experiences such as trauma, demographic factors, mental health diagnoses, and exposure to social influences. Some staff described the practical determinants of injury location, such as ease of access, and considered the impact of self-injury location on themselves and their colleagues. Conclusions: Injury location can influence staff perceptions of risk, self-injury functions and distress, underscoring the need for individualized assessment and formulation of each self-injury episode to ensure appropriate risk management. Staff training should be adapted to address injury location to improve understanding, raise awareness of related attributions, and enhance the development of clinical skills. Organizations should support staff in their role due to the potential emotional impact of working with individuals who self-injure and are at risk of suicide. Future research should investigate whether location-based attributions are associated with unintended clinical consequences, such as inaccuracies in risk assessment and formulation.

This editorial explores dual harm – the co-occurrence of self-harm and aggression – particularly among forensic populations. Historically approached as two separate and even opposing behaviours, emerging evidence shows that those who engage in self-harm and aggression experience greater adversity and poorer outcomes. This underscores the importance of enhancing our understanding of dual harm. We review key developments within the field, including how dual harm may be best conceptualised and managed, and identify critical gaps in the literature. In order to improve the care and outcomes of those who engage in self-harm and aggression, emphasis is placed on adopting more integrated approaches that consider the duality of these behaviours, as well as the complex needs of this high-risk group, within research and practice.

Domestic violence (DV) against ethnic minority women is often an understudied social and psychological problem in the United Kingdom. The aim of this qualitative research is to fill a gap in the existing literature by identifying service providers’ perceptions about the barriers and facilitators for help-seeking behaviours among British South Asian women who have experienced DV. This study used 18 semi-structured interviews of service providers from third-party organisations. In addition, it used qualitative methods and applied thematic analysis within an ecological framework to analyse interviews with service providers. Five main themes were identified relating to barriers and facilitators for help-seeking behaviours among British South Asian women who have experienced DV. These include: stereotypical thinking and the misuse of religious beliefs; fear of negative consequences; emotional states that act as both barriers and facilitators; informal and formal help-seeking opportunities, as well as the challenges associated with each. These research findings can initiate positive social change by leading to development of culturally appropriate interventions which can bridge the gap between British South Asian women who experience DV. The findings of this study contribute to Sustainable Development Goal (SDG) 5: Gender Equality by identifying key barriers, facilitators, and culturally informed recommendations for help-seeking among British South Asian women experiencing domestic violence. These insights can inform the development of effective policy, practice, and research to address domestic violence as a major public health issue and challenge the intersecting racial, ethnic, and gender inequalities that exacerbate it.

BACKGROUND:Previous research suggests that complex trauma and Complex Posttraumatic Stress Disorder (C-PTSD) experiences can contribute to the risk of developing and possibly maintaining Non-Suicidal Self-Injury (NSSI). Individuals' accounts of how complex trauma and subsequent development of C-PTSD experiences can contribute to the difficulties of NSSI remain underexplored. This qualitative study aimed to explore in-depth: (1) how individuals with C-PTSD experiences narrate life conditions and events that influenced their difficulties with NSSI over time and (2) what factors the individuals perceived to have helped the process of controlling their experience of NSSI. METHODOLOGY:This novel qualitative narrative study used an adapted version of the Free Association Narrative Interviewing Method (FANIM) to facilitate the exploration of the lived experiences of eight individuals aged 20-56 years. The initial data analysis involved an interpretation of individuals' stories followed by a thematic narrative analysis of 14 interviews to explore the shared and unique experiences narrated by participants. RESULTS:Four primary themes were established: (1) Voiceless, invisible, and out of control within the dysfunctional system during childhood, (2) "shaky foundation" leading to future traumas, (3) the link between complex trauma, mental health difficulties, and NSSI, and (4) Regaining autonomy and a sense of control in managing NSSI. The findings highlight the importance of adopting a flexible and person-centred treatment that addresses the specific needs of these individuals. The treatment plan should empower individuals to improve their control and autonomy and support them to live a meaningful life.

BACKGROUND:Bisexual youth are at a disproportionate risk of non-suicidal self-injury (NSSI). Unique stressors, such as biphobia and bi-erasure, and their impact on self-esteem, identity and a sense of belonging may help explain this disproportionate risk. Affirmative therapies promote self-acceptance and identity affirmation and may therefore be effective in boosting self-esteem and reducing NSSI. AIMS:This study aimed to assess the feasibility and acceptability of a cognitive behavioural therapy-based, self-esteem intervention for young bisexual people (aged 16-25) with experience of NSSI thoughts, urges and behaviour. Secondarily, this study examined indicators of change on measures of self-esteem, NSSI, identity and belongingness. METHODS:A case series design was used with eight participants who experienced NSSI urges, thoughts or behaviours in the previous 6 months. Participants received an affirmative, 8-week, self-esteem intervention and completed measures of self-esteem, NSSI, belongingness and identity. RESULTS:Six participants attended all eight therapy sessions, and two opted out before completion. There were no serious adverse events. The intervention was deemed to be acceptable and feasible, and evidence of improvements on measures of self-esteem, NSSI, positive identity and thwarted belongingness was observed. CONCLUSIONS:The results suggest that this intervention is a safe, acceptable and feasible intervention, warranting further evaluation. Revisions and considerations for future trials of this affirmative therapy are proposed.

Background Self-harm is widespread and often occurs in the community without resulting in hospital presentation. Individuals with depressive symptoms are at elevated risk. There are limited self-harm interventions designed for community and primary care settings. The Community Outpatient Psychological Engagement Service for Self-harm (COPESS) is a brief talking therapy intervention for self-harm based in community settings. Aims To assess the feasibility of evaluating the COPESS intervention in a community setting in relation to participant recruitment, retention, data collection and the acceptability of the intervention. Method We used a mixed-method approach and a single-blind randomised controlled trial design with 1:1 allocation to either COPESS plus treatment as usual or treatment as usual alone. Adults with depressive symptoms and self-harm in the past 6 months were recruited from general practices. Secondary outcome measures were assessed at baseline and 1 month, 2 months and 3 months after randomisation. The trial was pre-registered on clinicaltrials.gov (NCT04191122) on 9 December 2019. Results Fifty-five people were randomised (of an initial target of 60). Retention rates at follow-up assessments were high (>75%), as was attendance by all participants for all therapy sessions (93%). At 3 months, there were trends towards lower levels of self-harm urges, depressive symptoms and distress in the COPESS group compared with controls. Fidelity to the manualised COPESS therapy was moderate to high. Conclusions All progression criteria were met, supporting further evaluation of the intervention in a full-scale efficacy and/or cost-effectiveness trial. These findings add to the growing evidence base supporting the utility of brief psychological interventions for self-harm. COPESS has potential as a brief primary-care-based intervention for those struggling with self-harm.

Self-harm is often stigmatised by healthcare professionals. Little is known about how certain characteristics of the behaviour, like the degree of suicidal intent, affect clinicians’ judgements and responses. This study explored how intent of self-harm (suicidal or non-suicidal) affects trainee practitioners’ views and attitudes towards behaviour and clinical decision-making. A qualitative study using semi-structured online interviews was conducted. Interviews were audio-recorded, transcribed verbatim and analysed using a reflexive thematic analysis. Fifteen trainee healthcare practitioners (psychological wellbeing practitioners, clinical/counselling psychologists, nurses, and medics) were interviewed. Three themes were identified: (1) interpreting intent in self-harm: clinical utility and challenges, (2) the perceived responsibility of self-harm, (3) trainees’ struggle for equal care in a hierarchical system. Participants observed staff expressing pejorative views towards both forms of self-harm but did not share them. Across most clinical decisions, intent informed trainees’ judgements and beliefs. Clients presenting with suicidal-related self-harm received more urgent care but fewer therapeutic interventions. Trainees felt ambivalent about distinguishing intent. Nevertheless, this distinction was evident across treatment, risk and care decisions. A consistent approach towards suicidal and non-suicidal self-harm is important. Trainees should be supported in addressing difficult emotions arising from this work, helping to shift the blame culture and promoting a more empathic approach.

INTRODUCTION:Many individuals with schizophrenia-spectrum disorder ('psychosis') lack capacity to make decisions about psychiatric treatment ('incapacity'), however we lack robust evidence from clinical trials on interventions to improve it. To accelerate their development, we tested whether an 'umbrella' trial was feasible. This involved running multiple randomised controlled 'interventionist-causal' trials (IC-RCTs) concurrently. Each tested the effect on incapacity of targeting an individual psychological mechanism. METHODS:We did 3 assessor-blind, multi-site, pilot IC-RCTs. Each compared 6 sessions of psychological therapy for either self-stigma (SS), low self-esteem (SE) or the jumping-to-conclusions (JTC) bias, to 6 sessions of collaborative assessment of the causes of incapacity (control). Adults with psychosis, incapacity and ≥1 target mechanism could participate. Primary outcomes were recruitment feasibility, and data retention on the MacArthur Competence Assessment Tool-Treatment (MacCAT-T). RESULTS:We recruited 57 participants and performed 60 randomisations (3 patients participated in 2 trials); 82 % provided post-treatment data. Standardised mean differences (Hedges' g) for MacCAT-T 'understanding' were g = 0.35 (SS; 95 % CI -0.51, 1.22), g = 0.41 (JTC; -0.55, 1.38) and g = 0.74 (SE; -0.73, 2.21), with positive values favouring treatment. For 'reasoning', they were -0.20 (SS; -1.05, 0.66), 0.79 (JTC; -0.20, 1.79) and 0.79 (SE -0.69, 2.27). For 'appreciation' they were -0.39 (SS; -1.25, 0.48), 1.76 (JTC; 0.62, 2.90) and 0.57 (SE; -0.87, 2.02). Four control participants had 9 serious adverse events between randomisation and post-treatment; two intervention participants had 2. DISCUSSION:An umbrella trial of psychological interventions to improve capacity in psychosis is feasible. A definitive trial is warranted. TRIAL PRE-REGISTRATION:NCT04309435.

OBJECTIVES:Higher education students experience elevated levels of suicidal ideation, but often face barriers in accessing support. The Mental Imagery for Suicidality in Students Trial (MISST; ISRCTN13621293; NCT05296538) tested the feasibility and acceptability of a six-session imagery-based approach called Broad-Minded Affective Coping (BMAC). This qualitative evaluation explored the experiences of MISST participants and staff. DESIGN:A qualitative study using one-to-one qualitative interviews with participants and staff recruited from MISST. Reflexive thematic analysis was used to explore trial participant and staff experiences to inform a future definitive trial. METHODS:Student participants (n = 16), research assistants (n = 4) and the trial therapist (n = 1) were interviewed and transcripts analysed using reflexive thematic analysis. RESULTS:Four key themes were identified. The first theme highlights the value and challenges for students in talking about suicide. The ways in which communication and rapport can be built to facilitate this conversation are explored in theme 2. Theme 3 explains how working with the BMAC therapist increased participants' awareness of their current mood, drew their attention to positive moments in their lives and helped them to actively recall these moments to interrupt negative cycles of rumination and suicidal ideation. The extent to which the BMAC is 'fit for purpose' is outlined in theme 4, generating specific recommendations for future intervention development. CONCLUSIONS:The BMAC offers a positive, time-limited, structured intervention that is well suited to meet the needs of higher education students experiencing suicidal ideation. Further research is needed to test the effectiveness on mental health and suicide-related outcomes.