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Connecting Knowledge and Research| Online Assignment Help

In order to provide the appropriate intervention, social workers first need to have conducted a thorough assessment. Having a comprehensive understanding of a client and their social environment, including the influence of racism and ethnocentrism, allows a social worker to accurately identify the presenting problems and help the client develop goals to address their needs. Not completing a full assessment may result in inaccurately identifying the presenting problem and pushing goals on the client to which they do not agree. A good assessment is the best foundation for treatment planning.

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In addition, evidence based practice requires social workers to use the best available evidence to inform their practice decisions. This assignment helps you prepare for the final project by beginning to identify the presenting problem and possible goals, as well as beginning the research process to inform your treatment recommendations when working with the identified client in a case study.

To prepare: Conduct research in the Walden library to locate at least 1 peer-reviewed scholarly resource(s) that could inform your assessment or intervention with the case you plan to use in your final project.

online homework help

By Day 7

Submit a 2-3 page paper in which you:

  • Identify the case you will be using for the final project
  • Describe the presenting problem(s)
  • Describe 2 goals for the client based on their presenting problem
  • Identify a specific peer-reviewed article and explain how it could inform understanding of the problem/population, development of goals, or intervention and treatment plan
  • Explain how ethnocentrism and racism may influence the case (make sure to draw from this week’s assigned readings)

Assignment: Connecting Knowledge and Research

In order to provide the appropriate intervention, social workers first need to have conducted a thorough assessment. Having a comprehensive understanding of a client and their social environment, including the influence of racism and ethnocentrism, allows a social worker to accurately identify the presenting problems and help the client develop goals to address their needs. Not completing a full assessment may result in inaccurately identifying the presenting problem and pushing goals on the client to which they do not agree. A good assessment is the best foundation for treatment planning.

In addition, evidence based practice requires social workers to use the best available evidence to inform their practice decisions. This assignment helps you prepare for the final project by beginning to identify the presenting problem and possible goals, as well as beginning the research process to inform your treatment recommendations when working with the identified client in a case study.

To prepare: Conduct research in the Walden library to locate at least 1 peer-reviewed scholarly resource(s) that could inform your assessment or intervention with the case you plan to use in your final project.

By Day 7

Submit a 2-3 page paper in which you:

  • Identify the case you will be using for the final project
  • Describe the presenting problem(s)
  • Describe 2 goals for the client based on their presenting problem
  • Identify a specific peer-reviewed article and explain how it could inform understanding of the problem/population, development of goals, or intervention and treatment plan
  • Explain how ethnocentrism and racism may influence the case (make sure to draw from this week’s assigned readings)
Submission and Grading Information

To submit your completed Assignment for review and grading, do the following:

  • Please save your Assignment using the naming convention “WK8Assgn+last name+first initial.(extension)” as the name.
  • Click the Week 8 Assignment Rubric to review the Grading Criteria for the Assignment.
  • Click the Week 8 Assignment link. You will also be able to “View Rubric” for grading criteria from this area.
  • Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK8Assgn+last name+first initial.(extension)” and click Open.
  • If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global

Assignment: Connecting Knowledge and Research

In order to provide the appropriate intervention, social workers first need to have conducted a thorough assessment. Having a comprehensive understanding of a client and their social environment, including the influence of racism and ethnocentrism, allows a social worker to accurately identify the presenting problems and help the client develop goals to address their needs. Not completing a full assessment may result in inaccurately identifying the presenting problem and pushing goals on the client to which they do not agree. A good assessment is the best foundation for treatment planning.

In addition, evidence based practice requires social workers to use the best available evidence to inform their practice decisions. This assignment helps you prepare for the final project by beginning to identify the presenting problem and possible goals, as well as beginning the research process to inform your treatment recommendations when working with the identified client in a case study.

To prepare: Conduct research in the Walden library to locate at least 1 peer-reviewed scholarly resource(s) that could inform your assessment or intervention with the case you plan to use in your final project.

By Day 7

Submit a 2-3 page paper in which you:

  • Identify the case you will be using for the final project
  • Describe the presenting problem(s)
  • Describe 2 goals for the client based on their presenting problem
  • Identify a specific peer-reviewed article and explain how it could inform understanding of the problem/population, development of goals, or intervention and treatment plan
  • Explain how ethnocentrism and racism may influence the case (make sure to draw from this week’s assigned readings)
Submission and Grading Information

To submit your completed Assignment for review and grading, do the following:

  • Please save your Assignment using the naming convention “WK8Assgn+last name+first initial.(extension)” as the name.
  • Click the Week 8 Assignment Rubric to review the Grading Criteria for the Assignment.
  • Click the Week 8 Assignment link. You will also be able to “View Rubric” for grading criteria from this area.
  • Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK8Assgn+last name+first initial.(extension)” and click Open.
  • If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global

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

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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

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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.

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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

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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

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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

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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.

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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.

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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

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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 catledge@mailbox.sc.edu. 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:catledge@mailbox.sc.edu
http://www.nice.org.uk/nicemedia/pdf/CG016NICEguideline.pdf
  • Assessment and Identification of Deliberate Self-Harm in Adolescents and Young Adults
    • BACKGROUND AND SIGNIFICANCE
    • ONSET IN ADOLESCENT AND YOUNG ADULTS
    • FUNCTIONS OF PARTICIPATING IN DSH BEHAVIOR
    • FACTORS ASSOCIATED WITH DSH
    • PRACTICE AND KNOWLEDGE ASSESSMENT OF DSH IN PRIMARY CARE
    • RECOMMENDATIONS
    • THERAPEUTIC RELATIONSHIP
    • PHYSICAL ASSESSMENT
      • Self-Injury Risk Assessment
      • Psychosocial and Psychological Risk Assessment
    • EVIDENCE-BASED MANAGEMENT AND FOLLOW-UP
    • PCP EDUCATION
    • PRACTICE IMPLICATIONS
    • NURSING EDUCATION IMPLICATIONS
    • CONCLUSION
    • References

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: dennis.ougrin@kcl.ac.uk).

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.

Teaching Therapeutic Assessment 73

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]).

74 Dennis Ougrin et al.

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.

Teaching Therapeutic Assessment 75

(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.

76 Dennis Ougrin et al.

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%) Solution-focused brief therapy 2 (8%) Mentalization-based therapy 1 (4%) Play therapy 1 (4%)

Clinicians with fewer than 2 years of CAMHS experience had a significantly lower mean TAQAT composite score pre-training than the clinicians with 2 or more years of CAMHS experience, 78.64 (SD = 22.23) versus 95.77 (SD = 18.63), t(22) = 2.10, p < .05. Gender, ethnic group, and being a doctor versus non-doctor had no effect on baseline TAQAT score (all p > .05).

TAQAT post-training scores There was a statistically significant increase in the clinicians’ TAQAT scores pre and post training: pre-training TAQAT composite mean 87.92 (SD = 21.73), post-training TAQAT composite mean 118.75 (SD = 19.32), t(23) = 8.69, p < .001). There was also a statistically significant increase in each individual TAQAT item and across the rating domains (Tables 2 and 3).

Those with more than 2 years’ experience still had higher TAQAT scores post training, although this difference was no longer statistically significant 111.45 (SD =

Teaching Therapeutic Assessment 77

Table 2. Pre- and post-training TAQAT scores. Rating domains’ breakdown

Means (SD)

TAQAT item Pre-training Post-training Difference in means 95% CI p

Total 87.92 (21.73) 118.75 (19.32) 30.83 (23.49–38.17) �.001 Self-rated 26.33 (7.89) 38.33 (5.16) 12.00 (8.77–15.23) �.001 Independently rated 28.83 (10.15) 40.00 (8.67) 11.17 (7.48–14.85) �.001 Young person rated 32.33 (8.49) 40.42 (7.73) 8.08 (5.18–10.98) �.001

24.07) versus 124.92 (SD = 11.95), t(22) = 1.78, p > .05). Repeated measures time by experience ANOVA revealed significant time effect (F(1,22) = 73.31, p < .001) and significant experience effect (F (1) = 4.61, p < .05), however no significant time by experience interaction (F (1,22) = .26, p > .05) was detected.

Satisfaction We used a six-item questionnaire called the post-training questionnaire (PTQ) to assess trainees’ satisfaction. Each item was rated on a 0–10 Likert scale (Table 4).

The sixth item of the PTQ (I would recommend this course to a friend) was used as a guide to the overall trainees’ satisfaction. A consistently high level of satisfaction was reported post training.

The choice of exits in TA The most commonly used TA exit at post-training OSCE was an exit based on SFBT. An SFBT-based exit was used by 10 (41%) clinicians, CBT by five (21%), systemic–narrative by five (21%), and MI by two (8%). SFBT was also considered to be the best exit strategy on post-training evaluation by 10 (41%) of the clinicians, systemic–narrative by five (21%), CBT by four (17%), and MI by three (13%) clinicians. SFBT exit teaching received the highest rating by 10 (41%) of the clinicians, followed by CBT five (21%), MI three (13%), and systemic–narrative three (13%) clinicians.

Use of TAQAT to rate quality and fidelity of TA in a randomized controlled trial In the TOTAL (Ougrin et al., 2011), 26 clinicians from three London NHS Trusts volunteered to participate in the trial and were randomized into two groups, 13 clinicians in each. The experimental group was trained in TA in five half-day sessions. The control group was offered training after the trial had been completed. Overall 11 clinicians

Table 3. Pre- and post-training TAQAT scores. Individual TAQAT items’ breakdown

Means (SD)

TAQAT item Pre-training Post-training Difference in means 95% CI p

Understanding 19.04 (4.82) 24.96 (6.42) 5.92 [3.48–8.35] �.001 Motivation 18.67 (4.82) 23.38 (5.00) 4.71 [3.38–6.03] �.001 Instilling hope 18.58 (4.11) 23.79 (4.17) 5.21 [3.66–6.76] �.001 Exploring alternatives 14.38 (5.89) 23.50 (4.63) 9.13 [6.45–11.80] �.001 Setting targets 17.17 (5.14) 23.96 (3.83) 6.79 [4.93–8.65] �.001

78 Dennis Ougrin et al.

Table 4. Trainees’ satisfaction post training

Mean score (from 0 to 10 rating scale)

PTQ item Year 2009 (n = 9) Year 2007 (n = 7) Year 2006 (n = 7) Well presented 9.0 9.1 9.3 Understandable 8.9 9.3 8.9 Relevant 9.2 9.1 8.7 Helpful 8.7 9.3 8.6 Practical 8.2 8.7 9.1 Recommend to a friend 9.0 9.3 9.2

Note. PTQ, post-training questionnaire; n, number of trainees.

(six in the experimental group and five in the control group) dropped out: two due to their Trust disengaging from the trial, one due to failing to complete TA training, the rest (eight) due to leaving their Trust or stopping their work with adolescents who self-harm.

Overall nine clinicians started TA. One of those did not complete the train- ing and one’s centre dropped out from the TOTAL. Fifteen clinicians in total (seven in the experimental group and eight in the control group) participated in the trial. They applied TA or Assessment as Usual (AAU), respectively, to all adolescents referred to them for an assessment who met the inclusion cri- teria of the trial. The initial sample of 26 clinicians had the following charac- teristics. The mean age was 35.9 (SD = 5.35). Clinicians had a mean of 7.38 (SD = 5.15) years of mental health experience. Eleven (42%) of the clinicians were doctors, seven (27%) nurses, five (19%) psychologists, and six (23%) social workers. The majority of the clinicians was White 17 (65%), followed by Asian five (19%), and Black four (15%).

Fidelity to Therapeutic Assessment To ensure fidelity to TA, a random sample of 10 (29%) of the clinicians’ audio-taped evaluations was selected. Two independent clinicians rated adherence to the seven components of TA. Adherence to these seven points averaged 90.7%, minimum 71.4% and maximum 100%. Inter-rater agreement was moderate (overall Cohen’s kappa = .64, p < .001, range .59–1). All 10 tapes achieved the required level of competence in TA (33 points or more on the objective rating of the TAQAT, a 0–50 scale completed by an independent clinician rating the extent to which the five objectives of TA had been achieved).

Discussion In this study, we found that clinicians who participated in TA training had significantly increased scores on TAQAT after training and that the clinicians who achieved the required quality of TA post assessments were likely to be able to carry out TA in real life with high fidelity and quality. In addition, prior to training significant differences in the quality of the assessment as measured by TAQAT were identified depending on the experience of the clinician. This discrepancy was not repeated in the TAQAT scores from the post-training OSCE, possibly indicating that the short period of training in TA

Teaching Therapeutic Assessment 79

removed the disadvantage of fewer years of service in terms of improving the quality of self-harm assessments.

The TA teaching involved combining a number of therapeutic techniques with the aim of providing an array of therapeutic exits. The investigation into which exit was most effective raises questions as to the refining of the TA training process. Should future training focus more on SFBT, which was the most widely chosen exit, considered ‘the best exit’ in the post-training evaluation and the exit with the highest teaching rating during training? This question is difficult to answer; the overall training experience is rarely equivalent to a simple sum of its parts and without further investigation, it is impossible to say whether the provision of multiple exit strategies enhanced or hindered the assessment process. Experientially, one can propose that the competent knowledge of a variety of different approaches enables the development of a well-integrated style within which the TA techniques can be used effectively. This concept is supported in the practice of mentalization-based treatment, which also draws upon the empirical data provided by a range of psychological therapy models (Bateman & Fonagy, 2006).

Comparison to other studies A recent systematic review of evaluation studies that looked at different psychosocial trainings found multi-component training packages to have the most compelling evidence of efficacy (Herschell et al., 2010). The TA training compares favourably to other studies identified in the review in that the following components were used: (a) TA was based on a manual, (b) 5 days of intensive workshop training was used, (c) expert consultation was available, (d) audio recording of TA sessions was required for those involved in the research studies, and (e) the trainees were required to practice a component of TA before each of the five training sessions and had a chance to discuss these sessions.

In addition, the TA-training evaluation consisted of both subjective and objective measures. Unlike other training courses there were no TA training booster sessions and there was no two-tier supervisor training used.

An ‘intention to teach’ design, to account for loss to follow-up, was used in this study to parallel the ‘intention to treat’ design in clinical trials, and allowed for clinicians unable to attend training for whatever reason to be included in the analysis. The use of this design allows the measurement of how efficacious a training course is when it is not always completed by 100% of participants, a likely problem for NHS staff.

The use of multiple perspectives for the TAQAT reduces the risk of skewed reporting on the quality of assessment, which is further improved by using a paid actor with no previous experience of mental health OSCE work and an independent observer.

Limitations Several limitations apply to this study. First, the study sample was small, leading to possibly spurious findings. Second, only volunteer clinicians were trained, possibly limiting the generalizability of the findings. Third, the study used patient-derived measures to assess the quality of TA and some of the key general measures of the quality of self-harm assessment (such as risk assessment and mental state examination) were not measured in this study. Although we had comparison groups for those trainees involved in the research projects, only a subgroup was randomized indicating a risk of bias in the assessments.

80 Dennis Ougrin et al.

Although we found excellent adherence to and quality of TA in the TOTAL study, we only had sufficient resources to test a random sample (29%) of the assessments. It is possible therefore that some of the untested assessments were of a lower quality. In addition, validity and reliability of the TAQAT have not been established before and none of the ratings were blinded. The quality of TA assessments was not measured against the NICE (2004) criteria and so no information about the quality of risk assessment could be inferred for the TA assessments. In addition inter-rater agreement for TA fidelity was only moderate.

We attempted to recruit a representative sample of CAMHS professionals. However, the majority of the trainees were junior mental health professionals. The results of the study may not therefore apply to the more experienced professionals.

Conclusions TA training is associated with an improved quality of assessment as measured by the TAQAT. TA training is short and lends itself well to being included in protected junior doctor teaching sessions or departmental CAMHS teaching. TA training is also associated with a good quality of TA in a pragmatic randomized controlled trial. TA training could be recommended as a feasible and effective intervention linked with improved engagement in adolescents after self-harm assessment.

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Appendix Therapeutic Assessment quality assurance tool (O) Following the assessment, to what degree do you think the therapist achieved the goals listed below?

Please give a score between 0 and 10, where 0 = goal not achieved; 10 = goal fully achieved.

(1) Developing understanding of the difficulties leading to self-harm

0 1 2 3 4 5 6 7 8 9 10

Teaching Therapeutic Assessment 83

(2) Enhancing motivation for change

0 1 2 3 4 5 6 7 8 9 10 (3) Instilling hope

0 1 2 3 4 5 6 7 8 9 10 (4) Exploring alternatives to self-harm

0 1 2 3 4 5 6 7 8 9 10 (5) Setting targets and goals for future work

0 1 2 3 4 5 6 7 8 9 10

Total:

Therapeutic Assessment quality assurance tool (S) Following the assessment, to what degree do you think you have achieved the goals listed below?

Please give a score between 0 and 10, where 0 = goal not achieved; 10 = goal fully achieved.

(6) Developing understanding of the difficulties leading to self-harm

0 1 2 3 4 5 6 7 8 9 10 (7) Enhancing motivation for change

0 1 2 3 4 5 6 7 8 9 10 (8) Instilling hope

0 1 2 3 4 5 6 7 8 9 10 (9) Exploring alternatives to self-harm

0 1 2 3 4 5 6 7 8 9 10 (10) Setting targets and goals for future work

0 1 2 3 4 5 6 7 8 9 10

Total:

Therapeutic Assessment quality assurance tool (YP) Following the assessment, to what degree do you think you have achieved the goals listed below?

84 Dennis Ougrin et al.

Please give a score between 0 and 10, where 0 = goal not achieved; 10 = goal fully achieved.

(11) Understanding of the difficulties leading to self-harm

0 1 2 3 4 5 6 7 8 9 10 (12) Feeling motivated to challenge problems

0 1 2 3 4 5 6 7 8 9 10 (13) Feeling hopeful that things will get better

0 1 2 3 4 5 6 7 8 9 10 (14) Discovering ways to tackle self-harm

0 1 2 3 4 5 6 7 8 9 10 (15) Setting targets and goals for future work

0 1 2 3 4 5 6 7 8 9 10 Total:

TAQAT Total:

Teaching Therapeutic Assessment 85

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