Adapting CAT to Help Self-Harm

Self-harm is a very common problem worldwide. It refers to  someone hurting themselves on purpose. This might be to end their life (i.e. a suicide attempt) but can also be done for other reasons. Many people self-harm as a way to cope with extremely difficult feelings or experiences, for example.

Self-harm is a concern for many reasons. It is related to emotional and psychological problems.  It can lead to physical problems such as scarring or infection. People who self-harm can also experience stigma and hostility from others, which can make their problems worse. Research has found that people who self-harm are at higher risk of death by suicide in the future.  For these reasons it is helpful to explore whether talking therapies can play a part in helping people cope differently with the issues or feelings that lead to their self-harm.

Many people who self-harm come to Emergency Departments (ED) in hospitals to get help.  This is an opportunity to provide psychological help in addition to treating the physical harm .

A hospital in the North West of England started to offer a brief form of talking therapy for people arriving at ED following self-harm. This was called the Hospital Outpatients Psychotherapy Engagement (HOPE) service.  This therapy combined ideas and approaches from Cognitive Analytic Therapy (CAT) and another therapy called Psychodynamic Interpersonal Therapy (PIT).

CAT tries to identify the patterns in a person’s life that cause their current difficulties, and looks for solutions or exits from unhelpful patterns. PIT focuses on helping people to be aware of and understand their difficult feelings.  Both these approaches have been used in the past to help people who have harmed themselves.  CAT and PIT share a focus on how people relate to others and also  how they relate to themselves.  Both of these may be important when it comes to self-harm.

In the HOPE study, nurses and psychiatric liaison team staff received some training and supervision in both CAT and PIT.  They offered four sessions of therapy to people attending ED with self-harm.  They also offered a fifth “booster” session a month later.  The sessions did not follow a set structure for everyone.  However they used both CAT and PIT approaches to help the person to:

  • explore and map out connections between their self-harm, their feeling states, and experiences with themselves and others
  • recognise what they were feeling and put their feelings into words
  • stay with their feelings rather than avoid them
  • understand  how their feelings connect with their self-harm
  • make use of maps and diagrams to capture these connections
  • explore what leads up to times they self-harm, and what happens afterwards

In the later sessions the focus shifted to helping the person to:

  • think about what else they could do to manage feelings or problems that might lead them to self-harm
  • consider how to prevent reaching a point when they self-harm again
  • prepare for the end of their sessions

The HOPE study aimed to see how many people attended the service over its first ten months of running, and whether their difficulties improved over time.  A team of researchers and clinicians worked together on this, from the University of Manchester, the University of Liverpool, Edith Cowan University in Australia, and Mersey Care NHS Foundation Trust.

The study found that during this time eighty-three people eligible to get help from the service were referred. Of these, 64% attended at least one session of therapy, and nearly half (49%) attended all four sessions.

People who arrive at ED following self-harm are often in crisis, and may feel too distressed to start new treatments. Therefore having nearly half of this group complete all four sessions was positive. It suggests that a lot of people coming to ED after self-harm are willing to take part in a talking therapy.

The study found that feelings of distress reduced over the course of the therapy. There was a small drop in how many people had suicidal plans as well, but this change was not large enough to be meaningful, according to the statistics used.

We need to view these results very cautiously. There was no control group in the study. This means we do not know if the people who had
therapy would have just got better anyway. Nonetheless, the study provides some very early evidence that this kind of therapy could be useful. Larger studies are needed to know for sure whether or not the therapy is helpful.

However, the results suggest that offering this brief talking therapy to people who self-harm and arrive at ED may be a good way to provide rapid support. We need more research to know if this kind of therapy is effective, and whether people benefit in the long-term.

You can read the orginal article about the HOPE study by clicking on this link: https://onlinelibrary.wiley.com/doi/full/10.1111/papt.12277

Dr Peter Taylor, Senior Clinical Lecturer & Clinical Psychologist, Division of Psychology & Mental Health, University of Manchester

Adapting CAT To Help Self-Harm by Peter Taylor                                      CC BY-NC-ND 4.0