Self-harm presentation — psychosocial assessment and crisis aftercare (MEQ)

(i) Definitions and continuum. Self-harm (service sense): intentional self-poisoning or self-injury irrespective of suicidal intent. NSSI: self-injury without intent to die, often for affect regulation. Suicide attempt: self-injury with at least some intent to die. This presentation is best framed as mixed/unclear or predominantly non-suicidal with ambivalence: she denies wanting to die yet used overdose plus cutting after interpersonal crisis; chronic cutting fits affect-regulation NSSI (Klonsky). Document both poles; do not collapse to "just NSSI" or "definite attempt" without enquiry about expectation of death at the time and now.[1]

(ii) Psychosocial assessment. After medical stability and sobriety for engagement: private interview; non-stigmatising language; episode timeline, precipitants, intent continuum, planning vs impulsivity, alcohol role, regret vs ongoing despair; 2-year NSSI functions; prior help-seeking; mental state (mood, psychosis, hopelessness, cognition); capacity; social context (partner conflict, flatmates, work/study); means at home (tablets, sharp objects); protective factors; collateral from partner/flatmates/GP if safe. Offer assessment as standard after hospital-treated self-harm (Kapur process evidence).[7][1]

(iii) Safety plan and means. Collaborative Stanley-Brown-style written plan: personal warning signs of rising distress/urges; internal coping (distress tolerance skills); social distraction people/places; people to call for help (named flatmate/friend); professionals and local crisis/ED numbers; means restriction — remove excess paracetamol/other meds (pharmacy return or trusted third party), safe storage of sharp objects, weekend alcohol plan; reasons for living. Patient keeps a copy; SPI with follow-up has RCT support in suicidal ED populations.[2]

(iv) Aftercare evidence. WHO BIC: brief education plus systematic contacts reduced suicide deaths after attempts in multicentre RCT.[3] Carter postcards: reduced repetition after hospital-treated self-poisoning.[4] Cochrane (Witt): structured psychosocial interventions (CBT-informed, DBT-related, problem-solving approaches) have the best evidence base among psychological options, with heterogeneous effects.[5] DBT (Linehan) for recurrent self-harm/suicidality in BPD-spectrum presentations when clinically indicated.[8]

(v) Disposition and prognosis. Intensity matches residual dynamic risk: if intent remains high, means cannot be secured, or supports fail → crisis team or admission pathway under least restrictive legal options. If engageable with good supports and secured means → urgent booked follow-up (e.g. within 24–72 hours), not weeks-away routine only. Hospital-treated self-harm elevates long-term suicide risk (Geulayov/Hawton multicentre long-term data); repetition risk is also substantial early on — empty discharge plans are indefensible.[6][7][2]