Acute self-harm or an attempt: treat the medical injury first and do a full psychosocial assessment every time. Avoid prolonged or coercive admissions without a clear therapeutic goal, which can worsen outcomes.
Presentation
- Emotional dysregulation, often after interpersonal stress
- Self-harm as a coping strategy, which may or may not carry suicidal intent
- Impulsivity, fear of abandonment, unstable relationships
- Each crisis still needs individual assessment
Helpful responses
- Calm, consistent, compassionate; validate distress without reinforcing harm
- Clear, kind boundaries; avoid power struggles and rejection
- Collaborate on a crisis plan the person helped write
- Continuity of staff and a clear care plan
Distress, no imminent risk
- Validate, stay calm
- Use the crisis plan
- Brief problem-solving
Escalating risk
- Self-harm urges, overwhelmed
- Crisis team, sensible risk plan
- Avoid long admissions
Acute high risk
- Imminent self-harm or suicide
- Ensure safety, treat injuries
- Urgent mental health assessment
Approach
1
1. Assess
Treat injuries. Assess suicidal intent for this episode (do not assume a 'behavioural' label makes it low risk). Full psychosocial assessment.
Treat injuries. Assess suicidal intent for this episode (do not assume a 'behavioural' label makes it low risk). Full psychosocial assessment.
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2
2. De-escalate
Low-stimulation environment, listen, and involve the person in decisions. Avoid unnecessary sedation.
Low-stimulation environment, listen, and involve the person in decisions. Avoid unnecessary sedation.
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3
3. Short-term plan
Agree coping strategies, who to contact, and rapid follow-up with the community mental health or crisis team. Brief admission only with a specific goal.
Agree coping strategies, who to contact, and rapid follow-up with the community mental health or crisis team. Brief admission only with a specific goal.
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4
4. Longer term
Structured psychological therapy (for example DBT or MBT) via specialist services; manage comorbid depression, PTSD or substance use.
Structured psychological therapy (for example DBT or MBT) via specialist services; manage comorbid depression, PTSD or substance use.
Avoid iatrogenic harm
- Benzodiazepines and sedatives can worsen impulsivity and dependence
- Medication is not first-line for the disorder itself
- Repeated lengthy admissions can be counter-therapeutic
Pitfalls
- Assuming self-harm here means no suicide risk
- A dismissive or punitive response
- Over-medicating or over-admitting
- No clear, shared crisis plan
MedPrep - www.medprep.uk - Educational revision aid only. Not clinical guidance. Doses are adult examples; check the BNF, current guidelines and local policy, and seek senior advice. Nov 2026