Identifying and measuring key cognitions in suicidal and non-suicidal self-harm

Identifying and measuring key cognitions in suicidal and non-suicidal self-harm

Background
Self-harm (SH) is 'self-poisoning or self-injury, irrespective of the apparent purpose of the act'. Examples include cutting, burning, scratching skin and preventing wounds from healing. SH is dangerous, widespread and brings with it considerable cost implications for public health services. However, SH research is still in its infancy and SH remains poorly understood. The research that has been conducted has been predominantly cross-sectional and existing measures of SH either assess SH behaviour (e.g., SH methods), or the functions of SH (e.g., to change how people feel). The proposed Fellowship aims to address these concerns by developing a self-report measure which examines the key cognitions which drive and explain SH behaviour, and then examining the longitudinal influence of these cognitions on SH behaviour.

Overview of the proposed Fellowship
Two inter-linked studies will investigate in detail the role of cognitions in suicidal and non-suicidal SH. Study 1 (Years 1-2) will develop and validate a self-report questionnaire which measures the central cognitions in adults who SH; Study 2 (Years 2-3) will then use this measure to examine key SH cognitions over time. The developed Self-Harm Cognitions Inventory (SHCI) will be helpful in explaining why some people initiate and/or repeat SH, and could be used in screening, assessment, individually-tailored interventions, monitoring and outcome evaluation. It is hoped that studies conducted during the Fellowship will lay the foundation for subsequent research examining cognitive factors in SH and, ultimately, the development and evaluation of a new cognitive-behavioural theory and treatment for SH. The proposed Fellowship carefully adheres to MRC guidance on developing complex interventions and would copy the design of successful previous research which examined cognitions in other psychological problems. The proposed Fellowship is expected to benefit patients, researchers and clinicians and influence future SH policy (e.g., NICE guidelines).

Methodology
Participants would be individuals aged 18 and over who currently SH. They would be recruited via SH support websites, community advertisements and local mental health services. A Delphi methodology will be used to develop the SHCI: to ensure that important cognitions are being measured, the questions to be included in the SHCI will be generated and revised by SH experts, NHS clinicians and individuals who SH. Participants will be invited to take part in a longitudinal study where they will complete various questionnaires initially and then again 6-9 months later. This design will allow the researchers to (i) establish how SH cognitions predict SH behaviour, (ii) explore differences between suicidal and non-suicidal SH, (iii) examine the extent to which SH cognitions are a cause and/or a consequence of psychological problems over time, and (iv) see whether SH cognitions are better predictors of SH behaviour than variables suggested by existing, non-cognitive theories of SH and known SH risk factors.

User involvement
The Delphi methodology involves clinicians and service-users throughout: in the development of the initial item pool for the SHCI, when validating the SHCI and in order to get feedback regarding the final SHCI questions. As a result of involving clinicians who work with individuals who SH as well as those individuals themselves, recruitment and retention are likely to be better (because the questionnaire will be valued by the very people who will use the SHCI), and the questionnaire is likely to be more clinically useful and accurate (because clinicians and service-users shaped its content). Involving service-users may also be empowering and de-stigmatising in and of itself, since it sends the message that the views of service users are central and valuable.

Aims
Self-harm (SH) is 'self-poisoning or self-injury, irrespective of the apparent purpose of the act'. Despite the dangerousness, prevalence and financial cost, SH has received relatively sparse research attention and remains poorly understood. There is very little longitudinal research and the predominance of behavioural theories means that existing measures either assess SH behaviour (e.g., SH methods), or SH functions (antecedents and consequences). The Fellowship aims to examine additional aspects of the phenomenology of SH by developing a questionnaire which examines the key cognitions which drive SH behaviour and then examining the longitudinal influence of those cognitions on SH behaviour.

Objectives
1) Develop and validate a psychometrically-robust, theory-driven, self-report measure of key SH cognitions in adults;
2) Use that measure to compare a cognitive explanation of SH against existing behavioural and functional theories of SH and known SH risk factors;
3) Explore differences between suicidal and non-suicidal SH over time;
4) Examine the extent to which SH cognitions are a cause and/or a consequence of psychological problems over time.

Methodology
Individuals aged 18+ who SH, recruited via SH support websites, advertisements and local mental health services (depending on ethical and practical issues). A Delphi methodology will be used to develop the questionnaire: items will be generated and revised by SH experts, clinicians and individuals who SH. A battery of questionnaires pertaining to mental health problems, SH behaviour, current SH theories, suicidality, and known SH risk factors will be administered 6-9 months apart.

Scientific and medical opportunities
The proposed Fellowship would lay the foundation for subsequent research examining cognitive factors in SH, the development and evaluation of a cognitive-behavioural theory and treatment for SH, and could influence the development of future policy (e.g. NICE guidelines).

The proposed Fellowship has potentially important implications for a range of audiences. Primarily, it would foster a better understanding of self-harm (SH) among academics and clinicians. For example, if a Self-Harm Cognitions Inventory (SHCI) were to be developed, Accident and Emergency staff could use it to supplement their existing assessments, better-understand and treat SH and suicidal behaviour, potentially increasing the effectiveness and decreasing the usage of Accident and Emergency services. The SHCI could be used at all levels of the NHS from primary care (e.g., GPs) to inpatient specialist care. Knowing reliably which cognitions explain individual differences in SH will aid the prediction of SH behaviour by researchers and clinicians alike and could be used to inform clinical interviews, risk assessments, interventions and risk-management across the NHS. The developed SHCI therefore provides a means by which clinicians can swiftly and easily examine the link between SH cognitions and SH behaviour for each and every episode of SH. The NICE (2004) SH clinical practice guidelines (CG16, CG133) stress that each episode of SH should be assessed in its own right, so the proposed research would provide a means for clinicians to more closely adhere to these guidelines and provide optimal clinical care. Additionally, SH cognitions may not always manifest as SH behaviour and beliefs about internal experiences (e.g., appraisals of mood, thoughts about how to cope with stress) are only ascertainable via introspective self-report. Therefore, at present, some important aspects of SH are not measured because clinicians and researchers focus more on SH behaviour. These factors mean that a self-report questionnaire which can measure SH cognitions has the potential to more powerfully explain important aspects of SH behaviour than current theories and SH questionnaires. Given the dangerousness of SH and its well-established strong link to suicide, having a clear understanding of the key cognitions in SH has the obvious potential to save lives. The proposed Fellowship may lead to the development of a cognitive-behavioural therapy for SH which would then be refined and tested in further research.

Making SH more understandable also has the potential to impact how the media portrays SH and perhaps reduce the currently stigmatising perceptions of SH by providing an alternative, more scientific explanation than popular stigmatising perceptions (e.g., that individuals who SH are "attention-seeking"). The applicant aims to actively engage with SH and suicide charities, support groups and specialist NHS services in order to widely disseminate the research results and gain feedback in order to plan future, clinically-relevant research.

Because the applicant plans to be publishing and disseminating the research results from the second year of the Fellowship, it is hoped that the research conducted will begin to have an impact for researchers and clinicians by the end of the Fellowship. The applicant and supervisors believe that this is a realistic timescale given that the supervisory team has a very strong background in suicide and SH research, and because the applicant has some existing experience of the research and publication process (see CV), meaning that less skills-development will be required than a typical PhD applicant and that the applicant will be capable of publishing during the Fellowship period. With regard to the applicant's development, it is hoped that as a result of the comprehensive training scheme outlined and the learning that which will come as a result of collaboration between experienced academics at two institutions, the applicant will be in a position to become an independent researcher by the end of the Fellowship. The planned training will equip the applicant with a range of psychological research skills that could be applied in academic settings, NHS clinical settings and in other employment sectors.