Reaching shared understanding, assessment and structured support around self-harm with a young person? The CaTS-app could help with that…

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We were very happy to have the wonderful Ellen Townsend join us back in September 2021 as keynote speaker for our Webinar: Responding effectively to young people who self-harm.

So many of you who attended, or watched the webinar on replay, reached out to us for more information about the CaTS (Card Sort Task for Self-Harm) and we heard you, so we got back together with Ellen and the lovely Jo and Camilla from the team at the University of Nottingham to find out more about the tool and how they are working to develop it further…

Jo Lockwood and Camilla Babbage are Research Fellows at NIHR MindTech MedTech Co-operative, Institute of Mental Health, School of Medicine, University of Nottingham. Ellen Townsend is Professor of Psychology and leads the Self-Harm Research Group, School of Psychology, University of Nottingham.

CaTS-app is a digital version of an existing research tool called CaTS (Card sort Task for Self-harm)

Late in 2021, we embarked on an exciting journey to develop and build a new digital tool to improve outcomes for young people who self-harm and address the needs of frontline practitioners supporting them. Among us are world-leading interdisciplinary researchers and clinicians and a large team of youth advisors brought together to deliver the UKRI funded Digital Youth programme. Our focus – as one of seven research projects– is to co-create a digital tool to help young people tell the story of their self-harm and in so doing improve shared understanding, assessment of needs and treatment.

Why are we doing this work?

There is a strong case of need. Self-harming thoughts and behaviours, which include any act of self-injury or self-poisoning, irrespective of the apparent purpose, are increasing in young people, and have almost tripled in England over the past decade. Aside from being a stark indicator of emotional distress, a history of self-harm is a hugely significant risk factor for suicide, the leading cause of death of children and young people aged 5-19 in England and Wales. We need to take self-harm seriously.

With the increasing rates of self-harm, staff in NHS and other frontline settings such as schools and third sector services are encountering young people who have self-harmed in increasing numbers. Given that most young people will chose to hide their self-harm, a child presenting with self-harm to formal support services provides a critical opportunity to understand and support a young person’s needs. Not all experiences of formal support are judged as helpful by young people. We need to think carefully about why this is, and how we can make our responses to young people who self-harm work best for them, wherever and whenever that opportunity presents.

Ensuring our approaches are informed by young people, and work for those delivering support, is a good place to start.

Framing ways of assessing and managing self-harm

Recent national guidance sets out optimum ways for professionals across frontline settings (e.g. education, health and justice) to assess and manage self-harm with young people (NICE, 2022). Setting-specific recommendations are provided. Collectively, these recognise the need for a compassionate and collaborative approach, working with a young person to develop a shared understanding of needs.

Practitioners, especially those who do not specialise foremost in mental health, may not always be aware of these guidelines, or feel ill-equipped to steer this collaborative process sensitively and effectively with a young person.

Self-harm is a complex behaviour. It results from an interplay between various genetic, biological, psychological, psychiatric, cultural and sociodemographic factors which act in concert to confer risk. These factors are developmentally charged and also fluid  – changing from episode to episode and over time. Given this complexity, and the very sensitive and serious nature of the behaviour, it is challenging to explore with a young person what has led them to self-harm and what support needs they may have.

So what are we proposing and how might it help?
CaTS-app is a digital version of an existing research tool called CaTS (Card sort Task for Self-harm)

Building on our work with The Card Sort Task for Self-Harm (CaTS) research tool (previous CaTS research can be viewed here) we are co-developing a prototype CaTS-app designed to be used one-to-one with a young person to develop a shared understanding and assessment of self-harm. CaTS helps young people describe the factors involved in an episode of self-harm through the positioning of cards chronologically along a timeline. Cards describe various thoughts, feelings, events and behaviours and are informed by previous literature, explanatory models and co-creation with young people with lived experience.

The process of selecting and manoeuvring cards enables a young person to understand, mentalise and describe their journey toward a self-harm episode, mapping the factors involved in the lead-up to and following a self-harm episode, and identifying factors that pose risk or protection. It permits communication that is non-verbal and allows very sensitive issues to be highlighted. You can read more about the tool here.

Crucially, young people say they find the tool easy to use and helpful in articulating and reflecting on their self-harm. They also suggest that we explore the potential of CaTS as a therapeutic tool and draw on digital technology to improve and extend the possibilities of CaTS.  

How might this work?

There are lots of ways in which CaTS could be developed from the existing table-top research tool to a digital tool that supports professionals in clinical and frontline spaces.

The CaTS-App could

  • Scaffold the development of a shared understanding of self-harm supporting and structuring a compassionate conversation

  • Frame a collaborative, young person-led, needs-based assessment

  • Support decision-making on the timing and pertinence of therapeutic support by identifying target factors, and time-specific points for intervention. (Many of the factors identified through CaTS are modifiable and exist as treatment targets within approaches such as DBT-A.)

  • Offer, as a digital tool, specific functionality, flexibility and scope, including a process for recording, coding and tracking card selections with a young person, and capturing a shareable means of telling their story so that they don’t have to continually repeat it

  • Provide support as a brief intervention, or offer a framework for ongoing work with a young person

  • Work as a standalone tool, or support existing care provision.

So where are we now? Early development phase

As part of our Digital Youth work, and in close partnership with our advisory group of young people (Sprouting Minds) and a multi-disciplinary research group, we are undertaking a programme of development work to deliver a prototype CaTS-app. First steps in this process include:

  • Learning what professionals have to say about how, where and when a CaTS-app tool might support their practice, and how feasible and viable it would be to implement within their setting

  • Running co-production workshops with young people and other stakeholders to explore the design, content and operability of the app. Does it look and function in line with needs and preferences?

  • Building a prototype app and testing and evaluating it with practitioner+young person dyads

To find out more about our work developing the CaTS-app and next steps in our research with practitioners register your interest online


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