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Book Review: Self-Harm Assessment in Young People â€“ A Therapeutic Assessment manual By Dennis Ougrin, Tobias Zundel and Audrey V. Ng Published by Hodder Arnold, 2010

Jenaway, Dr A., 2010. Book Review: Self-Harm Assessment in Young People â€“ A Therapeutic Assessment manual By Dennis Ougrin, Tobias Zundel and Audrey V. Ng Published by Hodder Arnold, 2010. Reformulation, Summer, p.49.

This is an ambitious book, based on the idea that it is possible to include a therapeutic element in assessments of adolescents after they have self harmed. It is centred on a small pilot study, involving 31 patients between 12 and 18 years, comparing standard psychosocial assessment with this new form of therapeutic assessment. The authors found that young people who had received the therapeutic assessment were significantly more likely to engage with the follow up arranged for them than those who had only had a standard assessment (75% versus 40%). Since engagement of adolescents is probably the hardest part of any intervention, this is encouraging, but maybe not encouraging enough to write a whole book about it at this early stage. I assume that the authors are planning a larger study to replicate the findings, and that this book is actually intended as the manual for the intervention, so that others can start to use it and research it.

So what is therapeutic assessment? It includes the standard psychosocial assessment and risk assessment that we would all do after someone has self harmed, then a ten minute break, followed by around half an hour of therapeutic conversation. This conversation is aimed at drawing a CAT diagram with the young person, showing their problematic reciprocal roles and one main procedure which has led to self harm. The young person is then encouraged to think about any possible exits from this procedure using a variety of psychotherapy models including solution focused therapy, motivational interviewing, problem solving therapy, cognitive behaviour therapy, interpersonal therapy and mentalisation based approaches! A sort of “throw anything at them which might work” approach.

The manual suggests that the assessor should use any approach that seems to fit, but gives no guidance as to how the assessor would decide which to use with whom. Since the assessors in the original study had no previous knowledge of CAT, and only had two 5 hour training sessions, they must have used whatever therapy styles they were already familiar with, as it would have taken most of the training to get them up to speed in drawing and using the diagrams. Certainly the chapter on CAT in the book is very rudimentary and I think would leave anyone who is not already trained in CAT rather confused, with only a basic understanding of reciprocal roles and procedures. Certainly not enough understanding to cope with the sorts of complicated young people, and families, that I have assessed after self harm. Although there are lots of clinical examples in the book, the young people described seem to respond, as if by magic, to the CAT intervention offered and, again, I feel this is not representative of many young people in this situation, who are often confused, ambivalent, angry or reluctant to talk at all. Interestingly, in the pilot study, a larger proportion of the young people in the TA group were seen in outpatients rather than the emergency department (47% versus 17%) and perhaps that means there was a delay before they were seen. They may have been more ready to engage in something therapeutic at that later stage. However, the authors say that the finding still holds despite this difference.

For a book that is concerned with improving engagement in adolescents, the authors did not really engage me in reading it. The book starts with five dry, densely packed, academic chapters on various aspects of self harm in young people, including a whole first chapter on defining self harm. This is all worthy information but it is a turn off for the reader who really just wants to know about this exciting new intervention they are proposing. It would have been better to put these in as later chapters or appendices. The chapter on CAT and drawing simple diagrams with adolescents will be interesting and useful to those already trained in CAT who want to think about modifying it for this age group. The diagrams are well designed and would be easy to create if you already have a CAT background. The chapters on all the different approaches to finding exits will also be of interest to CAT therapists. In a way, this area of finding exits has been slightly neglected in the CAT literature, with our emphasis on reformulation and recognition. It has been assumed that the exits will just appear but, as we know, it is not always that easy. Since the authors have had to simplify each approach into the bare minimum, they become more understandable, and more memorable (a bit like a CAT reformulation itself). I particularly enjoyed the chapters on Interpersonal therapy and on Mentalisation based therapy.

In summary, I think this book is a really good start in encouraging assessors to make their self harm assessments therapeutic and it gives a practical way forward for this for a group that is difficult to engage. I think it will be useful for those already trained in CAT who want to work with this group, but I do not think that it is a clear enough manual for those who are new to the field.

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Book Review: Self-Harm Assessment in Young People â€“ A Therapeutic Assessment manual By Dennis Ougrin, Tobias Zundel and Audrey V. Ng Published by Hodder Arnold, 2010

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