Understanding the Processes in Assessing Risk of Deliberate Self Harm in Systemic Family Therapy

Introduction: The subject of self-harm in the adolescent population is a source for public concern likely grounded in the suicide rates for this age group and the perception that the risk of suicide is increased for individuals who regularly harm themselves. This leaves clinicians working with those who self-harm with the task of assessing the risk of those who access services. The literature base for risk assessment of suicide/self-harm is populated with studies which focus on the ‘whats’ of risk assessment, for example: what a clinician needs to cover to ensure safety or what service users think of their assessment. I argue the need to build on this knowledge base, and understand the ‘hows’ of risk assessment, e.g. how does a therapist complete an assessment and how does a therapist ensure engagement. The current study takes place within the context of a Systemic Family Therapy study and explores how a therapist completes their assessment with a family. Method: Grounded Theory was employed in order to analyse videotapes of Systemic Family Therapy sessions. A single case of a female adolescent was selected based on characteristics of her therapy. The key research questions address the processes the therapist employs to move between therapeutic and assessment tasks; how the therapist’s approach changes in the face of changing risk; and how the therapist maintains engagement throughout the therapy. Results: Themes emerging from the data revealed that the therapist employs a number of subtle processes in order to switch interchangeably between assessment and therapy tasks and that these foci are not mutually exclusive. These process occur within the context of a balanced, conversational relationship in which therapist and family has an equal footing. When the perceived level of risk changes, the therapist’s approach still fits within this framework, with a key difference being a more direct establishment of therapist goals. Engagement is maintained by the therapist’s negotiation of balance, collaboration and mutuality within the therapeutic relationship. Furthermore, the therapist moderates emotion in the room in a way that avoids re-traumatisation, and in a way that encourages the family and young person to continue to contribute to the discussions in safety. Discussion: The findings of the current study provides a preliminary model of risk assessment for this particular therapy which facilitates thinking about risk assessment in a wider sphere. The findings of the current study are then considered as part of a growing body of literature, with further recommendations made for future research.