An investigation of the effectiveness of a therapeutic assessment intervention on engagement in aftercare services for young people who present to the emergency department for deliberate self-harm

This project will involve the delivery of a brief collaborative intervention called the Therapeutic Assessment (TA) to young people aged 12-17 years who present to the emergency department (ED) for deliberate self-harm (DSH) at the following sites: 1) Perth Children’s Hospital ED 2) Albany Health Campus ED 3) Geraldton Regional Hospital ED The TA is a brief psychological intervention that has been designed to make the assessment of young people who have engaged in DSH behaviour more therapeutic (Ougrin et al., 2011). TA builds upon standard clinical assessment to identify factors that drive and maintain DSH behaviour. TA involves brief recovery-focused problem-solving therapy to identity the young person’s strengths and uses this to encourage help-seeking behaviours. The major components of Therapeutic Assessment are as follows: 1) Standard psychosocial history and risk assessment (approximately 1 hr) completed by Psychiatric Liason Nurses (PLN) 4-hours of presentation to the ED per the Child and Adolescent Mental Health Services (CAMHS) protocol. 2) A 45 min intervention completed bt the PLN nurse within 7-days of presenting to the ED for DSH. Participants will be given the option to attend the assessment at the hospital or online through teleconferencing. The TA intervention includes: a) Joint construction of a diagram aiming to capture the vicious cycles that maintain DSH. b) Identifying a target problem contributing to the patients DSH. c) Considering and enhancing motivation for change. d) Exploring potential ‘exits’ (i.e., ways of breaking the cycles of DSH identified during the intervention). e) Describing the diagram and the exits in an ‘understanding letter’ which the clinician is required to prepare based on the initial assessment. The understanding letter outlines the primary concerns identified by the young person during the TA intervention. It includes a copy of the diagram including the coping strategies identified during the TA. The understanding letter is a tool that the young person can draw on during their recovery and offers a secondary source of support to the young person. The study will occur over 34-months and will be split into two time periods with a two-month gap at months 11-12 to allow for training of staff at each participating trial site. Period 1 comprises months 1-10. Participants who present to participating trial sites during Period 1 will be enrolled into Group 1 and will receive standard clinical care. Each participant will receive follow-up at 6-months and 12 months. During the training period (months 11-12) staff will be trained in the TA assessment at each participating trial site. During the training period there will be no further recruitment of participants. Young people who present to participating EDs during this time for an index event of DSH will not be eligible to participate in the study. Period 2 comprised months 13-22. Participants who present to participating trial sites during Period 2 will be enrolled into Group 2 and will receive the TA intervention. Each participant will receive follow-up at 6-months and 12 months from their index presentation. Training The training package for TA will be based upon the two-full day routinely delivered training package, delivered in person via face-to-face workshops by a trained clinical psychologist. Training will consist of 5 half-day seminars including theoretical background, viewing clinical videos of TA being delivered, followed by completing two TA interventions directly supervised by PI Pedro with agreeable, eligible but non-participating patients within the final two weeks of the Training and Implementation Phase. Ongoing clinical supervision will allow for continuity of support. Clinical supervision will occur weekly for 1.5 hours for the duration of the trial. Model Fidelity Model fidelity will be based on the procedures used by Ougrin and colleagues for the clinical trial of TA (Ougrin et al., 2011). Initial fidelity will be established during the final two weeks of the training phase. Post-completion of the training package and directly supervised interventions on two occasions, clinicians will complete a further two interventions with agreeable, eligible but non-participating patients during the Training and Implementation phase. Standard clinical delivery of TA requires written transcript of the interview, including co-construction of the model and 'Exits' on a standardised proforma. These written transcripts and the accompanying 'Therapeutic Letter' will be de-identified and submitted for external review against the Therapeutic Assessment quality assurance tool (TAQAT). Fidelity audits will be completed by a combination of an external auditor, a participant and the clinician delivering the intervention. Audit outcomes will be reviewed during clinical supervision. Fidelity will also be supported via weekly clinical supervision sessions. Ongoing fidelity will be monitored throughout the intervention via monthly audits of randomly selected, de-identified transcripts and Therapeutic Letters. Fidelity will also be supported via weekly clinical supervision sessions.