Harmless is a user led service that provides support, information, training and consultancy to those who self-harm (or at risk of), their friends and families, carers and professionals. Established in October 2007, Harmless set out to provide a self-harm service which gave service users a sense of hope and empowerment alongside giving them a voice in the development.
Harmless is a user led service that provides help and support to people that that self harm their friends and families. We believe in recovery and work hard to reduce stigma, isolation and distress and promote health, hope and wellbeing. Harmless provides a range of frontline services: two drop ins for young people, and one for adults 18+.
Harmless provides weekly counselling, this service is available to people who self harm and friends/family members and is a well-evidenced successful provision. Harmless provides information services and products to challenge stigma and develop awareness, in the form of leaflets, a DVD, a book, a workbook and an extensive website. We work with the media wherever possible to improve public perception and compassion. Harmless also provide email support services helping hundreds of people UK-wide each month and a comprehensive bespoke training service to develop skills and services in the wider community.
Provided Services.
Information.
Harmless provides a range of information products and services, to include: website, a set of leaflets, DVD-rom, posters, publications, workbook, policy guidance and poetry book and awareness raising sessions.
Training.
A range of formalised and bespoke training packages and workshops are delivered to other professionals and carers to promote awareness, understanding, compassion and effective interventions.
Consultancy.
Harmless will act as a consultancy body to advise other agencies in the production of external publications, products and the media.
Research.
Harmless undertakes research and consultations to develop and enhance current understanding of self harm and psychological distress. We use this information to promote public understanding, and to advocate for increased and appropriate needs led services for people who self harm.
Support.
Harmless provides a range of health and recovery promoting supportive activities for people in psychological distress who do, or are at risk of self harming and/or suicide. These shall include an email support system, drop-in sessions for support, one to one sessions of support, direct access counselling and therapeutic groups.
Harmless have worked with a broad range of partners in the development, design and implementation of the service, reviewed monthly. In the time since commencement, and more recently over the last year wee work closely with:
Public Health (local, regional and national)
Strategic boards, where we represent at TASC, NSPA, SBSP, Support After Suicide, APPG Self Harm and Suicide Prevention, Suicide Prevention Steering Group (Notts, Lincs, Derbys, Leics)
GP’s/primary care
Secondary mental health services
People with lived experience
Carers
Academics
Commissioners
Police
Emergency services
NHS Foundation Trusts
EMAHSN
We have a stakeholder group of professionals and lived experience to whom we consult on a monthly basis, to ensure that the service is representative and remains consistently held in high esteem.
Harmless has two founders who have personal experience of SELF HARM, a third director that used to SELF HARM, a 4th director (& senior member) who are family member/carers of those who have self-harmed. Harmless’ concept was born out of dedication to meaningful involvement of service-user experiences to inform and create change in service provision for SELF HARM.
Harmless has an advisory group consisting of c.29 individuals with experience of SELF HARM (nationally), that consult upon service design and delivery. Advisory group views are secured by undertaking surveys/inviting feedback which is then collated to influence the decision-making process.
Harmless routinely runs consultations with it’s service-users, which has helped us develop the vision/direction of Harmless by informing what stakeholders want/need and how to do this; combined with professional feedback and research to determine Harmless’ direction/services.
Harmless actively encourages the participation of people with personal experience of self harm to be involved in the project.
Harmless has a staff team with 90% user-representation; we assertively and actively recruit for people with lived experience.
As previously detailed, Harmless has undertaken extensive consultation with its advisory group and with it’s members, and on-going surveys with those who access any part of our service. This enables us to develop a better sense of the types of services that people want/need, which would be accessed, and most effective.
In one consultation 84% of respondents wanted to see increased work with schools, 87% an increase in specialist services for young people, and a higher and staggering proportion (94%), greater access to counselling. 96% of service-users state they would be more-likely to access services from Harmless or another user-led service over statutory provision. Combined feedback from schools clearly inform us that schools are left floundering with self harm/distress and need a worker to support and co-ordinate efforts to offer outreach support to young people. Consultation with men shows that they do not want to access traditional healthcare settings for these needs, and that carers are left floundering without help. These are but examples of how consultation yields service change and design.
Provided Services.
Information.
Harmless provides a range of information products and services, to include: a set of leaflets, DVD-rom, posters, publications and awareness raising sessions. All of these items hand the voice of lived experience to the user and place them central to the production of the information, involving them and their experiences at the heart of all materials, uncensored and unmitigated.
Training, teaching and education including e-learning.
A range of formalised and bespoke training packages and workshops are delivered to other professionals and carers to promote awareness, understanding, compassion and effective interventions. We deliver across age groups, venues, services delivering a bespoke learning experience, ensuring that at the heart of our work is user-involvement. All of our training team have lived experience, and share their own experiences throughout deliveries to overcome stigma and to enhance the user production element of our work – we host guest speakers, and use co-produced
Consultancy.
Harmless acts as a consultancy body to advise other agencies in the production of external publications, products and the media.
Research.
Harmless undertakes research and consultations to develop and enhance current understanding of self harm and psychological distress. We use this information to promote public understanding, and to advocate for increased and appropriate needs led services for people who self harm.
Support.
Harmless provide a range of health and recovery promoting supportive activities for people in psychological distress who do, or are at risk of self harming and/or suicide. These include an email support system, drop-in sessions for support, one to one sessions of support, direct access counselling and therapeutic groups. We also provide crisis cafes at a range of rotating venues, and ad-hoc support clinics in any community location.
We provide a tiered approach to the help that we provide that falls into
three categories:
-early intervention and prevention
-intervention
-postvention
And we believe that all three aspects of this work is vital in changing the face of provision for people that self harm, ensuring that our work considers, at all aspects of it’s work, how we can provide a high standard
of effective intervention, broad reach, is user-led but also how our work consistently feeds into change at a bigger level, e.g. by training broad audiences, by influencing stigma, or feeding into research and strategy
changes to uphold improved care
Since our launch in 2007, we have had direct clinical contact with 1000’s of individuals, and estimate a support reach of over 25,000 individuals in distress.
Within our clinical and support services, we deliver a range of activities,
to include:
o Short term therapeutic help
o Long term therapeutic help
o Project worker support (to promote self-help and overcome practical life difficulties e.g. finance, housing, employment)
o Group work, where appropriate
o Primary care crisis service (short term intervention for people with elevated levels of risk)
o Suicide bereavement service
From a training perspective, we have reached over 3,750 delegates individuals from over 100 services across the UK; we deliver a broad range of courses, including MHFA, ASIST and Self harm.
The support we give the delegates enables them to support others with an estimated reach of 75,000 people in distress in the last 3 and a half years.
The most notable distinction re: Harmless and its organisational approach is that we are the only specialist self harm service-user led provider in the UK, that provides the broad range of services within one organisation and that works across age, ethnicity and gender to yield change.
We have faced a large number of challenges over the years. Given what we do, and the life-saving nature of our work, we were perhaps naïve in the delivery of our work. We assumed that people would care a great deal about what we had to say. What we have learned over the years that we wish that we knew before, is that we are as stigmatised as a service, as our clients are in their own lives. This means that we have had to develop creative, innovative and self-sustaining ways of ensuring that ten years on (and October, 2017 is our tenth anniversary) our service is still in operation, growing and strong. We have had to head stigma head on and find new ways of challenging this. We have had to clearly define who we are, what we do, how we do it and be firm and clear about our boundaries.
We are often perceived as:
–clinically substandard – we have trained our team to a higher national delivery standard than our NHS counterparts, in order that we can be viewed as clinically robust; developing safeguarding and clinical protocol that is clear, coherent and respected as a high standard in clinical governance. We have voluntary invited and often paid for external assessment to evidence this standard and robustness and trail blaze for co-produced services.
–We are not peer support.
We are a service that delivers a range of clinically relevant, user led, co-produced services that are stigma challenging and whilst we deliver lived experience within every aspect of our service delivery we deliver them from a professional, skilled, qualified and experienced position. This is NOT to say that peer support isn’t a highly relevant aspect of service delivery, however, it is not what we deliver but because of our co-production it is often an assumption made of us that we have to consistently challenge to ensure that we are met in professional circles as any other professional may be. This is a vital aspect of our work; challenging stigma and misconceptions in every walk of life.
–We have to self-sustain.
Naively, ten years ago we hoped that commissioned services for self harm would be in place by now. In learning that this is not [even yet] going to be the case, we have needed to develop a sustainability strategy. We are a community enterprise. In our ten years of operation we have reviewed the need for our work, an developed commissionable, relevant products and services that we can retail. All of the products and services that we sell within our business model ensure that we preserve free access to support for those at need. For instance, we sell training – training achieves our social aim of improving awareness, skill and ability to help those that self harm, whilst generating an income that is then spent directly upon those that cannot and will not access support via existing services. This business model ensures that we are self-reliant on funding and for the last few years have been approximately 75% self sustained either through contracted or commissioned/sold services and products. All of our support services remain free to access. This is both an immense challenge, and also an excellent model that has enabled the service to grow and thrive in times of great community funding crises.
As above, we have needed to develop a sustainability strategy. We are a community enterprise. In our ten years of operation we have reviewed the need for our work, an developed commissionable, relevant products and services that we can retail. All of the products and services that we sell within our business model ensure that we preserve free access to support for those at need. For instance, we sell training – training achieves our social aim of improving awareness, skill and ability to help those that self harm, whilst generating an income that is then spent directly upon those that cannot and will not access support via existing services. This business model ensures that we are self-reliant on funding and for the last few years have been approximately 75% self sustained either through contracted or commissioned/sold services and products. All of our support services remain free to access. This is both an immense challenge, and also an excellent model that has enabled the service to grow and thrive in times of great community funding crises.
We have invested to grow, through our own profit, developing a training team, out-sourced counselling and a range of other services that then mean that we have a steady stream of income that can supplement all support activity.
Harmless is a CIC. The ethos of sustainability & value is built into legal structure, aims & objectives. We believe in delivering frontline services, but also in improving the mental health sector in a cost effective way with greatest impact.
Social
There is a large social impact incurred by mental health difficulties amongst children and young people.
For children and young people that experience mental health we will improve their social well-being by:
– Decreasing stigma associated with their difficulties, this will in turn
– Decrease social isolation experienced by children and young people with mental health problems (Social isolation is a particular risk factor for suicide, so this could have direct impact upon suicide rate in locality).
Mental health problems & suicide has a renowned ripple effect upon families & communities (leading to increased suicide risk 80-300%) and stigma has a direct correlate to significant risk factors, including social withdrawal and the withholding of help-seeking.
Economic impact
The economic cost of self harm, mental health issues & suicide is great; with a c. £105bn billion (2009/2010) social/economic cost.
Prevention & early intervention services), have ability to build capacity & influence costs.
Some of our sustainability, business case approaches:
When we commenced service delivery we worked closely with NHS partners and the Institute of Mental Health, and our service users, to develop outcomes and measures of those outcomes that would be academically robust and appeal to commissioners and academics but also be accessible for our client group. As such, we developed a tool that amongst other things has enabled us to measure the following:
Outcome: Improvement in Self Harm
Indicators: Level of the rate of self harm; Level of the severity of self harm
Outcome: Improvement in Psychological Wellbeing
Indicators: Level of Satisfaction in Daily Activities; Level of Satisfaction in Relationships
Outcomes: Improvement in Aspirations for the Future
Indicators: Level of Hopefulness in the Future; Level of Suicidal Thinking
Outcomes: Reduction in the Risk of Completed Suicide
Indicators: Level of Suicidal Planning; Level of Suicidal Thinking
The above indicators are measured along a ten point scale and collated every fortnight across the life span that we see individuals. We also collate the same 0-10 point scores of level of satisfaction in service provision and how listened to the clients felt in accessing our service. These are vital questions for us to ask to ensure that user-led remains a focus of all of our work, with empowerment a focus in everything that we do.
In addition and within the last two years, we have also introduced further measures of recovery that speak to a broader NHS audience to evidence our work further. With the collaboration and commitment of our service users, we have introduced the:
. BDI-21
. PHQ-9
. GAD-7
. Service evaluation
. Risk management plan (with UPPS measure)
. Traumatic Grief Inventory (bereavement only)
. Inventory of Statements About Self-Injury – ISAS (crisis only)
Clinical assessment
Harm others/ self
PTSD
Head Injury
Psychosis
Physical Health
Sleeping patterns
Eating patterns
Caffeine intake
Smoking habit
Alcohol use
Substance misuse
Financial difficulties
Add-ons
Child safeguarding
Sexual exploitation risk assessment tool SERAT
CAMS Suicide Status Form-SSF IV
Padesky 5 aspects
The Adult Autism Spectrum Quotient (AQ) ages 16+
The Adolescent Autism Spectrum Quotient (AQ) ages 12-15
Cambridge University Behaviour and Personality Questionnaire For Children –
ages 4+
Across our clinical assessments, monitored frequently to ensure that we are reviewing steps towards recovery.
We have applied academic rigour to evidencing our recovery work with clients and as such are able to demonstrate the below methodology and confidence in the tools that we use:
Upon visiting Harmless Nottingham, clients are requested to complete the Harmless Service Evaluation Form upon completion of their support session. The current paper set out to determine the test-retest reliability of the Harmless Service Evaluation form. Establishing the test-retest reliability of the various measures is vital if future research using the Harmless Service Evaluation is to hold any weight.
2.1.Participants.
An opportunistic sample of 43 clients of the Harmless service were used in this analysis. The sample’s age ranged from 14 to 54 years (M=_, S.D=_). 37 of the sample were females, and 6 males. All participants gave informed consent for their evaluation scores to be used as part of future research.
2.2 Apparatus and Materials.
Participants completed the Harmless Service Evaluation Form which contains, in its current format, 11 questions: 1) “How often have you self-harmed in the last fortnight?”; 2) “How severe has your level of self-harm been in the last fortnight?”; 3) “To what extent have you been troubled by suicidal thoughts in the last fortnight?”; 4) “To what extent have you engaged in suicidal planning in the last fortnight?”; 5) “To what extent have you felt able to tolerate your distress in the last fortnight?”; 6) “To what extent have you felt able to tolerate your thoughts in the last fortnight?”; 7) “How positive have you felt about your relationships in the last fortnight?”; 8) “How positive have you felt about your daily activities (e.g. school or work) in the last fortnight?”; 9) :How positive have you felt about the future in the past fortnight?”; 10) “To what extent do you feel as though you have been listened to in you support session today?”; 11) “To what extent do you feel that you have been helped to think about moving forwards in your support session today?”. Clients give responses on the form by making a cross along a 10cm line, with “not at all” at one end and “very often” at the other for question 1, “not at all” and “very severe” for question 2, “not at all” and “a lot” for questions 3-6, “not at all positive” and “very positive” for questions 7-9, and “not at all” and “a great deal” for questions 10 and 11. In order to turn this marking into a quantitative figure, the length along the line where the cross has been marked (in cm) is measured using a ruler, and is used as a score. For example, if a client were to mark a cross 6cm along the line from the “not at all” end, this would constitute a score of 6 for that question.
Data was collated using Microsoft Excel, and correlation analyses were conducted using SPSS Statistics version 22.0.
2.3 Procedure
Participants completed one evaluation form upon coming into the Harmless offices, before their support session commenced. The second was completed following completion of the support session.
2.4 Design and analysis.
A repeated measures design was used, with participants completing two evaluations. Correlation analyses were conducted using a 2-tailed Pearson’s r correlation.
Scores for most questions correlated highly and significantly between the two evaluations: question 1) “How often have you self-harmed in the last fortnight?” (r=.958 , p<.001 ), question 2) “How severe has your level of self-harm been in the last fortnight?” (r=.406 , p<.01), question 3) “To what extent have you been troubled by suicidal thoughts in the last fortnight?” (r=.958 , p<.001), question 4) “To what extent have you engaged in suicidal planning in the last fortnight?” (r=.899 , p<.001), question 5) “To what extent have you felt able to tolerate your distress in the last fortnight?” (r=.861 , p<.001), question 6) “To what extent have you felt able to tolerate your thoughts in the last fortnight?” (r=.814 , p<.001), question 7) “How positive have you felt about your relationships in the last fortnight?” (r=.959 , p<.001), question 8) “How positive have you felt about your daily activities (e.g. school or work) in the last fortnight?” (r=.919 , p<.001), question 9) “How positive have you felt about the future in the past fortnight?” (r=.909 , p<.001), question 10) “To what extent do you feel as though you have been listened to in you support session today?” (r=.109 , p=.629), question 11) “To what extent do you feel that you have been helped to think about moving forwards in your support session today?” (r=.190 , p=.409).
This gives us the faith that we can make confident assertions about our recovery rates based upon the tools that we have used to collect them.
Harmless consistently evaluate our project. We follow a monthly stepped process of review for all service types, involving service users and stakeholders in the process, as below, identifying evolution that needs to take place to ensure that clients needs are well met and their recovery is upheld.
We have received many recognition awards,
Awards:
Investors in People Award: 2016
We have also been involved in a broad number of academic papers as patient participation and involvement lead, references:
Some of which evidence peer review of our work:
Results of our work:
We break each piece of work down by funder, or can isolate beneficiary type, demographic, postcode, gender in order for us to report on, for instance enabling us to report back (below, is a summary of a 1 year piece of therapeutic work with young people)
Total number of unique beneficiaries to date
People benefiting directly 120
Frontline workers benefiting 111
Other people benefiting 79
Outcome: Improvement in Self Harm
Indicators: Level of the rate of self harm; Level of the severity of self
harm
CR: 104
Outcome: Improvement in Psychological Wellbeing
Indicators: Level of Satisfaction in Daily Activities; Level of Satisfaction
in Relationships
CR: 117
Outcomes: Improvement in Aspirations for the Future
Indicators: Level of Hopefulness in the Future; Level of Suicidal Thinking
CR: 56
Outcomes: Reduction in the Risk of Completed Suicide
Indicators: Level of Suicidal Planning; Level of Suicidal Thinking
We also collate testimonies when people leave, hich feeds into our qualitative evaluation. Below is examples of evaluation of our work.
I started struggling with suicidal thoughts and SH after my parents had a very messy split and I was living in a home that seemed broken. I lived with my Dad who was struggling too and my brother. I was self harming as a way of people noticing I couldn’t take much more and I wanted some sort of release.
I struggled with this for four years.
I decided to go to the doctors who referred me to primary care, who I followed forward to Harmless. When I was referred my counsellor was fantastic and throughout my time in harmless, I felt listened to. I was given multiple ways to control my self harm and how to notice that day by day things would get better.
Without Harmless I wouldn’t be the way I am now. They offered me fantastic support. Since I have been at Harmless my self harm has decreased dramatically, and I can now say that I haven’t self harmed in two months. I don’t think about dying now. I have improved on how I respond to my thoughts and alternative ways of seeing hard times in my life. Harmless has given me support and self-belief to stop. My recovery has been more successful than I would have ever imagined four years ago. I couldn’t have asked for any better support than what I have received in my time with Harmless.
(Female – Aged 19)
Again, we can review a one year piece of work in under 18’s:
Outcome: Improvement in Self Harm
Indicators: Level of the rate of self harm; Level of the severity of self
harm: 63
Outcome: Improvement in Psychological Wellbeing
Indicators: Level of Satisfaction in Daily Activities; Level of Satisfaction
in Relationships: 62
Outcomes: Improvement in Aspirations for the Future
Indicators: Level of Hopefulness in the Future; Level of Suicidal Thinking: 61
Outcomes: Reduction in the Risk of Completed Suicide
Indicators: Level of Suicidal Planning; Level of Suicidal Thinking
‘I started coming to Harmless after my parents had a very mess split and I was living in a home that seemed broken. I lived with my Dad who was struggling too and my brother. I was self harming as a way of people
noticing I couldn’t take much more and I wanted some sort of release. When I was referred my counsellor was fantastic and throughout my time here, I felt listened to. I was given multiple ways to control my self harm and how to notice that day by day things would get better. Without Harmless I wouldn’t be the way I am now. They offered me fantastic support. ‘
(Young Person Aged, 16)
‘I first started self harming two years ago, after one year I decided to go to the doctors who referred me to CAMHS, who I followed forward to Harmless.
Since I have been at Harmless my self harm has decreased dramatically, and I can now say that I haven’t self harmed in two months. Harmless has given me support and self-belief to stop. They introduced me to multiple ways of how to distract myself and taught me better things to do instead of cutting, etc. My recovery has been more successful than I would have ever imagined two years ago from today. I have improved on how I respond to my thoughts and alternative ways of seeing hard times in my life. I couldn’t have asked for any better support than what I have received in my time with Harmless. ‘
(Young Person Aged, 15)
For instance, we able to clearly demonstrate the rate of reduction in self harm over time for our service users…
Figure 1. Mean and median scores for rate of self-harm over time.
And break this down by gender, to see whether there are any specific needs split by gender, see below.
Figure 2. Mean Rate of Self-Harm by gender (time 1)
Figure 3. Mean Rate of Self-Harm by gender (time 2: 100 days)
We have undertaken external evaluation by the Institute of Mental Health, full document available upon request, but demonstrating:
Summary
Overall improvement was evidenced across all of the scales included in the evaluation except for suicidality. Frequency and severity, particularly, showed marked improvement, with improvements of 3 and 2.5 scale points on average achieved over a 100 day period. Satisfaction with daily life also showed a moderately large move, with a 1.5 point improvement in this scale over a 100 day period. Relationships and optimism also showed statistically significant shifts, of 1 point/ 100 days and 0.7 points/ 100 days respectively. There were no significant differences in these effects between individuals of different genders, ethnicities, and ages, although for some scales there was some evidence of this (the difference not reaching statistical significance).
The lack of a control group makes it impossible to unambiguously attribute improvement to the help offered. The data overall do suggest that it is unlikely that the effects reported here are due to changes unrelated to the intervention, such as spontaneous improvement or “faking good” (where individuals feel compelled to make increasingly positive returns on questionnaire measures). There is a fairly consistent pattern within the data of scales which were specifically targeted (i.e. frequency and severity of self harm) to show large shifts, related but untargeted scales (such as relationships) to show smaller changes, and scales which might be expected to be unaffected by the intervention (i.e. suicidality) showing no change. Although this pattern could have emerged by chance if the change in responses was not due to the intervention, this is unlikely.
User satisfaction with being listened to and being helped was high, with most responses in each case being 7/10 or above. A pattern was apparent which suggested that older and younger service users might be slightly less satisfied than those in the 20-40 years range, however this pattern was not statistically significant and would need to be confirmed, were it to exist, using more data.
In essence, and since that time, we can demonstrate an 86% rate of recovery over a 100 day time span, as measured by statistically significant reduction in rate and severity of self harm.
We also have a 0.1% re-referral rate to our service, which we hope is indicative of lasting recovery amongst our clients.
Harmless’ service shares it’s work, presents locally, regionally and nationally.
Our service approach is that we are not precious. We share our successes and our failings with openness in an ethos of change so that we are enhancing the field of self harm and suicide prevention work in a way that saves lives, whether by us or others. The success of our service, is in us no longer being needed!
