When self-harm keeps happening

Respond to what is happening today. A previous episode or assessment cannot tell you whether they need medical help now.

Try to avoid responding as though they have broken an agreement with you. A return to self-harm does not erase the times they managed differently. Demanding a promise that it will never happen again can make the next conversation harder.

Once immediate needs have been dealt with, look at where the previous arrangement failed. Was there someone to call? Did they know how to reach the team? Was the suggested way of coping something they could use at that moment? Take that specific problem to the next appointment.

Agree when you will be in touch and what that contact is for. A planned call can be time to talk, company during a difficult evening or help contacting a service. It does not need to become a daily account of whether they have self-harmed.

Do not make photos of injuries, body checks or access to their phone the price of your support. Medical staff can assess an injury when treatment is needed.

Discuss unanswered messages in advance: whether to try a call, who else may be contacted and what would make you seek urgent help. An unanswered message alone does not tell you what has happened; respond to the circumstances and any specific warning signs.

Keep invitations and conversations that have nothing to do with self-harm. They should not have to report improvement to remain part of your life.^[2]

A plan is useful only if the person can find and use it when distressed. If there is already one, work from it with them and their team rather than creating a competing set of rules.

• Check the contact details. Does the number work outside office hours? What happens if nobody answers?
• Make each person's role clear. A name on a plan is not confirmation that they have agreed to be available.
• Check the practical barriers. If speaking is difficult, could they use an agreed phrase or message to ask for help?
• Keep an accessible copy. Agree where it will be and who can see it.

Ask the care team to help agree any changes to access to potentially harmful items. Avoid secret searches as a routine response. In immediate danger, use emergency help and follow professional instructions.

The crisis-plan tool can help record an agreement. It cannot assess safety or replace professional care.^[3]

For frequent self-harm or ineffective treatment, NICE recommends a review involving the person and the professionals supporting them, with a named coordinator and a joint plan.

Ask the current team for a review. If there is no team, contact the GP. Describe what keeps happening and which part of the response is missing: for example, repeated hospital visits with no follow-up, or a plan that relies on you staying awake.

Include what the person says is unhelpful, if they want you to. If they do not want you at the appointment, offer written observations instead.

If an assessment or follow-up is missing, there are specific questions and contacts to try.^[4]

Be honest about your availability. If the plan depends on you answering every call or staying with them overnight, tell the care team exactly when that is not possible. Ask for the plan to be reviewed before treating your availability as settled.

If they say they will hurt themselves when you say no, see how to respond and get help without promising constant availability.

You can pass concerns to their GP or team even if they do not consent to you being involved. The service may not be able to discuss their care with you. Explain any concern about them learning who provided the information; do not assume your message will remain secret.

What to do when nobody can take over explains how to describe the gap and follow up. If they may act on suicidal thoughts now, use the urgent route and say if you cannot stay or are not safe with them.^[5]

Support can include making an appointment possible, staying in touch or helping them use an approach already agreed with their therapist. Ask about the part that is difficult to put into practice, rather than adding another list of things they should try.

The NHS has ideas for getting through an urge to self-harm. These may help in the moment; they do not deal with every underlying problem or replace treatment. Do not turn an activity into a demand to prove they can stop.

Discuss progress on their terms. They may want to talk about asking for help earlier or explaining something to a professional, rather than counting days. If things are becoming more dangerous, seek a review regardless of any progress elsewhere.

Your own sleep, fear and ability to work also matter. Support when you are exhausted and groups for people supporting someone who self-harms can help you find the next step.^[6]