A new twist on Problem Solving Therapy can reduce self-harm rates by a spectacular amount.
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Problem Solving Therapy is not exactly new. Developed more than 20 years ago, cognitive behavioural therapists have been using it as part of their approach for years, and its general themes underlie those books, aimed at improving the problem-solving skills of high-level executives, that are sold in airport bookshops around the world. It’s not a therapy that requires years of specialised training, or one that will appeal to the articulate middle-class seeking insight into the self.
Yet it could be a short, cost-effective style of therapy that changes the fortunes of some particularly vulnerable people.
The merits of Problem Solving Therapy have been shown in a large-scale randomised trial, led by Simon Hatcher, associate professor of psychiatry at the University of Auckland, and published last month in the British Journal of Psychiatry. The study involved more than 1000 people, from four district health board areas, who had ended up in hospital because they had tried to kill or deliberately harm themselves. After a year, those who received the therapy (around five sessions of an hour’s duration) reported feeling considerably less hopeless, less depressed and less suicidal than those who didn’t. Those who had a history of self-harm were 40% less likely to do so again within the year.
Hatcher, an academic who works part-time as a liaison psychiatrist for Waitemata Health and whose professional mission is to “reintroduce psychology into medicine”, says most people who end up in hospital after deliberately injuring themselves receive little access to mental health services – after they are discharged they might get one therapy session in three months.
This inadequate level of treatment may reflect historical attitudes. Self-harm describes acts – such as taking an overdose, swallowing poison or deliberately injuring oneself – which, in the past, would have been described as attempted suicide. However, this presumes a motivation that may not exist; people who self-harm don’t always intend to kill themselves. However, people who self-harm and end up in hospital will, at some stage, have wanted to die, and there’s a reasonable chance they will go on to commit suicide.
“At Waitemata, we see maybe 600 to 700 each year who come into hospital with an episode of self-harm,” says Hatcher. “Of those, six or seven will kill themselves the next year.” And of the remainder, another six will kill themselves the following year and so on for several years. They also have a high rate of death resulting from heart and respiratory illness, as well as high incidences of accident-related death. “So, after five years the mortality rate climbs to about 10%. This is a group that first presents at an average age of 30. I can’t think of any other disorder that presents at such an early age that has such a high mortality.”
Therapy usually is about solving problems; Problem Solving Therapy, however, does not aim to solve the problems themselves but to teach problem-solving skills. As Hatcher’s study shows, many people who self-harm say they have lost – or never had – confidence in their ability to solve problems.
“It’s a whole-of-brain approach rather then a wait-and-see approach … part of that is being aware of those cues that indicate you’ve got a problem, recognising that you’ve got a problem, stepping back and learning how to define the problem properly and then brainstorming potential solutions and coming up with sensible action plans.” The therapist tends to start with the easy problems, but one problem solved builds confidence in the ability to solve others.
“If it’s done well, it looks like personal coaching in a mental health context,” he says. “A minor intervention that is straightforward and which can change people’s outlook. It’s about containing immediate distress, understanding the meaning of what’s happened and then getting into the problem solving.”
Hatcher and his team plan a follow-up trial, looking at the impact of the therapy on the original participants over a longer period. They are also conducting larger and more complex trials around the same theme, and hope to develop a model for rolling the therapy out nationwide. Hatcher notes that if they had developed a drug that reduced rates of self-harm by 40% in a year, the drug would have been rushed to market by now. “But because it’s a talk-therapy there’s no equivalent framework for rolling it out. I’m not selling it as the treatment for every-thing, because I don’t think it is, but it’s a way of thinking about things which is very useful.”
SKIN CELLS TO STEM CELLS
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UK scientists have shown it is possible to treat liver disease in mice with a combination of stem cells and genetic correction therapy. The research, published in Nature, took skin cells from a person with a genetic liver disorder, turned them into stem cells and used those to fix the genetic defect in the rodent. Scientists caution that clinical trials showing the treatment can be used safely and effectively in humans may be some years away.
SOFT TOY SAFETY
Sleeping with toys infested with house-dust mites can exacerbate asthma, but researchers at the University of Otago, Wellington, have figured out the three best ways to get rid of them: freezing the toys for at least 16 hours at -15°C, soaking them in an emulsion of eucalyptus oil and liquid detergent for one hour, then rinsing and drying, or putting them in a tumble dryer for one hour.
MALARIA VACCINE
The long-awaited results of the largest-ever malaria vaccine study, involving 15,460 babies and small children across seven African countries, has shown that it could halve the risk of the disease. Around 800,000 deaths are caused by malaria each year, mostly among children under five. The vaccine has been researched for more than two decades by scientists at the UK drug company GlaxoSmithKline, which has promised to sell it at no more than a fraction above cost-price. Chief executive Andrew Witty told the Guardian that when the scientists were shown the data, “quite a number of them broke down in tears”.