How acceptable is a Culturally adapted Manual Assisted Problem solving (C-MAP) intervention for Self-Harm? Therapist and patient participant perspectives.

Problem

Suicide is a serious global public health problem, ranked amongst the leading causes of death in the world. Each year more than 800,000 people worldwide kill themselves; 75% suicides occur in Low and Middle Income Countries (LMIC). The World Health Organisation (WHO) Mental Health Action Plan 2013-2020 is committed to working towards a global target of a 10% reduction in the suicide rate by 2020. Self-harm (SH) is a risk factor for suicide. Offering appropriate treatment to individuals presenting after SH is considered a key component of suicide prevention strategies. In Pakistan, there are more than 100,000 episodes of self-harm annually. SH and suicide are under-studied due to legal, social and religious implications. A multi-centre Randomised Controlled Trial (RCT) is being conducted in Pakistan, aimed at testing the effectiveness of a psychosocial intervention (Culturally-adapted, Manual-Assisted Problem-solving intervention - the C-MAP Intervention) for patients following an episode of SH. The intervention comprised 6 sessions delivered by wellbeing practitioners.

Approach

Semi-structured interviews with therapists who had delivered, and participants who had completed, the intervention. Topic guides were used to generate data. We explored acceptability of the intervention and changes reported by patient participants since participating in the trial. Interviews with therapists explored acceptability of experiences of delivering the intervention and supervision.

Findings

Interviews with 20 people (9 males, 11 females) who had completed the trial, and 20 therapists who had delivered the intervention.People who had completed the trial reported valuing the problem-solving and distraction techniques, use of the crisis plan and letter writing, describing improvements in motivation, mood and learning to cope. Participants suggested that they were more able to share problems, particularly within their family, and attributed this to the C-MAP intervention.Therapists found the training and supervision useful in supporting them deliver the intervention to trial participants. They described challenges in delivering the intervention including lack of privacy when family members were present, but not seemingly interested, in sessions, which impacted negatively on engagement of patient participants with the intervention.All participants made suggestions of how the intervention could be improved, including the use of more picture content in the patient manual. Therapists suggested that the intervention should be more inclusive of family members in the sessions, whilst some patient participants expressed reluctance to include their family.

Consequences

The C-MAP intervention is acceptable to people who have self-harmed, and to therapists delivering the intervention. The intervention may help people presenting after SH to develop problem-solving skills, and thus may have a role in the prevention of suicide. The RCT will establish the clinical and cost-effectiveness of the C-MAP intervention. The qualitative work will inform modification of the intervention for use in routine care.