Insights from Intervention Research in Self-Harm and Career Advice from Peter Taylor

What are your main research interests?

My main research interest at the moment is self-harm and to a slightly lesser extent, suicide prevention, but I tend to focus on self-harm more broadly. So that includes a mix of things. More recently, I’m doing more work around developing and evaluating therapies and interventions for self-harm, but I’ve also done a fair bit of more mechanistic work and looking at risk factors and correlates as well. I’ve done some work that’s focused more specifically on nonsuicidal self-harm, and I’ve done some stuff that’s more broadly in self-harm as a broader concept as well. I am terrible at maintaining any sort of a good research focus, and so, I do end up picking up other odds and ends along the way as well. For example, in the past, I have done some bits of work around psychosis and stuff. So, I have dabbled with other areas of research.

What led you to an interest in self-harm and suicide as a topic area?

It’s a good question. So, the first time I got involved researching this area, it was for the MRes that I completed a little while ago. It was more focused on suicide specifically. Focusing on my interest in self-harm, I guess it’s for a few different reasons. I think it’s quite different to a lot of psychological problems in that it’s a behaviour and it’s a functional thing. So, you know, if you know someone’s depressed, generally speaking, people don’t want to be depressed and they want their depression to go, whereas I think the thing about self-harm is there’s a lot more complexity and ambivalence because, you know, often it serves a purpose in someone’s life. And whilst I think people often have mixed feelings about it and often feel that their self-harm in whatever form that takes, creates a lot of challenges or difficulties for them; I think it also kind of helps in various ways or it’s something that has maybe helped them through some very dark times in some ways. So, it’s interesting I think, from that perspective that it isn’t like a clear cut, ‘this is a problem in my life, I want rid of it’. It’s quite a complex functional thing to look at.

Can you describe your career path so far?

Yeah. So, it’s not very exciting, I should say. I did my undergrad at University of Manchester, and then I went on to do an MRes, which is a research Masters. So, I did that sort of immediately after my undergrad. I guess because I was getting more interested in research, but also not entirely sure what I wanted to do at that point, so why not? So, did an MRes. During that I got more into research and was doing a project supervised by Trish Gooding and Nick Tarrier.

Then I applied to do a PhD which I was able to get onto. So that was a university funded one in the end that was focused on suicide, looking at concepts like defeat and entrapment, though it didn’t quite start out that way. It was going to be more about cognitive processes and phenomena linked to suicide risk, but it shifted slightly more to the concepts of defeat and entrapment. So, I did that PhD for three years and then I was sort of unsure where to go really, and I was interested in clinical practice, and I was interested in doing more research. I applied for the ClinPsyD, and I’ve got a little bit of clinical experience that I picked up here and there. So, I think I was quite lucky to get on the ClinPsyD at Manchester. So far this is all at Manchester, which is why it’s very dull. So, what’s that? That’s like 10 years of studying at Manchester, which you should get like a free T-shirt or something.

I did the ClinPsyD at Manchester, qualified from that, and I took up a move away. During my ClinPsyD research, I did some more stuff around adolescent mental health and explored some other options. The first job I got after was actually a lectureship at Liverpool on their ClinPsyD programme, which I quite liked because I could use my knowledge of the ClinPsyD and it was nice to be involved in the training element, and it was a chance to back involved in research and stuff. So, I worked at University of Liverpool for I think three years, and that was great. It’s a really nice university to work at, and a nice department, but the commute was awful because I was still living in Manchester. So, I think after three years I kind of had enough of that. Luckily, a position came up back at Manchester and I thought that’s handy because that’s where I live. So yeah, applied for that. About six years ago, I got that, and I’ve been here since really. Since that time, my research focus probably shifted a little. I’ve moved on to doing more intervention focused work, and I’m involved in a number of clinical trials at the moment. I’ve started doing more stuff like that. That’s kind of it, in a nutshell anyway, sort of career path. It’s not that exciting. I’ve mostly just stayed in the same place except a slight detour to Liverpool essentially.

What have you been finding so far in your intervention research?

Yeah. I guess it’s worth saying, it’s all kind of early stages, really. At the moment there’s a few different things going on, so I’ll sort of talk about them chronologically. When I was at Liverpool, there was a group set up which was a collaboration between the local NHS trust and the universities looking at projects and as part of that, there was some interest in the trust for piloting a brief psychotherapy for people turning up at A&E having self-harmed, which was interesting. So, I got involved in that, did a lot of pilot evaluations of some existing data using a therapy that draws on cognitive analytic therapy (CAT), but it kind of combines it with aspects of psychodynamic interpersonal therapy. So, it’s a little bit of a mash up of a few ideas. It was developed by Clive Turpin, who’s a therapist in in the Northwest. He’s a great guy to work with.

So that’s why I got involved in Liverpool with that and then we wanted to expand and evaluate that further. So I was moving back to Manchester, but a colleague Pooja who’s based at Liverpool John Moores University, led on that project, trialing this brief therapy, and it has just finished. It’s like four sessions of Psychotherapy essentially and with the trial, we shifted the focus slightly because something I’ve been interested in is around the potential for brief therapies to fill gaps in existing services. So, we’re interested in the idea of this therapy maybe in a GP setting. At the moment people think you had to go into A&E and then I think the therapy rooms were in A&E, so there’s a issues on how accessible that was for people. I don’t think it was good for people who didn’t need to go to A&E, you know, so I was thinking about other ways they could access that- so that’s the COPESS trial.

I had some really positive data from that, but that was very much the first step of evaluating this therapy. So this was a feasibility trial. Typically, running a big definitive trial to say whether a therapy actually works or not is expensive and difficult, and they need to be very large . What people do first is this feasibility step to run the trial on a smaller scale to say is it possible to actually do this, we can get the data we need, and people actually show up to therapy and all that kind of stuff. So, it’s kind of at that level. That’s just wrapped up. The next step with that will be to apply for some more funding to do the definitive trial, which is what we’re working on at the moment. That’s being led by Pooja at Liverpool John Moores. But I’ve been involved in that. So that’s one piece of work. I think a lot of the stuff I’m doing around self-harm therapies has focused a little bit more on shorter interventions.

I think for me one big issue is access to therapies for people who self-harm, and there’s a few different interrelated issues around that. Obviously, there’s the stigma that comes with it and people have often had quite negative experiences at times sometimes with clinicians in the past, and so there’s a lot of potential barriers to seeking help in the first place. But I think when you do go, there’s issues around accessibility of interventions. I think sometimes your too risky for some things, but not risky enough for other things; and I think where people do warrant (or are offered) support it is from longer-term therapies. These can be helpful; I mean we know from more recent meta-analyses, there was a Cochrane review by Keith Hawton’s team, which suggests that, there is some efficacy to these therapies, things like CBT and so on, and potentially DBT as well for adolescents. It’s just I think there is just a big waiting list often and people are waiting a very long time and I think briefer therapies have potential in fulfilling some of those gaps, or maybe where people don’t need longer term support, it could be quite helpful.

So, we did COPESS, but I’ve been involved in a few other things. We’ve got a trial at the moment with just midway through, which is looking at CAT, so eight sessions of cognitive analytic therapy, and it’s a more relational therapy which again I’m interested in as an approach for self-harm. So, we’re doing that at the moment, but again it’s a feasibility trial so from that we are not really able to say: ‘Does CAT work or not?’, but what we’re hoping to do is get that first step on the ladder, really to get into that point and just establish the feasibility of this work.

Another trial which I’m co-lead on is MISST, which is looking at an imagery-based therapy for suicide prevention in students. There is a growing concern about suicide risk in higher education in university students. MISST builds on the therapeutic technique, Nick Tarrier at Manchester developed a while back, more in the context of PTSD work, but it’s around using positive imagery and imagery to pre-sort past positive experiences and memories as a way to challenge unhelpful cognitions that often surround suicidal thinking, and break someone free of that slightly. So that’s a therapeutic approach called broad minded affective coping. We’re just wrapping up that trial now so we’re just starting to look at the data and stuff. But again, that’s a feasibility trial. So, we’re limited to what we can say about impact.

But certainly, in terms of feasibility I should say, across the board, across those three trials, all the data so far in terms of feasibility is looking really strong. I think they’re all very positive in terms of going for larger definitive trials, but I think that’s a really difficult step to make in terms of convincing funders and so on to get to that point. In terms of like things I’ve learned from them so far about suicide and self-harm, well, there are some observations that I have made. One thing that’s come across actually quite strongly, I don’t know if it’s a surprise, but it stood out certainly like the MISST data and actually also in our RelATe trial to some extent but a big chunk of participants are from the LGBTIQA+ community. I’ve been involved in bits of work in that area as well, and we’ve done some studies looking at self-harm in bisexual people, for example, and risk around that. We’re not actively trying to recruit a specific subgroup, but it just comes through really strongly in terms of the type of people we’re seeing coming through the door. I think it just highlights how this is a group of people who just face a lot of challenges from, you know, how the world is treating them at the moment, and I think that is reflected in what we’re seeing around self-harm and so on. So I think, although obviously I was aware of that, the fact that we weren’t even really looking for it in some of these trials and yet it still comes through in the data that this is a really large demographic, a larger demographic chunk of the sample than you might anticipate.

It remains to be seen how effective these approaches are, but I guess certainly anecdotally and from some of the qualitative data that’s come out, it does highlight to me how even short-term approaches can be really powerful and have a big impact for people. I think there can understandably, sometimes be a slight anxiety about shorter term therapy, but actually I think it can make a big change to people’s lives and I think obviously it has to be built into the therapy, how you manage the ending of that work. But actually, certainly from some of the qualitative data we’ve seen, I think it’s been really well received.

There’s a lot of a debate around cessation versus harm reduction, especially in addiction spaces. For self-harm, do you think cessation or harm reduction are more of a goal for interventions?

Ah, that’s really good question. Definitely a really important issue. I was going to say harm reduction but even then, I think that’s quite a medical terminology and its questionable who’s judging the harm in that situation. This is going to sound really like wishy washy, sort of psychological stuff, but I think ideally you want to work towards some sort of recovery that is meaningful for that person. And I don’t think that necessarily is that person stop self-harming, although it might be for some people. I’ve done some work on this actually. A trainee clinical psychologist, Emily, that I’ve supervised, did a review looking at experiences of or perceptions of recovery from self-harm and how people define that. And yeah, I mean I guess it’s maybe not a kind of an earth shatteringly novel finding, but, actually for some people obviously ending self-harm is what they want, but not for everyone. And you know, you’ll get people who say that there’s always the possibility they might self-harm. It’s not about cessation for them. It’s about, having more autonomy in their life or at least feeling more in control over their self-harm or feeling better in themselves. And so, you know, I think often it’s broader than that.

I know Penelope Hasking in Australia has done some good work on this. She did a paper looking at that idea of recovery from self-injury more specifically. But thinking about how we need to take this kind of broader perspective on it, which I think is really important, I think there’s some problems being too hung up on cessation. I think it makes sense that, as a clinician, you’re worried about that because there’s obviously risk attached to self-harm, and you ultimately don’t want people hurting themselves and you don’t want that to escalate. And so, it’s understandably a focus, but I think the dangers are where you have someone where the self-harm from their perspective is the thing that’s keeping them going. You can end up in, a kind of a tension or a conflict there between the goals of what people want from the therapy. And I think that’s ultimately probably going to hinder the success of it. So having agreed goals of where you want to get to be is really important and  think there needs to be care around that. And I think maybe cessation isn’t always the outcome. I’ve got a colleague, Cameron, who we’ve worked quite a bit together and he’s involved in the trial I mentioned the trial looking at CAT. He’s got a lot of his own lived experience of self-harm and I think he’s always held that view and felt that sometimes trying not to self-harm is almost more, you know, from his experiences, it’s been almost more harmful because then the self-harm will just come back, but in a more severe form than it might have. So that’s a very long-winded way of saying I think cessation can be important but only where it’s important for the person, and obviously we need to be mindful of risk. Ideally we go with more what that person wants from the therapy, and that doesn’t really work at all for a trial because how do you define that? I think understandably, the trials are often focused on nice concrete outcomes, but then it’s tricky.

At the moment, there’s not really any good, validated recovery scale for self-harm – at least not that I’m aware of, so someone should do that at some point. It makes sense to look at things like self-harm behaviour and urges and so on as outcomes in a trial. But I think, yeah, it’s also thinking about what those other outcomes might be.

Would you have any recommendations for any ECR’s wanting to embark on intervention studies in this area?

Yeah, I think they’re really tricky. That’s not recommendation, is it. I think it’s hard because, I’m trying to think of this in a way that doesn’t sound like I’m putting down the process, because obviously, we need approval processes; but the number of steps you have to go through around ethics and so on has exponentially grown. Since I’ve been doing this work and certainly when you’re doing an intervention-based study, I think one of the issues is that there isn’t really a separate pathway for, a small-scale case series versus a big definitive trial. It’s all the same route.

I suppose maybe that’s the advice is just to be ready for that, because there is a lot in terms of the bureaucracy around it being ready, and for just the extra time needed to get approvals. You know you need to go through the whole pre-register your protocol which makes absolute sense. But even if you’re doing something quite small you know like a case series of five people, there’s going to be a similar bar. So, I guess that’s one thing to hold in mind. I think it’s very rewarding as there’s a really clear focus and outcome to that kind of work, and I think it’s nice to be working in the context of trying to establish treatments and find out what works and what helps and so on.

I think it depends a bit on your position, but I think having a kind of team around you and having good clinical collaborators is essential for that kind of stuff. For people like earlier career researchers, I guess depends about your own background and whether you’re in a position to be offering the therapy or whether you’re working with others to do that, or maybe some kind of online intervention or whatever. But I think either way you want to make sure there’s good clinical oversight. You’re obviously working with self-harm risks and all the rest of it. So, I think having good collaborators, but certainly having clinicians involved and on board is really important.

I suppose it’s relevant for any trial, but certainly in this area I think really good communication within the team as well, because again, just for dealing with anything to do with risk, you don’t want to be holding making that decision in isolation. So, by having a really good team and having clear lines of communication, so you can always discuss stuff with the urgency as needed when things come up so that you’re not carrying things by yourself.

So, I think that’s all really important. This is kind of the obvious one, but involving people who self-harm in the study obviously is really important. It’s so easy to get caught up with a particular idea, but actually, you have that conversation and a whole new set of perspectives can be thrown your way, and that can be really important to rethink what you’re doing. Certainly, I’ve found that really useful with all the research we’ve been doing. So, I think having that from the start is, yeah, it’s invaluable For early career researchers just thinking about how you cost or fund or support that, and that can sometimes be one of the tricky things because there’s not always lots of money bouncing around.

In terms of getting people who have lived experience from self-harm involved in research, what are your recommendations on that?

I think it’s good to formalise it, I mean essentially you want that involvement not to be tokenistic. You want people to actually be able to have as much of an input on how the study goes as possible. I think what’s tricky sometimes, and I’m guilty of this, is that you have an idea, you run with it, and you get so far, and then if you don’t get that input soon enough, it limits what that person can offer you because you’ve already shaped it up to some extent. I think sometimes that can be the issue, is that the input comes in too late. So, bringing it in early is important. I think formalising it helps around funding, because you want to reimburse people for their time as much as you can really. And like I said, getting hold of funding can sometimes be challenging so I think it’s good to have it formalised and costed. There’s lots of people who are really keen to get involved and help out with research. So, there’s lots of ways you can advertise around local trusts and services. There are so also groups like McPin who do really good work, I know in in the past McPin have helped us in identifying people who’d be interested in getting involved in an advisory group. It’s also how you set it up to support people to have those conversations. If you’ve got like one person, and you bring them along to like a big meeting full of the rest of the research team and they don’t really know anyone you put them in quite a disempowered position. It’s hard to kind of get your point across, so that’s the other thing, just thinking about how you maximise the potential for them to say what they want to say essentially.

Another thing just to keep in mind is you know, for many people, this won’t be an issue, but it is potentially a difficult topic. Have quite an open conversation with the person you’re working with around that from the start, just to check how that feels and if it’s worth having anything in place to help them feel supported. There’s lots of things you can do right down to just having an agreed sign in a meeting that just they can share if they need to leave for a bit. It’s simple stuff like that, but it’ll be different for everyone.

Back to your career in general, what would you say your career highlights are?

Gosh. It’s tricky. I think you do research you’re happy with and then later on you become aware of limitations of it and you’re like, oh, I’ll do it differently now. I’m always constantly trying to do a bit better and rethinking what I’m doing. In terms of career highlights though, towards the end of my PhD I got a paper in Psychological Bulletin which is a big fancy journal, so that was a lot of work to get that review together. So that was pretty good. I think these trials now that’s been a highlight as well because it’s a lot of work to get the funding and so on. It’s not just about the application for the trial, but often you’ll need the pilot and smaller scale stuff to even get make the case for that initial bit of funding so it can be a long road, so that feels important as well. It’s not really a specific highlight, but I’ve just worked with a lot of great people as well, which has always been nice along the way. A lot of really good students
that I’ve had the pleasure to work alongside who’ve done really good research as well.

On the other side of that what would you say some low lights of your career have been?

Oh well, you know. Academia’s rife with rejection, so there’s a there’s a tonne of that. Anyone who’s got any bit of funding for anything will have like thirty things they don’t have funded, so all the rejection emails. Rejected papers. I feel like I’m better at getting papers rejected now, but still, sometimes it kind of gets you. It’s grants and things because you put so much work into them, it’s always a bit much when they’re just sort of turned down on reasons, that don’t always feel particularly valid or meaningful. It’s hard, you know, it can hit you hard. But yeah, so all that, all that fun of academia.

Do you have any kind of advice for how to deal with those difficult moments?

Yeah, I suppose not to take it personally is one thing, because it isn’t, you know. I don’t think that helps. I think giving yourself some space and time sometimes helps, and then coming back to the comments and seeing what you can take from the feedback, if there is any. Giving ourselves a bit of space to process it, I suppose, rather than doing it all at once because that may just soften the impact slightly. I suppose just be nice to yourself, because it is kind of horrible; I mean not always, you can get a nice rejection, but you can also get one where the reviewers just tear you apart. I think most reviewers aren’t quite terrible like that, but you know, occasionally you get a reviewer who just really doesn’t like what you did for whatever reason, so I think it’s easy to kind of fall into various traps of becoming self-critical or holding onto some of that, and none of that’s helpful so. I think generally working in research is really hard in a lot of ways. I think working academia has a lot of loads of perks, but I think also there’s a lot of challenges and it can be really difficult and there’s a lot of pressure to strive for perfectionism that you’ll never achieve. Just being nice to yourself, I think is essential. Because I think academia can be a bit brutal when it when at its worst, and so you need to make sure you’re not internalising that.

Do you have any specific advice for early career researchers in self-harm and suicide research?

I think good collaborations are just really important. The best work I’ve done isn’t stuff that’s just me going off and doing a bit of research, it is always with teams and other people. I think, you always get your best work as part of a really good team of people. I think when you’re starting out, it’s finding those collaborators and starting to build those links. I think part of that is about finding people who do good work in the area. But I think it’s also finding people you can work well with, and you can be open with and get along with. From those comes the opportunities for side projects and possible grants and ideas bounce around. I think getting that in early is really helpful. So, definitely go for that. Just hold in mind that research can be slow, and things take time and that’s fine. You have to kind of just plug away at it really. It takes a while to get projects off the ground and get stuff running as well.

I think ongoing CPD makes it really formal, doesn’t it? But trying to hone your skills and so on. I think it’s really hard when you’re in a lectureship as It doesn’t really give you a lot of time spare to do that. But, I think it is good to try where you can, and other people do this much better than I do. Just keep up to date with developments and doing some of your own learning about approaches and so on is really helpful because there’s always more to learn and develop your understanding. Hold on to time to do that and to value that, because sometimes it gets less valued than just getting stuff done, but it is important to have those background skills and knowledge as well. So, I think valuing that and keeping CPD going, whether that’s in an informal or formal sense is important.

For you personally, what is essential to your well-being?

Oh gosh, it’s corny, isn’t it to say family? I think it’s for me, I need a separation from work and home. A lot of people, me included, go through a period where you don’t necessarily have that. I think certainly doing my PhD, I would work through weekends and stuff like that, and I think that’s quite common. Likewise, with the ClinPsyD. But I think it’s really important to have a life outside and have other interests in a life beyond academia. Partly because it helps you deal with things, like where stuff gets rejected, because you haven’t got all your eggs in that one basket and you haven’t got your whole identity wrapped up about this one thing, like you’ve got other stuff going on. So that’s just one part of it. I think having a life beyond and having that separation and having time away from work is just essential.

I think I’ve found it’s gotten easier to kind of carve that time out now, than it was. I think it can be hard when you are doing a PhD and so on. But I think at the same time, there’s never a point where an employer will tell you you’re allowed to have your weekends off now, you’ve got to decide that, because no one’s going to just offer it to you if you see what I mean. So, it is kind of how you negotiate that. But I guess just acknowledging that can be difficult depending on where you’re at. It’s not always easy.

What are your favourite resources on self-harm and suicide?

There’s so much good stuff out there. I guess there’s certain key researchers, who have really active and productive research groups and it’s always worth keeping an eye on what’s going on there. In the UK, Ellen Townsend’s got a group down Nottingham, who do a lot of great work, there is also Rory O’Connors group in Glasgow who have the Suicidal Behaviour Research Laboratory, there’s the Oxford group, and there’s the group in Bristol, David Gunnell’s team who do the epidemiological stuff. So, I don’t know if that’s really a ‘resource’ as such, but just being aware of those people and of the outputs because there’s a lot of really important work that comes out of that.

Elsewhere, I mentioned Penny Hasking in Australia, obviously not just her, but her wider team do some really good research, really interesting stuff around self-injury. It’s worth keeping an eye on. I could plug a book now. So, the Oxford Handbook of Nonsuicidal Self-Injury is coming out or is out. You can find it online and that is looking to be a good resource when it comes to understanding self-injury.  There’s loads of big, big, research names in there and there’s me. I’ve got a couple of chapters. That’s nice. I don’t know whether it’s going to be like a landmark resource, but hopefully it’ll be a good place to look. It covers a lot of ground as a book, as books go.

Is there anything else you’d like to say or add?

Oh, actually I will add something I’ve not mentioned. So I’ve talked a bit about my trial stuff. I’m also involved, not leading on this by any means, but involved in some work in India and Pakistan and Sri Lanka as well as involved in the SASHI project at Manchester which is led by Catherine Robinson who’s great to work with and she’s doing some really good work around exploring the issue of self-harm in South Asia. I’m not at all someone who travels much, but I think I think the reason I’m flagging it, is often we focus on self-harm at our doorstep. But actually, a huge amount of self-harm is occurring in South Asia and it’s a huge problem around there. Often, we focus on the UK, and where we are, and I think practically that makes a lot of sense, but I think it is a global issue. Although the majority of self-harm occurs in lower- and middle-income countries, the majority of research occurs in higher income countries and although there’s loads of challenges to working internationally, I think it’s really important to hold that in mind and think about ways of doing that or supporting that as well.

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