Adolescents at risk of self-harm in Ghana: a qualitative interview study exploring the views and experiences of key adult informants

Background In Ghana, rates of self-harm in young people are as high as they are in high income countries. Self-reported interpersonal, familial and societal stressors form the most important background, and self-harm is seen by young people as a way of responding to that stress. In the present study, we obtained the views of key adult informants about self-harm among adolescents in Ghana – what they thought as possible reasons for self-harm in young people and what actions might be needed at an individual or population level to respond to the problem. Methods We interviewed face-to-face 11 adults, using a semi-structured interview guide. We used an experiential thematic analysis technique to analyse the transcribed interviews. Results The analysis identified five themes: “underestimating the prevalence of self-harm in adolescents”, “life on the streets makes self-harm less likely”, “self-harm in adolescents is socially and psychologically understandable”, “ambivalence about responding to adolescent self-harm”, and “few immediate opportunities for self-harm prevention in Ghana”. Adolescent self-harm was acknowledged but its scale was underestimated. The participants offered explanations for adolescent self-harm in social and psychological terms that are recognisable from accounts in high income countries. Low rates among street-connected young people were explained by their overarching orientation for survival. Participants agreed that identification was important, but they expressed a sense of inadequacy in identifying and supporting adolescents at risk of self-harm. Again, the participants agreed that self-harm in adolescents should be prevented, but they recognised that relevant policies were not in place or if there were policies they were not implemented – mental health and self-harm were not high on public or political priorities. Conclusions The adults we interviewed about young people who self-harm see themselves as having a role in identifying adolescents at risk of self-harm and see the organisations in which they work as having a role in responding to individual young people in need. These are encouraging findings that point to at least one strand of a policy in Ghana for addressing the problem of self-harm in young people

Lucas Shelemy - A thesis submitted in partial fulfilment of the requirements of the degree of Doctor of Clinical Psychology (DClinPsych)

Critical Review of the Literature Many trans* people experience high levels of mental health difficulties. Different gender-affirmative interventions exist which aim to alleviate gender dysphoria, with the hope that this in turn will improve the mental health and quality of life of trans* people. This systematic review aims to examine the effectiveness of affirmative dysphoria-focused interventions in improving mental health outcomes. Only studies with pre- and post-intervention measurements were included. Database searches were conducted from Medline, PsycInfo, Web of Science, Scopus and Embase with additional hand-searching (database inception to May 2022). Quality assessment of studies used the EPHPP Quality Assessment Tool. Twenty-six studies were identified that quantitatively assessed, via prospective pre- and post-test design, mental health outcomes (including depression, anxiety and self-esteem) following hormone, surgical and/or psychotherapeutic interventions. The majority of studies of hormone treatments found that mental health significantly improved following intervention and at follow-up. There was no significant change following surgical interventions at post-test to 6-month follow-up, although improvements were reported at longer follow-up time points. The majority of psychological interventions reported improvements in various mental health outcomes. The quality of the majority of included studies was assessed as being ‘medium’ or ‘weak’. There were no found qualitative pre- and post-intervention research or research examining voice and communication therapy or hair removal/electrolysis. This review indicates that interventions for gender dysphoria, especially hormone and psychological treatments, may have mental health benefits for trans* people. Further research is required to examine the relationship between mental health post-intervention and minority stressors, visual congruity with one’s gender and intersectional factors. Service Improvement Project Adolescents with eating disorders experience higher levels of psychological distress compared to the general population. Distress is particularly pronounced during the first stage of the Family Based Treatment due to the focus on refeeding and weight restoration. It is feasible that equipping adolescents to manage distress early on in treatment may positively impact on later engagement and recovery. This service improvement project describes the feasibility and implementation of a brief distress-tolerance intervention delivered alongside the first phase of FBT in a community Child and Adolescent Eating Disorder Service. This study was approved by the service NHS Research and Development team (ID: 286525). 15 adolescents (aged 11-18) in the first phase of FBT received two fortnightly 1-1 sessions with an Assistant Psychologist. Intervention content was based on distress tolerance dialectical-behavioural strategies. The Distress Tolerance Inventory (DTI) was administered at pre-test and two-week follow-up. Participants were interviewed about their experience and usefulness of the intervention sessions. Paired sample t-tests indicated tentative effectiveness of the intervention. Thematic analysis identified key superordinate themes: ‘Empowerment and Skilling Up’, ‘Delivery and Relevance’ and ‘Connection and Psychological Support’. The intervention was seen as highly acceptable and empowering for participants starting FBT. More sessions may be needed to ensure consolidation of newly learnt skills. Next steps regarding wider service implementation and empirically evaluating impact (e.g. on crisis referrals) are discussed. Theoretically Driven Research Project Individuals suffering from OCD experience a heightened sense of responsibility compared to community sample and anxious controls. This responsibility may vary depending on the subject of potential harm (e.g. I am responsible for my own safety vs I am responsible for other people’s safety). 5 causal factors or ‘pathways’ to the development of heightened responsibility have been proposed. This study aims to examine the relationship between the pathways to heightened responsibility towards oneself vs towards others. 60 participants with OCD and 60 community controls completed an online questionnaire measuring childhood and early adulthood experiences and responsibility dimensions. Regression analyses established the predictive value of each pathway. ‘Responsibility for oneself’, ‘responsibility for others’ and four of the five pathway subscales were significantly higher for the OCD group. The extent that participants had acted to influence misfortune was a significant predictor of heightened responsibility for oneself. Increased responsibility as a child and experience of overprotective parenting significantly predicted responsibility for others. This study indicates that heightened responsibility for oneself vs others may develop via separate pathways. Prospective studies are needed to understand how responsibility and other OCD-related beliefs develop in adolescence and early adulthood.</p