In this article, Dr Isabel Adeyemi, research associate on the RELATE trial, and based at Greater Manchester Mental Health Trust, provides and overview of the RELATE trial (Relational Approach to Self-harm). This is a feasibility randomised controlled trial (RCT) looking at the use of CAT for adults who self-harm. The principal investigators are Dr Peter Taylor and Dr Stephen Kellett. The study is now completedand the researchers are in the process of publishing the outcomes.
Self-harm is intentional self-injury or self-poisoning, irrespective of suicidal intent. Self-harm is a growing problem in the UK that is linked to emotional distress, psychological problems and suicide risk. In England it was found that in 2014, 6.4% of people had experience of self-harm. Amongst young women, this figure was nearly 20%. For those who struggle with self-harm, getting access to support is very difficult. People often feel they are passed between services, being too complex or risky for some but not complex enough for others. Having effective treatments that fill this gap in current provision is vitally important. Cognitive Analytic Therapy (CAT) is a relational approach, meaning it focuses on the relationships people form with others and with themselves, and there is some preliminary work that suggests it may be well suited to helping people who self-harm, but further research is needed.
The RELATE trial (Relational Approach to Self-harm) is a feasibility randomised controlled trial (RCT) looking at the use of CAT for adults who self-harm. As a feasibility trial, RELATE is focused on answering key questions about how participants find the therapy, and whether testing the therapy on a larger scale is possible. The trial is a major stepping stone in identifying new effective treatments for this group and filling a gap in current services. The trial is highly novel, being the first to look at CAT for self-harm, and the results have important implications for how we support people who self-harm in the UK.
Sixty adults who self-harmed three or more times in the last 12 months and who were in contact with psychological services took part in the study. Twenty-nine adults were randomly allocated treatment as usual and 31 adults were allocated brief CAT for self-harm. The latter comprised 8 weekly sessions of 50 minutes either face to face in services or through remote conferencing, and a follow up session over the phone. All participants completed research assessments before receiving any treatment, and 12 weeks and 18 weeks later. These research assessments included questions about quality of life, urges to self-harm, how often they self-harmed, and relationships with others.
Some participants were also invited for more in-depth interview. Seven participants who received treatment as usual were interviewed about their experiences of taking part, and 16 participants who received brief CAT for self-harm were interviewed about their experienced of taking part and of receiving the therapy.
The research was designed with the involvement of adults with lived experience of self-harm at its core. An Expert-by-Experience (EBE) co-investigator was involved in the oversight and management of the study. A panel of five advisory group members with lived experience of self-harm met every three months to review progress on the study and provide feedback towards decision making and problem solving in study processes. Lastly, three experts-by-experience were part of the qualitative analysis team to interpret and analyse the interview data.
The study finished data collection in June 2024. 91% of the 60 participants taking part in the study completed their 12 week follow-up research assessments on time and 83% completed their 18 week follow-up research assessment. All recruitment and follow-up data collection targets were met. Over 80% of participants attended at least 4 sessions of CAT within a 10-week period.
From the interviews with participants, researchers and lay members identified themes running across transcripts. From what participants expressed in the interviews, participants understood the need for randomisation in the study and that they were not guaranteed to receive CAT. Participants reported that the research assessments were not burdensome but that in using multiple choice answers, some participants felt that the available options for responding did not always capture well their experiences. About brief CAT for self-harm, the analysis team identified four core themes from the interview transcripts. These were:
As the study met all recruitment and follow-up data collection targets, this suggests that the study could be replicated in a large scale and to explore the efficacy of brief CAT for self-harm. The findings from the qualitative interviews will be used to improve the study processes refine the therapy.
Taylor, P. J., Adeyemi, I., Marlow, K., Cottam, S., Airnes, Z., Hartley, S., Howells, V., Dunn, B. D., Elliott, R. A., Hann, M., Latham, C., Robinson, C., Turpin, C., & Kellett, S. (2024). The Relational Approach to Treating Self-Harm (RELATE): study protocol for a feasibility randomised controlled trial study of cognitive analytic therapy for adults who self-harm versus treatment at usual. Pilot and feasibility studies, 10(1), 101. https://doi.org/10.1186/s40814-024-01526-z
