U-COPE: targeted interventions for students in crisis

The Improving student mental health through partnerships project aims to develop a student-focused, innovative best practice model for collaboration between university and NHS mental health services.

The focus of this case study is on targeted interventions for students in crisis.

The University of Liverpool (UoL) is the leading partner for a Liverpool-based project working to develop an integrated model of support for student mental health.

Partners of the project include:

• Liverpool John Moores University (LJMU)
• Mersey Care NHS Foundation Trust (MCT)
• Brownlow Health (a GP practice)
• Innovation Agency (the Academic Health Science Network for the North West Coast).

The project aims to develop an integrated approach between universities and the NHS, offering seamless referral pathways and shared protocols supported by a clear risk management strategy which clearly specifies the responsibilities of partner agencies and allows for more effective planning for services to meet the varying and escalating needs of students.

This project is funded through the OfS mental health Challenge Competition. An additional case study, 'Improving student mental health through partnerships', provides an overview of the project and partnerships.

Student reports of poor mental health and disclosures of mental health conditions have risen (Royal College of Psychiatrists, 2021) and this is also noted as a strategic priority of NHS England (NHS Long Term Plan, 2019).

Suicide is the leading cause of death in young people in the UK (Gunnell et al, Journal of affective disorders, 2020), and reported as the fourth leading cause of death among 15-29 year olds globally (WHO, 2021), though the suicide rate of students is lower than the general population (Gunnell et al, Journal of affective disorders, 2020).

With 75 per cent of adults experiencing the first symptoms of mental health problems before the age of 25 (Kessler et al, 2005), university students are a key population who will need to access and navigate NHS mental health services for diagnosis and ongoing support. Yet, this journey is not always straightforward for them.

The project has undertaken a range of approaches and activities to embed various methods of improved partnership working to benefit student mental health, but this case study focuses specifically on the approach to working with students who self-harm as part of the project's wider work on suicide prevention.

At the design stage of this project, the team reflected on clinical evidence that links self-harming behaviour to suicidality. For example, the risk of suicide in the first year following self–harm presentation to hospital is 49 times greater than the general population, especially in the first six months (Hawton et al, 2015).

Studies demonstrate that self-harm can predict a suicide attempt (Klonsky, May and Glenn, 2013), and one study found that almost half of people who self-harm have reported at least one suicide attempt (Klonsky, 2011).

Nationally 1 in 10 (9.4 per cent) students think about self-harming often or all the time (Rethink Mental Illness, 2019). Linking this with local evidence from the 2020 bi-annual UoL/LJMU Mental Health Survey, which indicated that almost half of all students report thoughts about self-harm, it was identified that interventions targeted at students presenting with self-harming behaviours should be explored.

HOPE

‘HOPE’ (Hospital Outpatient Psychotherapy Education) is an innovative clinical intervention delivered by Mersey Care Trust which offers a brief therapeutic intervention aiming to support a patient’s understanding of their mental health and wellbeing and build lasting coping mechanisms to address their self-harming behaviour.

Previously, the HOPE service could only be accessed following presentation at A&E. Discussions were already taking place within the Trust about extending the service to community locations COPE (Community Outpatient Psychotherapy Education), as there is evidence from studies of younger adolescents that the majority of young people who self-harm do not present at A&E (Geulayov et al, 2018). This supports practitioner knowledge locally and nationally in the student age group.

Given the prevalence of self-harm among the student population, the project team identified a need for a student specific service which offered opportunities for earlier intervention. The HOPE service was therefore redesigned and piloted as U-COPE (University – Community Outpatient Psychotherapy Education).

U-COPE

U-COPE is a campus based therapy which offers a six-session blended model of Psychodynamic Interpersonal Therapy (PIT) and Cognitive Analytical Therapy (CAT).

Throughout the therapy, the therapist develops a conversation with the patient starting with a detailed account of the episode of self-harm and the circumstances leading up to it, particularly exploring feelings, mood and relationships.

Specific PIT model techniques, such as ‘staying with feelings’ and getting the patient to work in the ‘here and now’ can facilitate this process (E. Guthrie, 2018). This is enhanced by elements of the CAT model, such as Vygotsky’s (1978) notion of the zone of proximal development (ZPD). This explains how constructing a ‘scaffolding’ of what a patient can manage and learn will inform both pace and depth of the therapeutic work.

Referral criteria have been designed to ensure accessibility, and the referral sources have been extended to UoL and LJMU Student Services teams, with a primary care GP practice being introduced in year two of the pilot.

All students are able to access the U-COPE service whether or not they are registered with a GP in Liverpool. Referral criteria are as follows:

• currently registered as a student at LJMU or UoL
• recent (within the last year) self-harming behaviour (may be self-reported). Self-harm refers to an intentional act of self-poisoning or self-injury, irrespective of the motivation or apparent purpose of the act and is an expression of emotional distress (NICE, 2004).

Students would be signposted to an alternative service if they are:

• presenting with symptoms of mental illness such as psychosis
• already engaged with a secondary mental health service
• currently having another therapy
• needing support primarily for drug or alcohol use.

Ongoing formal service evaluation is taking place to explore the clinical effectiveness of the U-COPE intervention, with results to be available June 2022.

Utilising CORE OM and CORE 10 clinical measures and quantitative research methods, the pilot service is expected to demonstrate that early intervention targeting self-harm supports the stepping down of students at risk of harm, from NHS services into university Student Services teams.

CORE OM is a 34 question clinical measure of psychological distress and covers wellbeing, symptoms, functioning and risk. This score is taken at the first and last session to provide a baseline and outcome measure. The CORE 10 is a condensed 10 question version of the same measure and is taken through sessions two to five to provide session-by-session monitoring.

Although the pilot continues and the final service evaluations are not yet complete, the early learning emerging from this element of the project indicates strong service related and user outcomes.

Qualitative evaluations of services have been extremely positive - in particular, the accessibility of the service and speed of referral has been very well received by students and practitioners. Practitioners have also noted that the links between the universities and NHS have facilitated better signposting and availability of care at the right time for each individual. Quantitative data provides the following outcomes to date (31 January 2022):

• 240 students have been referred for U-COPE therapy.
• Over 660 therapy appointments have been delivered.

Next steps

In the final stages of this project, the team are seeking ongoing funding to ensure the approaches introduced are sustainable and scalable across the Liverpool City region.

A business case is being prepared for submission to MCT strategic leaders and commissioners. The aim is that the partnership approaches developed during the project life becomes business as usual and can be offered across all universities in Liverpool and available to all students in the city.