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Self-Harm and Suicidal Thoughts and Behaviors

Deliberate self-harm, and suicidal thoughts and behaviors, are transdiagnostic difficulties. Self-harm is often viewed as a behavioral strategy which is implemented as a consequence of difficulty regulating affect. Therapeutic approaches for working with self-harm include risk-management planning, developing and practicing effective emotional regulation strategies, and reducing reactivity to triggers for self-harm. Read more
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ABC Model

ABC is an acronym for Antecedents, Behavior, Consequences. It is used as a tool for the assessment and formulation of problem behaviors and is useful ... https://www.psychologytools.com/resource/abc-model

All-Or-Nothing Thinking

All-or-nothing thinking (often also referred to as ‘black and white thinking’, ‘dichotomous thinking’, ‘absolutist thinking’, or ‘binary ... https://www.psychologytools.com/resource/all-or-nothing-thinking

Arbitrary Inference

Arbitrary inference is one of the earliest and broadest cognitive disotortions described in CBT. Beck defines it as "the process of forming an interpr ... https://www.psychologytools.com/resource/arbitrary-inference

Fortune Telling

The Fortune Telling information handout forms part of the cognitive distortions series, designed to help clients and therapists to work more effective ... https://www.psychologytools.com/resource/fortune-telling

Grounding Objects (Audio)

The Grounding Objects exercise is a simple technique which teaches people with PTSD or dissociative disorders how to use objects with particular senso ... https://www.psychologytools.com/resource/grounding-objects-audio

Grounding Statements (Audio)

The Grounding Statements exercise is an audio track from the Psychology Tools For Overcoming PTSD Audio Collection. This audio track is designed for p ... https://www.psychologytools.com/resource/grounding-statements-audio

Jumping To Conclusions

The Jumping to Conclusions information handout forms part of the cognitive distortions series, designed to help clients and therapists to work more ef ... https://www.psychologytools.com/resource/jumping-to-conclusions

Mental Filter

The Mental Filter information handout forms part of the cognitive distortions series, designed to help clients and therapists to work more effectively ... https://www.psychologytools.com/resource/mental-filter

Mind Reading

The Mind Reading information handout forms part of the cognitive distortions series, designed to help clients and therapists to work more effectively ... https://www.psychologytools.com/resource/mind-reading

Overgeneralization

The Overgeneralization information handout forms part of the cognitive distortions series, designed to help clients and therapists to work more effect ... https://www.psychologytools.com/resource/overgeneralization

Permissive Thinking

The Permissive Thinking information handout forms part of the cognitive distortions series, designed to help clients and therapists to work more effec ... https://www.psychologytools.com/resource/permissive-thinking

Personalizing

The Personalizing information handout forms part of the cognitive distortions series, designed to help clients and therapists to work more effectively ... https://www.psychologytools.com/resource/personalizing

Safety Plan

The collaborative development of a safety plan is a brief psychosocial intervention for suicidal patients. The intent of a safety plan is to help ... https://www.psychologytools.com/resource/safety-plan

Social Comparison

The Social Comparison information handout forms part of the cognitive distortions series, designed to help clients and therapists to work more effecti ... https://www.psychologytools.com/resource/social-comparison

Thought-Action Fusion

The Thought-Action Fusion information handout forms part of the cognitive distortions series, designed to help clients and therapists to work more eff ... https://www.psychologytools.com/resource/thought-action-fusion

Links to external resources

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Assessment

  • Reasons for Living Scale | Linehan | 1996
  • Suicidal Behaviors Questionnaire – Revised (SBQ-R) | Osman, Bagge, Gutierrez, Konick, Kopper, Barrios | 2001
    • Scale
    • Reference Osman, A., Bagge, C. L., Gutierrez, P. M., Konick, L. C., Kopper, B. A., & Barrios, F. X. (2001). The Suicidal Behaviors Questionnaire-Revised (SBQ-R): validation with clinical and nonclinical samples. Assessment, 8(4), 443-454.
  • Self-Injurious Thoughts And Behaviors Interview (SITBI) | Nock, Holmberg, Photos, Michel | 2007
    • SITBI – Long form
    • SITBI – Short form
    • Paper Nock, M. K., Holmberg, E. B., Photos, V. I. , & Michel, B. D. (2007). The Self-Injurious Thoughts and Behaviors Interview: Development, reliability, and validity in an adolescent sample. Psychological Assessment, 19, 309-317.
  • Non-Suicidal Self-Injury Assessment Tool (NSSI-AT) | Whitlock, Exner-Cortens, Purington | 2014
  • Interpersonal Needs Questionnaire (INQ-15) | Van Orden, Cukrowicz, Wittered, Joiner | 2012
    • Scale
    • Psychometrics
    • Van Orden, K. A., Cukrowicz, K. C., Witte, T. K., & Joiner Jr, T. E. (2012). Thwarted belongingness and perceived burdensomeness: Construct validity and psychometric properties of the Interpersonal Needs Questionnaire. Psychological assessment, 24(1), 197.
  • Columbia Suicide Severity Rating Scale (C-SSRS) | Posner, Brent, Lucas, Gould, Stanley, Brown, Fisher, Zelazny, Burke, Oquendo, Mann | 2008
    • Full scale for healthcare professionals lifetime/recent
    • Columbia Lighthouse Project (formerly the Center for Suicide Risk Assessment) link
    • Posner, K., Brent, D., Lucas, C., Gould, M., Stanley, B., Brown, G., … & Mann, J. (2008). Columbia-suicide severity rating scale (C-SSRS). New York, NY: Columbia University Medical Center.
  • Acquired Capability for Suicide Scale – Fearlessness About Death (ACSS-FAD) | Ribeiro, Witte, Van Orden, Selby, Gordon, Bender, Joiner | 2014
    • Scale
    • Psychometrics
    • Ribeiro, J. D., Witte, T. K., Van Orden, K. A., Selby, E. A., Gordon, K. H., Bender, T. W., & Joiner Jr, T. E. (2014). Fearlessness about death: The psychometric properties and construct validity of the revision to the Acquired Capability for Suicide Scale. Psychological assessment, 26(1), 115.

Guides and workbooks

  • Suicide assessment fact sheet | American Counseling Association
  • Assessment of suicide risk in people with depression: clinical guide | Centre for Suicide Research, University of Oxford
  • The Hurt Yourself Less Workbook | Dace, Faulkner, Frost, Parker, Pembroke, Smith | 1998

Information Handouts

Schools

Parenting strategies and self-injury

Disclosure

Recovery

Schools

  • Connectedness and suicide prevention in college settings: directions and implications for practice

Parenting strategies and self-injury

Schools

Media

Detection, intervention and treatment

Parenting strategies and self-injury

Detection, intervention and treatment

Information (Professional)

  • Suicide Assessment Kit (SAK): A comprehensive assessment and policy development package | Deady, Ross, Darke (National Drug & Alcohol Research Centre) | 2015
  • Self-harm and suicidality | Janina Fischer
  • Risk and protective factors for suicide and suicidal behavior: fact sheet | American Psychological Association Working Group on Suicide Risk Assessment Resources
  • Self-harm, suicide, and risk: a summary | Royal College of Psychiatrists | 2010
  • Risk assessment packet | Thomas Joiner
  • Suicide risk assessment guide | Veterans Association

Presentations

  • The Safety Planning Intervention to Reduce Suicide Risk for People with SMI | Stanley & Brown | 2020
  • Using the interpersonal theory of suicide to guide risk assessment, crisis management, and intervention with suicidal clients | Van Orden | 2013
  • Why people die by suicide | Thomas Joiner | 2012
  • Empowering clients to thrive despite their desire for death | Barnes, Sorensen, Smith, Borges, Walser | 2018

Treatment Guide

  • Self-Harm: Assessment, Management, And Preventing Recurrence (NICE Guideline) | NICE | 2022
  • Assessing and treating suicidal behaviors: a quick reference guide | American Psychiatric Association | 2003
  • Assessment and treatment of patients with suicidal behaviors: practice guideline | American Psychiatric Association, Jacobs, Baldessarini, Conwell, Fawcett, Horton, Meltzer, Pfeffer, Simon | 2003

Recommended Reading

  • Brown, G. K., & Jager-Hyman, S. (2014). Evidence-based psychotherapies for suicide prevention: future directions.American Journal of Preventive Medicine,47(3), S186-S194
  • Comtois, K. A., & Linehan, M. M. (2006). Psychosocial treatments of suicidal behaviors: A practice‐friendly review.Journal of clinical psychology,62(2), 161-170
  • Joiner, T. (2007). Why people die by suicide. Harvard University Press.
  • Rudd, M. D., Berman, A. L., Joiner, T. E., Nock, M. K., Silverman, M. M., Mandrusiak, M., … & Witte, T. (2006). Warning signs for suicide: Theory, research, and clinical applications. Suicide and Life-Threatening Behavior, 36(3), 255-262
  • Sheard, T., Evans, J., Cash, D., Hicks, J., King, A., Morgan, N., … & Slinn, R. (2000). A CAT‐derived one to three session intervention for repeated deliberate self‐harm: A description of the model and initial experience of trainee psychiatrists in using it. British Journal of Medical Psychology, 73(2), 179-196.
  • Stanley, B., & Brown, G. K. (2012). Safety planning intervention: a brief intervention to mitigate suicide risk.Cognitive and Behavioral Practice,19(2), 256-264
  • Van Orden, K. A., Witte, T. K., Cukrowicz, K. C., Braithwaite, S. R., Selby, E. A., & Joiner Jr, T. E. (2010). The interpersonal theory of suicide. Psychological Review, 117(2), 575

What Are Self-Harm And Suicide?

Signs And Symptoms Associated with Self-Harm and Suicide

Parasuicidal behavior is defined as a deliberate destruction of body tissue, with or without suicidal intent (Kreitman, 1977) and may include a clear intent to die, no intent to die, or degrees of ambivalence about the intent to die.

Deliberate self-harm (DSH) is a form of parasuicidal behavior that involves no intent to die. Not everyone who engages in DSH is suicidal or has attempted suicide (Kessler, Borges, & Walters, 1999; Velamoor & Cernovsky, 1992).

Conceptualized in CBT terms self-harm is the behavioral consequence of distressing thoughts and emotions. Individuals who self-harm may be experiencing high levels of affect and often have few or ineffective coping strategies.

Psychological Models and Theory of Self-Harm and Suicidal Thoughts and Behaviors

There are a number of psychological models which address self-harm and suicidal thoughts and behaviors. These include:

  • Dialectical Behavior Therapy (DBT), which views suicide and self-harm as the product of emotional dysregulation. Linehan views emotional dysregulation (the inability to change or regulate emotional cues, experiences, actions, verbal or nonverbal responses) as a product of an interaction between biological vulnerability and an invalidating environment (Linehan, 2014).
  • Joiner’s Interpersonal Theory of Suicidal Behavior (Joiner, 2005; Van Orden et al., 2010), which proposes that suicidal desire is caused by “thwarted belongingness” and “perceived burdensomeness” (and hopelessness about these states). The model also proposes that the desire to engage in suicidal behavior is separate from the capacity to engage in suicidal behavior—capability is said to emerge in response to repeated exposures to physically painful and/​or fear-inducing experiences.
  • The Experiential Avoidance Model of deliberate self-harm (Chapman, Gratz, & Brown, 2006) proposes that deliberate self-harm is maintained by negative reinforcement in the form of escape from or avoidance of negative emotional experiences.
  • The hopelessness theory of suicidality (Abramson et al., 1989 / 2002) proposes a causal chain in which life events are perceived as negative, stable (i.e., unlikely to change), global (i.e., affect many outcomes), likely to lead to other negative outcomes or consequences, and seen as implying that the individual concerned is flawed, unworthy, or deficient. The result of this chain is hopeless depression and suicidality.

Evidence-Based Psychological Approaches for Working with Self-Harm and Suicidal Thoughts and Behaviors

Depending upon the types of experience, and functions of behavior then a variety of therapeutic approaches are potentially appropriate for working with self-harm and suicidal thoughts and behaviors. These include:

Resources for Working with Self-Harm and Suicidal Thoughts and Behaviors

Psychology Tools resources available for working therapeutically with self-harm and suicidal thoughts and behaviors includes risk and safety plans, grounding strategies, and emotional regulation skills resources. It may also include:

  • psychological models of self-harm and suicidal thoughts and behaviors
  • information handouts for self-harm and suicidal thoughts and behaviors
  • exercises for self-harm and suicidal thoughts and behaviors
  • CBT worksheets for self-harm and suicidal thoughts and behaviors
  • self-help programs for self-harm and suicidal thoughts and behaviors

References

  • Abramson, L. Y., Metalsky, G. J., & Alloy, L. B. (1989). Hopelessness depression: A theory-based subtype of depression. Psychological Review, 96(2), 358–372.
  • Abramson, L. Y., Alloy, L. B., Hogan, M. E., Whitehouse, W. G., Gibb, B. E., Hankin, B. L., & Cornette, M. M. (2000). In T. E. Joiner & M. D. Rudd (Eds.), Suicide science: Expanding the boundaries(pp. 17–32). New York: Springer.
  • Chapman, A. L., Gratz, K. L., & Brown, M. Z. (2006). Solving the puzzle of deliberate self-harm: The experiential avoidance model.Behaviour Research and Therapy, 44(3), 371–394.
  • Joiner, T. (2005). Why people die by suicide. Cambridge, MA: Harvard University Press.
  • Kessler, R. C., Borges, G., & Walters, E. E. (1999). Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey. Archives of General Psychiatry, 56(7), 617–626.
  • Kreitman, N. (1977). Parasuicide. New York: Wiley.
  • Linehan, M. M. (2014). DBT skills training manual(2nd ed.). New York: Guilford Press.
  • Van Orden, K. A., Witte, T. K., Cukrowicz, K. C., Braithwaite, S. R., Selby, E. A., & Joiner, T. E. Jr. (2010). The interpersonal theory of suicide. Psychological Review, 117(2), 575–600.
  • Velamoor, V. R., & Cernovsky, Z. Z. (1992). Suicide with the motive ‘to die’ or ‘not to die’ and its socioanamnestic correlates. Social Behavior and Personality,20(3), 193–198.