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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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Resource type


Therapy tool

A Guide To Emotions (Psychology Tools For Living Well)

Cognitive behavioral therapy can help your clients to live happier and more fulfilling lives. Psychology Tools for Living Well is a self-help course ...


Autonomic Nervous System

The autonomic nervous system (ANS) automatically regulates the function of body systems outside of voluntary control. The Autonomic Nervous System han ...

Information Handout

Behavioral Experiment

Behavioral experiments are planned experiential activities to test the validity of a belief. They are one of the most powerful techniques available to ...


Behavioral Experiment (Portrait Format)

Behavioral experiments allow individuals to test the validity of their beliefs and assumptions. They are a core experiential technique for therapeutic ...


Dissociation Record

Dissociation is a set of physical and behavioral adaptations (‘skills’) that human beings have developed because they can help us to survive extre ...


Functional Analysis

Functional analysis examines the causes and consequences of behavior. This classic A-B-C Functional Analysis worksheet can be used to collect informat ...


Functional Analysis With Intervention Planning

This classic A-B-C functional analysis worksheet can be used to collect information about what came before a behavior (antecedents), the behavior itse ...


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 ...


Grounding Statements (Audio)

Grounding techniques are used to help people to reorient themselves to the present moment and to safety. Grounding Statements are a form of cognitive ...


Grounding Techniques

Individuals who have experienced trama often find it difficult to stay within the ‘window of tolerance’. Grounding techniques (which can b ...


Grounding Techniques Menu

Dissociation can be described as a shift of a person’s attention away from the present moment. When working with traumatized clients, this shift oft ...

Information Handout

Intrusive Memory Record

Intrusive (unwanted, involuntary) memories are a common feature of PTSD, but also depression and other conditions. This Intrusive Memory Record is des ...


Mindful Attention (Audio)

Mindful Attention is a technique for becoming aware of one’s thoughts and experiences, and being able to observe these as transient mental events. ...


Relaxed Breathing

Practising Relaxed Breathing serves to reduce physiological arousal and can be an excellent grounding technique. This client information handout descr ...


Relaxed Breathing Exercise 1 (Audio)

Breathing Exercise 1 guides the listener through simple instructions to make their breathing slower, deeper, and more regular. ...


Relaxed Breathing Exercise 2 (Audio)

Breathing Exercise 2 uses the imagery of inflating a balloon to help the listener make their breathing slower, deeper, and more regular. ...


Relaxed Breathing Exercise 3 (Audio)

Breathing Exercise 3 uses the imagery of breathing air of different colours to help the listener make their breathing slower, deeper, and more regular ...


Relaxed Breathing Exercise 4 (Audio)

Breathing Exercise 4 guides the listener through simple instructions to breathe in a more relaxed fashion. ...


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 ...


Sensory Grounding Using Smells (Audio)

The Sensory Grounding Using Smells exercise is an audio track from the Psychology Tools For Overcoming PTSD Audio Collection. It is designed to teach ...


Sensory Grounding Using Your Five Senses (Audio)

The Sensory Grounding Using Your Five Senses exercise is an audio track from the Psychology Tools For Overcoming PTSD Audio Collection. It is designed ...


Therapy Blueprint

Since the publication of this version of the therapy blueprint we have also developed a more sophisticated version: Therapy Blueprint (Universal) A th ...


Trauma, Dissociation, And Grounding

Trauma, Dissociation, and Grounding is a guide written for clients who have experienced trauma and who are troubled by dissociation. It provides clear ...


Types Of Dissociation

The Types Of Dissociation information handout is designed for clients who have experienced trauma and describes dissociation using accessible terminol ...

Information Handout

Unhelpful Thinking Styles

Human thinking is subject to a number of characteristic biases. Cognitive restructuring is the process of helping individuals to overcome their biases ...

Information Handout


Assessment measures

  • Acquired Capability for Suicide Scale – Fearlessness About Death (ACSS-FAD) | Ribeiro, Witte, Van Orden, Selby, Gordon, Bender, Joiner | 2014
    • Scale download archived copy
    • Psychometrics download
    • 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 assessment26(1), 115.
  • Columbia Suicide Severity Rating Scale (C-SSRS) | Posner, Brent, Lucas, Gould, Stanley, Brown, Fisher, Zelazny, Burke, Oquendo, Mann | 2008
    • Scale download archived copy
    • Scale download  archived copy
    • 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.
  • Interpersonal Needs Questionnaire (INQ-15) | Van Orden, Cukrowicz, Wittered, Joiner | 2012
    • Scale download archived copy
    • Psychometrics download
    • 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 assessment24(1), 197.
  • Non-Suicidal Self-Injury Assessment Tool (NSSI-AT) | Whitlock, Exner-Cortens, Purington | 2014
  • Self-Injurious Thoughts And Behaviors Interview (SITBI) | Nock, Holmberg, Photos, Michel | 2007
    • SITBI – Long form download archived copy
    • SITBI – Short form download archived copy
    • Scale – Long form download archived copy
    • 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.
  • Suicidal Behaviors Questionnaire – Revised (SBQ-R) | Osman, Bagge, Gutierrez, Konick, Kopper, Barrios | 2001
    • Scale download  archived copy
    • 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. Assessment8(4), 443-454.


  • Assessment of suicide risk in people with depression: clinical guide | Centre for Suicide Research, University of Oxford   download archived copy
  • Suicide risk assessment guide | Veterans Association download archived copy
  • Suicide risk assessment guide | Canadian Patient Safety Institute download archived copy
  • Suicide assessment fact sheet | American Counseling Association   download archived copy


Information for professionals

  • Risk assessment packet | Joiner Lab download archived copy
  • Self-harm, suicide, and risk: a summary | Royal College of Psychiatrists | 2010 download archived copy
  • Assessment and treatment of patients with suicidal behaviors: practice guideline | American Psychiatric Association, Jacobs, Baldessarini, Conwell, Fawcett, Horton, Meltzer, Pfeffer, Simon | 2003 download archived copy
  • Assessing and treating suicidal behaviors: a quick reference guide | American Psychiatric Association | 2003 download archived copy
  • Risk and protective factors for suicide and suicidal behavior: fact sheet | American Psychological Association Working Group on Suicide Risk Assessment Resources download archived copy
  • Self-harm and suicidality | Janina Fischer download archived copy

Information Handouts


  • The truth about self-harm: for young people and their friends and families | Mental Health Foundation   download  archived copy
  • Alternatives to self-harm and distraction techniques | Royal College Of Psychiatrists download
  • archived copy
  • Self-harm: the ‘secret’ self | SANE download archived copy
  • Deliberate self-harm and suicide fact sheet | Living Is For Everyone download archived copy
  • Help is at hand: a resource for people bereaved by suicide and other sudden, traumatic death | Hawton, Simkin | 2010 download archived copy
  • The Hurt Yourself Less Workbook | Dace, Faulkner, Frost, Parker, Pembroke, Smith | 1998 download archived copy

Self-Injury basics, myths, and facts


Detection, intervention and treatment





Parenting strategies and self-injury


  • Using the interpersonal theory of suicide to guide risk assessment, crisis management, and intervention with suicidal clients | Van Orden | 2013 download archived copy
  • Why people die by suicide | Thomas Joiner | 2012 download archived copy
  • Empowering clients to thrive despite their desire for death | Barnes, Sorensen, Smith, Borges, Walser | 2018 download archived copy

Recommended Reading

  • Brown, G. K., & Jager-Hyman, S. (2014). Evidence-based psychotherapies for suicide prevention: future directions. American Journal of Preventive Medicine47(3), S186-S194 download  archived copy
  • Comtois, K. A., & Linehan, M. M. (2006). Psychosocial treatments of suicidal behaviors: A practice‐friendly review. Journal of clinical psychology62(2), 161-170 download  archived copy
  • 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 download archived copy
  • 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 Practice19(2), 256-264 download  archived copy
  • 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 download

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


  • 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.