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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Assessment

Reasons for Living Scale | Linehan | 1996
- Scale (Long Form)
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- Scale (Short Form)
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- Scoring
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Suicidal Behaviors Questionnaire – Revised (SBQ-R) | Osman, Bagge, Gutierrez, Konick, Kopper, Barrios | 2001
- Scale
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- 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
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- SITBI – Short form
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- 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.
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Non-Suicidal Self-Injury Assessment Tool (NSSI-AT) | Whitlock, Exner-Cortens, Purington | 2014
- Brief version
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- Full version
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- Severity assessment
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- Whitlock, J.L., Exner-Cortens, D. & Purington, A. (2014). Validity and reliability of the non-suicidal self-injury assessment test (NSSI-AT). Psychological Assessment, 26(3): 935-946.
Interpersonal Needs Questionnaire (INQ-15) | Van Orden, Cukrowicz, Wittered, Joiner | 2012
- Scale
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- Psychometrics
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- 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
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- Columbia Lighthouse Project (formerly the Center for Suicide Risk Assessment) link
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- 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
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- Psychometrics
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- 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
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Assessment of suicide risk in people with depression: clinical guide | Centre for Suicide Research, University of Oxford
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The Hurt Yourself Less Workbook | Dace, Faulkner, Frost, Parker, Pembroke, Smith | 1998
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Information Handouts

Schools

Respectful curiosity
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Parenting strategies and self-injury

For parents: the importance of self-care
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Family policies: safety concerns and contracts
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Dealing with power struggles
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Information for parents: what you need to know
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Disclosure

Reaching out for help: talking about ongoing self-injury
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Recovery

Wounds heal but scars remain: responding when someone notices and asks about your past self-injury
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Recovering from self-injury
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Schools

Connectedness and suicide prevention in college settings: directions and implications for practice
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Parenting strategies and self-injury

Positive communication strategies
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Schools

Information for patients: what you need to know about self-injury
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Non-suicidal self-injury in schools: developing a school protocol
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Media

What is the link? The relationship between non-suicidal self-injury and social media
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Self-injury in the media
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Detection, intervention and treatment

Bringing up self-injury with your clients
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Understanding the stages of change model (for parents and other caring adults)
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Understanding and using the stages of change to assess your own progress (for individuals who self-injure)
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Therapy: what to expect
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Parenting strategies and self-injury

Understanding and using the stages of change model
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Alternatives to self-harm and distraction techniques | Royal College Of Psychiatrists
The truth about self-harm: for young people and their friends and families | Mental Health Foundation
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Self-harm: the ‘secret’ self | SANE
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Deliberate self-harm and suicide fact sheet | Living Is For Everyone
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Help is at hand: a resource for people bereaved by suicide and other sudden, traumatic death | Hawton, Simkin | 2010
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What is self-injury? | Whitlock | 2010
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Top 15 misconceptions of self-injury | Caicedo, Whitlock | 2009
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How does self-injury change feelings? | Franklin | 2014
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What role do emotions play in non-suicidal self-injury? | Prussien, Rosenbaum, Whitlock
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What’s the relationship? Non-suicidal self-injury and eating disorders | Ernhout, Babington, Childs | 2015
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The relationship between non-suicidal self-injury and suicide | Whitlock, Minton, Babington, Ernhout | 2015
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Coping: stress management strategies
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Distraction techniques and alternative coping strategies (for self-harm) | Kilburn, Whitlock | 2009
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Finding your voice: talking about self-injury
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Telling family and friends | Purington, Whitlock (The Cornell Research Program On Self-Injury And Recovery)
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What is emotion regulation and how do we do it? | Rolston, Lloyd-Richardson (Cornell Research Program On Self-Injury And Recovery)
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Detection, intervention and treatment

Therapy: myths and misconceptions
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Information (Professional)

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

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

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

DBT, which targets the development of emotional regulation skills;
trauma-focused therapies, which target the experiences which can trigger self-harm;
cognitive behavioral treatments for depression and suicidal thinking.

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.

Self-Harm and Suicidal Thoughts and Behaviors

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Parenting strategies and self-injury

Schools

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Detection, intervention and treatment

Parenting strategies and self-injury

Detection, intervention and treatment

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Recommended Reading

What Are Self-Harm And Suicide?

Signs And Symptoms Associated with Self-Harm and Suicide

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

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

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

References

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