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

All resources

See popular resources

Recent releases

Links to external resources

Psychology Tools makes every effort to check external links and review their content. However, we are not responsible for the quality or content of external links and cannot guarantee that these links will work all of the time.

Assessment

Acquired Capability for Suicide Scale – Fearlessness About Death (ACSS-FAD) | Ribeiro, Witte, Van Orden, Selby, Gordon, Bender, Joiner | 2014
Primary Link Archived Link
- 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.
- Psychometrics
  Primary Link
- Scale
  Primary Link Archived Link
Columbia Suicide Severity Rating Scale (C-SSRS) | Posner, Brent, Lucas, Gould, Stanley, Brown, Fisher, Zelazny, Burke, Oquendo, Mann | 2008
Primary Link Archived 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.
- Columbia Lighthouse Project (formerly the Center for Suicide Risk Assessment) link
  Primary Link
- Full scale for healthcare professionals lifetime/recent
  Primary Link Archived Link
Interpersonal Needs Questionnaire (INQ-15) | Van Orden, Cukrowicz, Wittered, Joiner | 2012
- Scale
  Primary Link Archived Link
- Psychometrics
  Primary Link
- 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.
Non-Suicidal Self-Injury Assessment Tool (NSSI-AT) | Whitlock, Exner-Cortens, Purington | 2014
Primary Link Archived Link
- 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.
- Brief version
  Primary Link Archived Link
- Full version
  Primary Link Archived Link
- Severity assessment
  Primary Link Archived Link
Self-Injurious Thoughts And Behaviors Interview (SITBI) | Nock, Holmberg, Photos, Michel | 2007
- SITBI – Long form
  Primary Link Archived Link
- SITBI – Short form
  Primary Link Archived Link
- 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.
  Primary Link
Suicidal Behaviors Questionnaire – Revised (SBQ-R) | Osman, Bagge, Gutierrez, Konick, Kopper, Barrios | 2001
- Scale
  Primary Link Archived Link
- 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.
Reasons for Living Scale | Linehan | 1996
- Scale (Long Form)
  Primary Link Archived Link
- Scale (Short Form)
  Primary Link Archived Link
- Scoring
  Primary Link Archived Link

Guides

Assessment of suicide risk in people with depression: clinical guide | Centre for Suicide Research, University of Oxford
Primary Link Archived Link
Suicide assessment fact sheet | American Counseling Association
Primary Link Archived Link

Information Handouts

General

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

Self-Injury basics, myths, and facts

What is self-injury? | Whitlock | 2010
Primary Link Archived Link
Top 15 misconceptions of self-injury | Caicedo, Whitlock | 2009
Primary Link Archived Link
How does self-injury change feelings? | Franklin | 2014
Primary Link Archived Link
What role do emotions play in non-suicidal self-injury? | Prussien, Rosenbaum, Whitlock
Primary Link Archived Link
What’s the relationship? Non-suicidal self-injury and eating disorders | Ernhout, Babington, Childs | 2015
Primary Link Archived Link
The relationship between non-suicidal self-injury and suicide | Whitlock, Minton, Babington, Ernhout | 2015
Primary Link Archived Link

Coping

Coping: stress management strategies
Primary Link Archived Link
Distraction techniques and alternative coping strategies (for self-harm) | Kilburn, Whitlock | 2009
Primary Link Archived Link
Finding your voice: talking about self-injury
Primary Link Archived Link
Telling family and friends
Primary Link Archived Link
What is emotion regulation and how do we do it?
Primary Link Archived Link

Detection, intervention and treatment

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

Media

Self-injury in the media
Primary Link Archived Link
What is the link? The relationship between non-suicidal self-injury and social media
Primary Link Archived Link

Schools

Non-suicidal self-injury in schools: developing a school protocol
Primary Link Archived Link
Information for patients: what you need to know about self-injury
Primary Link Archived Link
Respectful curiosity
Primary Link Archived Link
Connectedness and suicide prevention in college settings: directions and implications for practice
Primary Link Archived Link

Recovery

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

Disclosure

Reaching out for help: talking about ongoing self-injury
Primary Link Archived Link

Parenting strategies and self-injury

Information for parents: what you need to know
Primary Link Archived Link
Dealing with power struggles
Primary Link Archived Link
Family policies: safety concerns and contracts
Primary Link Archived Link
For parents: the importance of self-care
Primary Link Archived Link
Positive communication strategies
Primary Link Archived Link
Understanding and using the stages of change model
Primary Link Archived Link

Information (Professional)

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

Presentations

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

Treatment Guide

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

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.