Self-Harm and Suicidal Thoughts and Behaviors
Links to external resources
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Acquired Capability for Suicide Scale – Fearlessness About Death (ACSS-FAD)
| Ribeiro, Witte, Van Orden, Selby, Gordon, Bender, Joiner | 2014
- 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.
Columbia Suicide Severity Rating Scale (C-SSRS)
| Posner, Brent, Lucas, Gould, Stanley, Brown, Fisher, Zelazny, Burke, Oquendo, Mann | 2008
- 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
- Full scale for healthcare professionals lifetime/recent
Interpersonal Needs Questionnaire (INQ-15)
| Van Orden, Cukrowicz, Wittered, Joiner | 2012
- 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
- 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
- Full version
- Severity assessment
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.
Suicidal Behaviors Questionnaire – Revised (SBQ-R)
| Osman, Bagge, Gutierrez, Konick, Kopper, Barrios | 2001
- 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)
- Scale (Short Form)
- Assessment of suicide risk in people with depression: clinical guide | Centre for Suicide Research, University of Oxford
- Suicide assessment fact sheet | American Counseling Association
- The truth about self-harm: for young people and their friends and families | Mental Health Foundation
- Alternatives to self-harm and distraction techniques | Royal College Of Psychiatrists
- Self-harm: the ‘secret’ self | SANE
- Deliberate self-harm and suicide fact sheet | Living Is For Everyone
- Help is at hand: a resource for people bereaved by suicide and other sudden, traumatic death | Hawton, Simkin | 2010
- The Hurt Yourself Less Workbook | Dace, Faulkner, Frost, Parker, Pembroke, Smith | 1998
Self-Injury basics, myths, and facts
- What is self-injury? | Whitlock | 2010
- Top 15 misconceptions of self-injury | Caicedo, Whitlock | 2009
- How does self-injury change feelings? | Franklin | 2014
- What role do emotions play in non-suicidal self-injury? | Prussien, Rosenbaum, Whitlock
- What’s the relationship? Non-suicidal self-injury and eating disorders | Ernhout, Babington, Childs | 2015
- The relationship between non-suicidal self-injury and suicide | Whitlock, Minton, Babington, Ernhout | 2015
- Coping: stress management strategies
- Distraction techniques and alternative coping strategies (for self-harm) | Kilburn, Whitlock | 2009
- Finding your voice: talking about self-injury
- Telling family and friends
- What is emotion regulation and how do we do it?
Detection, intervention and treatment
- Therapy: myths and misconceptions
- Therapy: what to expect
- Understanding and using the stages of change to assess your own progress (for individuals who self-injure)
- Understanding the stages of change model (for parents and other caring adults)
- Bringing up self-injury with your clients
- Self-injury in the media
- What is the link? The relationship between non-suicidal self-injury and social media
- Non-suicidal self-injury in schools: developing a school protocol
- Information for patients: what you need to know about self-injury
- Respectful curiosity
- Connectedness and suicide prevention in college settings: directions and implications for practice
- Recovering from self-injury
- Wounds heal but scars remain: responding when someone notices and asks about your past self-injury
- Reaching out for help: talking about ongoing self-injury
Parenting strategies and self-injury
- Information for parents: what you need to know
- Dealing with power struggles
- Family policies: safety concerns and contracts
- For parents: the importance of self-care
- Positive communication strategies
- Understanding and using the stages of change model
- Suicide risk assessment guide | Veterans Association
- Risk assessment packet | Thomas Joiner
- Self-harm, suicide, and risk: a summary | Royal College of Psychiatrists | 2010
- Risk and protective factors for suicide and suicidal behavior: fact sheet | American Psychological Association Working Group on Suicide Risk Assessment Resources
- Self-harm and suicidality | Janina Fischer
- Suicide Assessment Kit (SAK): A comprehensive assessment and policy development package | Deady, Ross, Darke (National Drug & Alcohol Research Centre) | 2015
- 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
- Assessment and treatment of patients with suicidal behaviors: practice guideline | American Psychiatric Association, Jacobs, Baldessarini, Conwell, Fawcett, Horton, Meltzer, Pfeffer, Simon | 2003
- Assessing and treating suicidal behaviors: a quick reference guide | American Psychiatric Association | 2003
- Self-Harm: Assessment, Management, And Preventing Recurrence (NICE Guideline) | NICE | 2022
- 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:
- 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
- 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.