How to replace self-injury and suicidal thoughts with other means of reducing stress


Self-harm describes the action of intentionally injuring or poisoning oneself, regardless of motivation or suicidal intent.1

Types of self-harm can be divided into two groups: self-injury (including such acts as self-cutting, ligature-tying and self-battery) and self-poisoning (by taking an overdose of legal prescription or over-the-counter medications, for example, analgesics such as paracetamol).

Risk factors for self-harm with both non-suicidal and suicidal intent include age, gender, mental health diagnosis, coping strategies, previous self-harm, acute stress response, relationship with family and friends, as well as social deprivation.2–7 The risk of attempted and completed suicide is significantly higher in those who have engaged in self-harm,8–10 with one study estimating that 50% of young people that had completed suicide would have previously self-harmed.11 A history of self-harm has been demonstrated to be one of the primary indicators of completed suicide.12

Self-harm on wards

In-patient services are highly specialised, reserved for the treatment of patients with the most severe mental health disorders.13 Unsurprisingly, incidents of self-harm are relatively commonplace on a psychiatric in-patient ward.14

Around 10–20% of adolescent in-patients will self-harm at least once during their stay, and a proportion of these will self-harm repeatedly as many as 130 times. 15–18

In addition, risk of suicide is increased soon after admission and immediately after discharge.19 The prevention of self-harm and suicide is one of principal preoccupations and primary roles of ward staff in a mental health setting.20

The in-patient environment has additional unique factors that can contribute to self-harming. Patients may be distressed by interaction with other in-patients, by the rules and routines of life on the ward, the amount of leave granted or by the restrictions of involuntary admission. 3,21,22

Feeling lonely, being isolated from others and a lack of stimulation can all contribute to self-harming behaviours on psychiatric wards. 23,24

Patients may use self-harming behaviour as a way of seeking help when they do not feel supported by nursing staff on wards. 25,26

Patients at risk of self-harm are almost always placed under constant observation. A nurse is required to observe the patient at all times, as they are thought to be at risk of suicide, self-harm or violent behaviour,27 although wide variations in actual practice of constant observation exist.28

The key purpose of increased observation is to provide a period of safety for people during temporary periods of distress when they are at risk of harm to themselves and/or others. Observation is, however, potentially distressing and personally invasive for patients, burdensome and time-consuming for staff and can still result in death by suicide for the patient.29,30

Restraint and seclusion are commonly used to manage self-harm behaviours, and other behaviours that pose a significant threat to other patients or staff members.31,32

However, such restrictive practices may lead to physical injury to both staff and patients,33 as well as the potential of significant negative psychological effects on staff and patients. 34

Consequently, there have been drives to reduce the use of restrictive practice except in the most serious of incidents and to explore more humane and ethical ways of reducing self-harm.

Reducing self-harm on psychiatric wards

There is a major question in current clinical practice as to whether admission to a psychiatric ward should be used to manage self-harm or suicide risk. A large proportion of patients presenting with these problems have a diagnosis of emotionally unstable personality disorder (EUPD).

The National Institute for Health and Care Excellence guidance for managing EUPD,35 states that clinicians should ‘explore other options before considering admission to a crisis unit or in-patient admission’. Further, longitudinal data-sets suggest that admission to hospital does not reduce the risk of suicide, and multiple admissions to manage suicide risk is associated with an increased risk.36

However, where the self-harm or suicide risk is associated with a mental illness that can be treated using medications, such as bipolar disorder, depression or schizophrenia, a short-term admission for medical treatment is clearly justifiable as the risk of self-harm reduces substantially following treatment.36

The management of self-harm and suicide risk on psychiatric wards will therefore need to be addressed on wards, whether or not these risks were the major reason for admission. Interventions to address these risks therefore remain pertinent.

Therapeutic approaches such as dialectical behaviour therapy (DBT) and cognitive–behavioural therapy (CBT), and emotion-regulation training may all be used to treat adolescents who self-harm.

Both DBT and CBT have been adapted to in-patient settings and have been shown to reduce self-harming behaviours in adolescents. 37–41

Treatment in out-patient settings is usually intensive and relatively prolonged, so the impact of treatment during a short in-patient admission is likely to be modest. Social and environmental factors also play a role in increasing the likelihood of self-harm. These factors include relationships between patients and staff, relationships with other patients, the physical environment and the organisation of care.42,43

These wider causes and influences can also be addressed in social and organisational interventions such as adjusting staff rotas to cover high-risk periods and providing additional interests and social activities.29 Such interventions, in the context of an in-patient environment, have the advantages of a relatively immediate impact, providing a more positive atmosphere for both patients and staff and potentially reducing the need for observation, restraint and seclusion.

Suicide is a highly complex phenomenon of human behavior. Most theoretical models attempt to explain suicide by reducing suicidal behavior to risk factors. In 1897 Durkheim, with “Le Suicide”, put forward a sociological model of suicide, in which problems with social integration were identified as the main causes of suicide [1].

These included risk factors such as being single, having higher levels of education, and being of Protestant denomination. In the second half of last century, theoretical models focused predominantly on medical risk factors. The classical studies by Robins [2], Conwell [3], and Harris and Barraclough [4] consistently found that in more than 90 percent of suicides the criteria for a psychiatric diagnosis were fulfilled. Since then, the association between suicide and mental illness has largely determined the practice of clinical suicide prevention.

The illness model of suicide has later received support from other studies [5,6]. In recent years, comprehensive models of suicide have been put forward [7,8]. Yet so far, no theoretical model has successfully been translated into a clinical treatment protocol with evidence of effectively reducing suicide.

In contrast, most psychological therapies have been developed from general psy- chotherapy research and practice, with a strong emphasis on therapy process factors such as treatment engagement and working alliance. By their nature, they focus on the person’s individual, subjective experience of a suicidal crisis. Today, there is compelling evidence that person-centered psychological treatments can significantly reduce suicidal behavior, particularly for patients with a history of attempted suicide.

The Limitations of Theoretical Suicide Models

In suicide literature, studies about suicide risk factors abound. Typical risk factors encompass psychiatric disorders and physical illness, personal characteristics such as a history of attempted suicide, relationship and work problems, separation and loss, isolation, etc. Biological risk factors include genetic and epigenetic factors and certain personality traits.

The biomedical model posits that suicide is mostly a consequence of psychiatric pathology [9,10], and inadequate treatment of depression [5,11,12]. Training schemes for primary care physicians and fight depression campaigns have been developed [13,14]. Yet, over the years, the results have been sobering. In spite of the widespread efforts to train health professionals, affective disorders in primary care continue to be underdiagnosed.

And, in spite of population-based campaigns, too many clinically depressed individuals— predominantly men—do not seek help. Bertolote and co-authors from the Department of Mental Health and Substance Dependence of the WHO in Geneva [15] took a worldwide view on the topic, assuming that antidepressants would be effective in treating depression in about 52% (a figure taken from the World Health Report 2001) and that some 50% of people with depression were correctly diagnosed and treated.

The impact on suicide rates was estimated to be about 7.8%, which would reduce suicide rates from a world average of 15.1 per 100,000 to 13.9 per 100,000. Furthermore, the evidence for the effect of antidepressant treatment on suicide is controversial [16–19]. Randomized trials of psychopharmacological interventions usually exclude patients with a history of suicidal ideation or behavior and those who are actively suicidal, limiting the generalizability of the findings [20].

In an attempt to improve current models of suicide, comprehensive models includ- ing different categories of risk factors have been developed. In Mann’s diathesis-stress model [7] diathesis is understood as a constitutional or acquired vulnerability (for instance, impulsive and aggressive traits) as risk factors for suicide. Stress factors are assumed to be internal (e.g., depression) or external (e.g., problems with relationships or employment).

Later, Mann and Rizk [21] updated the stress-diathesis model with a “brain-centric model of suicidal behavior”, and added recommendations for suicide prevention. The biopsy- chosocial model by Turecki et al. [22] differentiates between distal, developmental, and proximal factors. Risk factors include early life adversities, epigenetic changes, personality traits such as impulsive aggression, hopelessness and unbearable psychological pain, etc.

The integrated motivational-volitional model of suicidal behavior [8] includes three dimensions: the biopsychosocial context as premotivational phase, the emergence and maintenance of ideation as motivational phase, and the transition to suicidal behaviors in the volitional phase. In a clinical application this model on suicide attempters did not reduce the risk of reattempts [23]. In Joiner’s interpersonal theory of suicide [24,25] individuals engage in serious suicidal behavior as a result of interpersonal psychological states, such as perceived burdensomeness (being a burden to others), and thwarted belongingness (feelings of alienation).

It is assumed that these feelings lead to the belief that one’s death is worthwhile to others, and to the desire to die. Repeated experiences of pain, often by self-injury, are seen as a way of acquiring the capability for suicide. To our knowledge, the interpersonal theory has not been tested in a treatment study.

These models normally assume a trajectory from suicide ideation to suicide action, that is, a developmental pathway from psychological stressors to ideation and from ideation to action, similar to a linear pathogenetic model in somatic medicine. For instance, in diabetes mellitus type 2, a causal factor is insulin resistance due to receptor abnormalities, leading to hyperglycemia, polyuria, inactivity, obesity, and, as long-term consequences to vascular lesions with coronary heart disease, retinopathy, nephropathy, and neuropathy–the concept of a progressing pathology from a molecular level to the long-term clinical consequences.

However, suicide as a behavior does not fit into a linear illness model. Theoretical models by their nature cannot accommodate the very personal psychology of the individual considering suicide. The emotional valence and the meaning of a specific psychosocial stressor are related to a person’s, often biographically determined, vulnerability (for in- stance early trauma).

Typically, suicidal risk waxes and wanes. Rudd [26] formulated The Fluid Vulnerability Theory, a concept which assumes a long-term baseline risk that varies from individual to individual, and a short-term risk that is highly determined by aggravating factors active for limited periods of time (hours, days, weeks).

Bryan and Rudd [27] argued that the “ideation-to-action framework” with suicidal thoughts as starting point and suicide or suicide attempt as an end point has little to do with the clinical reality of suicidal individuals.

In clinical practice, risk factor models are used for suicide risk assessment. However, studies on the predictive value of suicide risk scales have yielded sobering results [28,29]. Suicide risk scales with multiple risk factors do not add to the statistical strength [30]. A meta-analysis on 365 studies concluded that the ability of risk factor models to predict suicide has not significantly improved over 50 years of research, and recommended a shift in focus from risk factors to machine-learning-based risk algorithms [31].

However, considering the very personal and specific individual psychological vulnerability of each individual, it is difficult to imagine how novel risk factors and machine learning involving large numbers (>100) of risk factors [32] will resolve the underlying conceptual problem.

No model can foresee the time and nature of intra- and interpersonal conflicts that may (or may not) trigger suicidal behavior. By their nature, risk factor models can only provide information on mid-term or long-term risk, but not on the risk in a time frame of hours and days. In clinical practice, risk-factor-based suicide screening can be used as an initial step leading to a person-centered risk assessment [33,34].
In recent years, several experts have argued that new approaches in clinical suicide prevention are needed [35–38]. The insight is growing that current practices will not get us any further in significantly reducing suicide.

The Promise of Suicide-Specific, Person-Centered Psychological Treatments

In contrast to risk-factor models of suicide, psychological treatment models focus on the person’s individual and “subjective” experience of a suicidal crisis. These models have usually been developed from general principles of psychotherapy. Key elements are the concepts of therapeutic relationships and alliances. The therapeutic alliance is best defined as “the active and purposeful collaboration between patient and therapist” [39].

There is a wealth of studies, most of them published in the second half of the last century, focusing on the characteristics of an effective therapeutic relationship [40–42]. In a meta-analysis of 201 psychotherapy research reports, Horvath et al. [43] found a strong relationship between alliance and the therapy outcome. They concluded that alliance is best understood as a measure of how well the therapist and client work together in therapy as a collaborative enterprise. In their contextual analysis, Wampold and Imel [44] stressed the importance of empathy, goal consensus, and collaboration to achieve change in psychotherapy.

Considering the high rates of non-attendance and treatment dropout of suicidal patients [45–47], treatment engagement is of paramount importance [48]. A prerequisite for treatment engagement is that the therapy model and content are meaningful to the patient. The therapist’s aim must be to understand the person’s subjective inner experience related to the suicidal crisis [49].

Patient-rated measures of therapeutic alliance can be an indicator of how meaningful a therapy concept for this group of patients is. In a review, Dunster-Page et al. [50] analyzed the effect of therapeutic alliance on suicidal ideation and behavior. Therapy models included Dialectical Behavior Therapy (DBT), Cognitive Behavior Therapy (CBT, BCBT), the Attempted Suicide Short Intervention Program (ASSIP), and dynamic psychotherapy. The authors concluded that an alliance with either a therapist, care coordinator, or mental health team has a significant impact on a patient’s suicidality. For example, assessment tools for therapeutic alliance used by Gysin-Maillart et al. [51,52] and Bryan et al. [53] were the Helping Alliance Questionnaire [54], and the Working

Alliance Inventory [55]. Both studies found an inverse relationship between alliance and suicidal ideation during follow-up.
Several treatment studies have focused on ED-based interventions, with usually short follow-up periods. The ED setting is particularly important, as large numbers of at-risk individuals use emergency services [56]. From a meta-analysis, Inagaki et al. [57] concluded that for patients admitted to ED active contact and follow-up may reduce the risk of a repeat suicide attempt up to 12 months, although the results are mixed [58].

The main psychological treatments based on manualized treatment protocols, with at least one well-conducted study that yielded significant effects in reducing suicidal behavior in high-risk patients, are Cognitive Behavioral Therapy (CBT, BCBT), Dialectical Behavioral Therapy (DBT), the Attempted Suicide Short Intervention Program (ASSIP), and the Collaborative Management of Suicidality (CAMS). The lengths of follow-up in these randomized studies range from six months [59] to 18 [60] and 24 months [61,62].

In Cognitive Behavioral Therapy [63] therapist and patient together explore the pa- tients’ core beliefs and automatic thoughts, to develop individual (often homework-based) goals. The emphasis is on the collaborative exploration of a person’s cognitions (the private meaning assigned by the individual) and the “suicidal belief system”. The therapist is an active and engaged expert, focusing on symptom management and crisis resolution, skill-building, and personality development.

A central element is the concept of the sui- cidal mode, based on a model of crisis as a time-limited mental state. Modes encompass cognitions, emotions, physiological symptoms, and behavior patterns, and are usually triggered, and typically have an on/off mechanism [64,65]. Dialectical Behavioral Therapy combines change strategies from cognitive-behavioral therapy with acceptance strategies, an active process, demonstrated through the use of validation strategies [66].

The main goal is to teach the patient skills to regulate emotions and improve relationships with others. The therapist’s role is characterized by the tension between accepting the patient’s inner ex- perience at a given moment, and simultaneously getting the patient to change maladaptive behavioral patterns. The therapeutic relationship is characterized by an ongoing expression of acceptance on the part of the therapist towards the patient [67].

The Attempted Suicide Short Intervention Program is a three-session patient-centered brief therapy that is aimed to maximize the patients’ active participation and treatment engagement [68]. Therapy components are a narrative interview, video-recorded (1st session), a video-playback of the patient’s narrative in which therapist and patient collaboratively reflect about the patient’s personal needs and vulnerabilities, trigger events, and the suicide action (2nd session), a collaborative psychoeducational handout, and a jointly developed case conceptualization with individual warning signs and safety strategies (3rd session).

The face-to-face sessions are followed by an active outreach element, that is, regular, personalized letters to the participants for 24 months, as a continuation of a minimal therapeutic relationship and a reminder of the work done. In an RCT with 120 patients, the risk of suicide reattempts in the treatment group was reduced by 80% [51]. In the Collaborative Assessment and Management of Suicidality [69] alliance is achieved by engaging the suicidal patient as an active participant in the assessment of the suicidal risk and by collaborating with the patient as a co-author of the suicide-specific treatment plan. The patient’s view is the “gold standard” for risk assessment. The focus of the Suicide Status Form SSF [68] is primarily on the patient’s psychological pain and suffering. The therapist serves as a consultant, coach, and co-author.

What are the therapy process factors that make psychological treatments for suicidal individuals effective? Rudd and colleagues [70] identified common elements of treatments that work, distilled from a review of available randomized clinical trials targeting suici- dality. One such element was providing patients with simple and understandable models for suicidality.

A second element is facilitating hope, which is expected to have positive implications in motivation, commitment, and overall treatment compliance. Others [71,72] have identified common elements of effective therapies, such as a clear treatment frame- work, active engagement and participation of the therapist and patient, and behavioral validation.

According to Self-Determination Theory adopting new goals and a new behav- ior requires intrinsic motivation, and this happens when clients feel listened to, valued, and understood by their therapist [73]. The therapeutic attitude should be noncoercive and nonthreatening, creating an atmosphere that is empathic, non-judgmental, and supportive of the patient’s concerns [48,74]. McCabe et al. [75] from a meta-analysis concluded that effective treatments are associated with changes in behavior (suicide attempts) but do not appear to reduce suicidal ideation.

Therapeutic interventions that directly address suicidal thoughts and behavior are particularly effective [76]. CBT, DBT, and ASSIP have highly structured therapy protocols with declared therapy goals, fostering insight, helping pa- tients to anticipate future suicidal crises, and recognizing their personal warning signs. The ASSIP treatment model is built on the theory that suicide is a goal-directed action, which, as in everyday life, is explained through stories [77].

The first session is fully reserved for the patient’s narrative of the suicidal crisis. The goal is a collaborative case formulation, which includes personal warning signs and safety strategies.

In interviewing suicidal patients, clinicians have a dual role: They must be interested and attentive listeners to the suicidal person’s story and try to understand the suicidal development, but they must also conduct a clinical assessment of medical and personal risk factors. However, interviews with suicidal patients should put the person-centered narrative approach first, with the interviewer in the not-knowing position, inviting the patient to explain his or her reasons for the suicidal behavior.

Risk Factor Models May Complement Psychological Treatment Models

There are areas where general suicide models and person-centered treatment models meet. For instance, the concept of epigenetics has helped to understand the psychological sequela of early traumatic experiences ([78,79]. Neurobiological research into problem- solving can help therapists in dealing with patients’ deficits in decision-making [80].

Similarly, the insight that problems of emotion regulation and impulse control have a neurophysiological basis has been incorporated in the Biosocial Theory of DBT, where biological vulnerabilities and individual factors (like temperament) interact with envi- ronmental factors [81]. We [82] have attempted to bridge the gap between the suicidal patients’ personal experience by measuring the suicide-script-driven neural activation with functional imaging.

The diathesis concept of neurobiological risk factors (early trauma, problems with emotion control, etc.) suggests that realistic treatment goals may not be to “cure” long-term suicide risk, but, above all, for patients to develop and acquire effective coping strategies, to compensate for biological vulnerabilities. In our clinical work, we found that including biological aspects as part of psychoeducation, can help to reduce shame and guilt related to impulsive behavior [83]. The model of an overresponsive stress system as a trait-like condition can help patients to understand why it is important to develop cognitive and behavioral skills to cope with future suicide-specific stressful sit- uations. This may also explain to patients the rationale for combining pharmacological treatments (for instance with lithium) with psychological treatments, where indicated.


Suicide is a complex and highly multifactorial phenomenon. Theoretical models of suicide are important and have contributed to our knowledge of factors involved in suicidal behavior. Yet, the expectation that comprehensive suicide models will lead to effective strategies in reducing suicide has not been fulfilled. We must abandon the idea that even more refined theoretical models will finally result in effective therapies for suicidal individuals.

In clinical suicide prevention, we must look beyond risk factor models. Suicidal behavior is inherently individual and personal. This does not preclude psychiatric assessment and treatment of associated psychiatric disorders as risk factors. However, engaging patients in collaborative treatment requires a patient-oriented approach and a strong therapeutic relationship. A meaningful therapeutic discourse needs two protagonists who share a common ground. This stands in contrast to an illness-based approach to the suicidal individual where the treatment of mental disorders has priority.

As long as clinicians see suicidal patients as passive objects and the clinician as the all-knowing expert we shall not move forward in reducing suicide. Clinical suicide prevention needs to integrate more psychotherapeutic concepts in the treatment of patients at risk of suicide.

There are now several effective psychological treatments, but, so far, they play a marginal role in the provision of care for suicidal patients. A major problem is a huge discrepancy between the number of suicide attempts and the limitations of the health care systems in the provision of therapies for suicidal patients. However, certain hope comes from studies that show that brief and specific therapies can be highly effective. Ideally, they have a clear structure, are easy to understand for patients, define clear treatment goals, and directly address suicidal thoughts and behavior.

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