What is the best treatment approach for a patient presenting with sadness, self-harm, and self-pathologization, without psychotic symptoms?

Treatment Approach for Non-Psychotic Patients with Sadness, Self-Harm, and Self-Pathologization

Begin immediately with a comprehensive therapeutic assessment that includes safety planning and formulation of contributing factors, followed by evidence-based psychotherapy—specifically Dialectical Behavior Therapy for Adolescents (DBT-A) if available, or modified CBT with explicit self-harm content if DBT-A is not feasible—while establishing an empathic therapeutic relationship and treating concurrent depression with SSRIs when indicated. 1

Initial Assessment and Safety Planning

Conduct a comprehensive therapeutic assessment after presentation, focusing on:

• Explicit screening for suicidal ideation, specific plans, access to means, and intent at every clinical encounter 2
• Formulation of factors contributing to self-harm, including concurrent depressive and eating disorders, as well as contributory factors such as harmful internet/social media use 1
• Safety planning rather than risk prediction, as safety planning has shown promise in reducing future risk 1
• Assessment of whether self-harm serves emotion regulation functions related to low mood or emotional dysregulation 2

The therapeutic assessment itself can increase engagement with subsequent treatment, particularly when provided in a timely fashion. 1

Establishing the Therapeutic Relationship

Prioritize establishing an empathic therapeutic relationship during initial assessment and all subsequent interventions. 1 Models such as the Collaborative Assessment and Management of Suicidality and Therapeutic Assessment have been found to improve engagement and cooperation. 1

Common pitfall to avoid: Negative experiences of clinical services may perpetuate a cycle of self-harm, so ensure all clinical staff treat patients in a person-centered and compassionate manner. 1

Evidence-Based Psychotherapy Selection

First-Line: DBT-A (When Resources Allow)

DBT-A shows the most promise for reducing both absolute repetition of self-harm and frequency of repeated self-harm in young people. 1 However, DBT-A is a relatively prolonged and intensive form of psychotherapy requiring highly experienced clinicians, making it unrealistic for most patients. 1

Alternative: Modified CBT with Self-Harm Content

When DBT-A is not feasible, use CBT adapted to the patient's context with the following specific modifications: 1

• Include explicit self-harm and suicidal-related content in the treatment, as self-harm ideation may persist even when depression is treated 1
• Modify language to suit the age group if treating adolescents 1
• Involve family members as appropriate (see below) 1

Individual CBT-based psychotherapy may reduce repetition of self-harm at longer follow-up time points (6- and 12-months), although evidence at immediate post-intervention is less clear. 3

Emerging Options

Mentalisation-based therapy (MBT) reduces repetition and frequency of self-harm based on high-certainty evidence from a single trial, and group-based emotion-regulation psychotherapy may also reduce repetition based on moderate-certainty evidence. 3 These warrant consideration when available.

Family Involvement

Greater family involvement in treatment may reduce non-adherence and improve treatment outcomes. 1 However, the extent of family involvement needs to be carefully tailored to the context, taking into account the views of the patient. 1

Pharmacotherapy for Concurrent Depression

Pharmacotherapy is not recommended solely for the prevention of self-harm. 1 However, when concurrent depression is present, treat vigorously with antidepressants (SSRIs), as depression is the most common complication and strongly associated with self-harm. 2, 4

Important consideration: Include specific self-harm content in psychotherapy even when treating depression pharmacologically, as self-harm ideation may persist despite depression treatment. 1

Resource-Limited Settings

When intensive psychotherapy is not available, implement:

• Safety planning interventions, which may be effective in reducing suicidal behavior post-discharge 1
• Brief, single-encounter interventions including care coordination 1
• Regular follow-up contact over the post-discharge period 1

Critical Pitfalls to Avoid

• Never assume self-harm is simply part of another condition without thorough assessment—this delays appropriate treatment for comorbid conditions 2
• Never minimize mild self-injury—even minor self-harm significantly increases suicide risk and warrants serious clinical attention 2
• Never delay intervention waiting for "stabilization"—evidence supports immediate intervention, and self-harm requires prompt, specific attention 2
• Never focus solely on prevention of self-harm rather than managing underlying distress—this can lead to continuation of distress and potentially more harmful coping methods 5, 6

Ongoing Monitoring

Screen for suicidal ideation, self-harm urges, and safety at every session. 2 Monitor for repeat self-harm, which is common and indicates need for treatment intensification. 2 More than 5% of people who present after self-harm will die by suicide within 9 years, making ongoing vigilance essential. 4