What is the safest and most effective adjunctive treatment for a patient who self‑injures?

Adjunctive Treatment for Self-Harm

Dialectical Behavior Therapy for Adolescents (DBT-A) is the most effective adjunctive treatment for patients who self-injure, reducing repetition of self-harm from 43% to 30% compared to standard care. 1, 2, 3

First-Line Psychotherapy Recommendation

DBT-A should be implemented as the primary adjunctive intervention for patients engaging in self-harm, particularly those with multiple episodes or probable personality disorder. 4, 1, 2

• DBT-A demonstrates the strongest evidence for reducing both absolute repetition (OR 0.46,95% CI 0.26 to 0.82) and frequency of self-harm in adolescents and young adults. 4, 3
• The intervention requires a comprehensive 16-24 week program consisting of weekly individual therapy, group skills training, telephone coaching, and mandatory family involvement. 1, 2
• Four essential modules must all be delivered: Core Mindfulness Skills, Interpersonal Effectiveness Skills, Distress Tolerance, and Emotion Regulation Skills. 2
• Family involvement is mandatory to improve the home environment and model adaptive behaviors, which reduces non-adherence and improves treatment outcomes. 4, 2

Important Caveat About DBT-A

DBT-A is resource-intensive, requiring highly experienced clinicians and prolonged treatment duration, making it inappropriate or unavailable for many patients. 4

Alternative Psychotherapy When DBT-A Is Unavailable

Adapted Cognitive-Behavioral Therapy (CBT) should be provided when DBT-A cannot be accessed, as it reduces post-treatment suicide attempts by approximately 50% compared to treatment-as-usual. 4, 1

• CBT-based psychotherapy shows a treatment effect for reducing repetition of self-harm (OR 0.70,95% CI 0.55 to 0.88), though the quality of evidence is lower than for DBT-A. 5, 3
• Critical adaptations for adolescents include: language tailored to younger age groups, explicit inclusion of self-harm and suicidal content within depression treatment (as self-harm ideation may persist even when depression improves), and family involvement where appropriate. 4, 1
• Treatment typically lasts up to 15 weeks. 1

Additional Evidence-Based Psychotherapy Options

For patients with multiple episodes of self-harm or probable personality disorder, consider these alternatives when DBT-A is unavailable:

• Mentalisation-Based Therapy for Adolescents (MBT-A) reduces repetition of self-harm (OR 0.35,95% CI 0.17 to 0.73) with moderate-quality evidence. 1
• Group-based emotion-regulation psychotherapy significantly reduces repetition (OR 0.34,95% CI 0.13 to 0.88), though evidence quality is low. 1

Resource-Limited Settings: Brief Interventions

When intensive psychotherapy is unavailable, implement brief safety-planning interventions that have shown efficacy in adults for reducing post-discharge suicidal behavior. 4, 1

• Safety planning should include concrete coping strategies, identified supports, and professional contact information rather than relying on risk-prediction models. 4, 1
• Brief, single-encounter interventions (safety planning, care coordination) may be effective in emergency department settings. 4
• Regular follow-up telephone contact over the post-discharge period may be effective in lower-resource settings. 4

What Does NOT Work in Resource-Limited Settings

Contact-based interventions alone (postcards, emergency cards, telephone contact) do not reduce repetition of self-harm and should not be relied upon as primary interventions. 1, 5

Pharmacotherapy: What NOT to Do

Pharmacotherapy should NOT be used solely for prevention of self-harm or suicide in adolescents or adults. 4, 1, 6

• No published trials demonstrate efficacy of pharmacological agents specifically for preventing self-harm or suicide in young people. 4
• Even in adults, pharmacological agents tested to date do not show evidence of benefit for self-harm or suicide endpoints. 4, 7
• Medications should only be continued when indicated for specific psychiatric disorders (e.g., antidepressants for concurrent depression, stimulants for ADHD). 1, 6, 2

Essential Therapeutic Assessment Components

Every episode of self-harm requires a comprehensive therapeutic assessment by a mental health professional to identify specific drivers and develop a personalized risk-management plan. 4, 1, 6

• Assessment must include formulation of contributing factors such as concurrent depression, eating disorders, harmful internet/social media use, and family dynamics. 4, 1
• Establishing an empathic, person-centered therapeutic relationship during initial assessment is critical, as negative clinical experiences perpetuate the cycle of self-harm. 4, 1, 6
• Models such as Collaborative Assessment and Management of Suicidality (CAMS) improve engagement and cooperation between therapists and patients. 4, 1

Immediate Safety Interventions (Mandatory)

All means of self-harm must be removed from the home immediately, including firearms (the single most critical safety measure), medications (both prescription and over-the-counter locked up), pesticides, and toxic substances. 1, 6

• Watch for akathisia (psychomotor restlessness) in patients taking antidepressants, which can drive suicidal impulses and may require treatment with benzodiazepines or beta-blockers. 6
• Establish regular contact with healthcare providers for anyone with acts of self-harm in the past year. 6

Staff Training and Service Delivery

All clinical staff must receive training to treat patients in a person-centered, compassionate manner, particularly in emergency departments and general hospitals where negative experiences are common. 4, 6

• Immediate mentoring and supervision should be available for emergency department staff managing self-harm presentations. 4, 6
• Consider dedicating a separate area within the emergency department to triage and assess these presentations. 4

Follow-Up Requirements

Schedule follow-up appointments within days (not weeks) after initial assessment, as the highest risk of re-attempt occurs in the months following presentation. 1

• Intensive monitoring is crucial in the first months of treatment and after every dose adjustment of psychotropic medications. 6
• Screen for suicidal ideation, self-harm urges, and safety at every session. 2

Common Pitfalls to Avoid

• Do NOT rely on "no-suicide contracts"—they have not demonstrated efficacy and do not replace vigilant monitoring. 1, 6
• Do NOT treat depression in isolation without addressing self-harm content, as self-harm ideation may persist despite mood improvement. 4, 1
• Do NOT assume case management alone is effective—it is not associated with significant reduction in repetition of self-harm. 4, 5
• Do NOT discharge patients with moderate-to-high risk factors without a psychiatric evaluation. 1
• Approximately half of young people offered therapy for self-harm do not attend all planned sessions, making engagement strategies critical. 2