Self-harm (such as cutting or burning) is one of the known predictors of suicide risk. The medical community has long been interested in potential psychological interventions that could target this behavior as a way of preventing future self-harm and/or suicide. A new study just published in The Lancet Psychiatry examines one such intervention: a brief worksheet for self-harm prevention. Unfortunately, the researchers found that their worksheet was ineffective at preventing future re-hospitalizations.
There is some evidence that psychological interventions can reduce self-harm or suicidal behaviors. Most of this evidence centers around longer-term psychological interventions such as dialectical behavior therapy (DBT), and cognitive-behavior therapy (CBT). However, even this evidence has been rated as “low quality” in a recent (2016) meta-analysis by the well-regarded Cochrane Group. Other interventions did not merit even this distinction, instead, they were rated as “inconclusive.”
The authors of the current study attempted to improve this inconclusive research by using a large randomized, controlled trial design to study the effectiveness of their brief worksheet-based intervention. The researchers studied 518 patients, randomly assigned to either a brief psychological intervention or to a control group that received treatment as usual (no additional treatment). All patients had been admitted to a single hospital in the UK after a suicide attempt.
The researchers termed their worksheet a “volitional help sheet (VHS).” It contained a number of “if… then…” statements which the researchers believed could enable participants to identify alternative coping strategies when feeling the urge to self-harm or attempt suicide.
The researchers measured three primary outcomes: 1) the percentage of participants who were hospitalized again for self-harm; 2) the number of times individual participants were re-hospitalized for self-harm; and 3) the estimated cost-effectiveness of the worksheet.
The results were striking: there was no difference in the percentage of participants re-hospitalized, nor was there a difference in the number of times individuals were re-hospitalized. That is, the researchers determined that their intervention was completely ineffective for preventing self-harm.
After the failure of their primary outcomes, the researchers conducted secondary analyses to determine if their intervention might be helpful for any subgroup. In this posthoc analysis, the researchers found that people who had previously been admitted to hospitals for self-harm behaviors appeared slightly more likely to improve after the VHS intervention. The researchers state that because this was not part of their original study design, the finding needs to be replicated in future studies before it can inform policy or treatment decisions.
According to the authors: “For those with no history of self-harm hospital admission, the VHS might increase self-harm (i.e., do harm).”
The study was also limited in that it only examined re-hospitalizations. Most self-harm behaviors do not result in hospitalization, which means that it is likely that a large number of participants continued self-harming and simply were not identified during the follow-up period of the study.
In a commentary on the study also published in The Lancet Psychiatry, Katrina Witt writes that researchers hope to find “brief psychological interventions that require minimal expertise to deliver” since many people who admit to hospitals with self-harm and suicidality will not go on to receive mental health services. However, Witt also questions whether brief interventions will do more harm than good:
“These interventions also have the potential to increase rumination and negative affect, and potentially self-harm repetition, by serving as unhelpful reminders of negative experiences in the lead-up to the index self-harm event or during hospital treatment.”
As it stands now, these interventions may do more harm than good. According to the researchers, further study is needed to determine the efficacy of any of these interventions for reducing self-harm and suicidal behavior.
O’Connor, R., Ferguson, E., Scott, F., Smyth, R., McDaid, D., Park, A. . . . Armitage, C. J. (2017). A brief psychological intervention to reduce repetition of self-harm in patients admitted to hospital following a suicide attempt: a randomised controlled trial. The Lancet, 4(6), 451-460. (Link)
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“researchers hope to find “brief psychological interventions that require minimal expertise to deliver”
They ought to be looking to attachment theory’s concepts of safe haven and affect regulation if they want ‘minimal-expertise’ solutions. When my wife started to self harm for a couple of years, I simply sat with her, wrapped her up in my arms when she was doing it, and held her thru the emotional storms that assailed her. I didn’t ‘stop’ her from doing it (she would viciously bite herself), but sometimes I had her bite me, sometimes I would minimize the biting that she did to herself, but mostly I stayed calm and ‘cocooned’ her in my embrace as I carried her thru the storm. It’s been awhile since the last time she did it.
Experts make this too difficult but they also want it too easy…back to our fast-food mentality. Attachment theory gives us solid concepts to deal with self-injury. They are easy to understand and simple to implement, but they aren’t quick fixes. It takes time to undo decades of emotional turmoil.
In my experience; as having done self-harm against myself several times in my life; the absolute best (for me, personally) is just a small written or perhaps “typed” contract between you and yourself that you will not harm yourself again. My college student therapist had me do this. I carried this small written contract that I signed and he may have signed in my billfold until it was tattered, torn and virtually unreadable for many years. Later with this contract no longer in my billfold and under the influence of the very toxic drugs, very toxic therapy, serious stress, and a very toxic, abusive work environment and supervisor; I did self-harm again (by cutting.) However, at the time, my sister, who has now passed away, just bandaged me up and listened to me although she had her own stress (she was dying of cancer.)
But, I think the point is that usually the simplest and most obvious ways to change or alter a harmful behavior is so easily dismissed by alleged educated professionals. But then, like in all these supposed “abnormal psychology things” the people who perpetuate these useless, toxic therapies and drugs need to perpetuate them for their self-interest; not the individual truth and good of the person. There are so many forms, methods, and reasons for mind control; but, they all fail. God gave us (our minds, etc. ) Free Will for a purpose. Religiously and spiritually it might be His purposes; rather than immature, small minded human purposes.
Once again, the intervention is wrong-headed – it is focused on trying to stop self-harming behaviors instead of trying to figure out why they’re happening and addressing the underlying causes. The first thing I learned as a counselor about self-harming behaviors (and I learned this from the clients, not any training I had) was that self-harming behaviors served a purpose, and understanding the purpose was the key to moving forward, regardless of whether the person continued to self-harm or not. The very concept of hospitalizing someone for self-harming (non-suicidal) behavior is stupid in the extreme. Most self-harming behavior is not intended to be lethal or anything close to it, but “professionals” end up punishing the coping measure instead of looking for what the client is coping with. When I worked a crisis line for 3 1/2 years, we had many cutters call us instead of their therapists, because they knew telling their therapists meant either shaming of them (you know you’re not supposed to do that) or being sent to the hospital. As long as we’re studying how to “stop self-harming behaviors,” we will continue to create “interventions” that do more harm than good.
Telling your therapist can also get you fired for breach of contract if you’re stupid enough to sign a safety contract. Ask me how I know.
The strange thing in my case is that I never self-harmed until I was drugged with SSRIs. And I have never had any impulse to do such since I went off SSRIs in August 2015. None. It’s yet another behavior completely attributable (in my case at least) to the effects of the poisons they call medicine.
Fired by whom? There is obviously a story under here…
Fired by the therapist. Which seems to be something I’ve heard of happening quite a lot to people who’ve struggled with self-harm or suicidality. I was also warned by another treatment provider before seeing this woman that she fires a lot of patients and that I wouldn’t last with her.
I am sorry about what happened to you, kindredspirit. Steve McCrea is probably right in that there is a story underneath your tragic situation.
When I signed my “contract” it was when I was in college; long before the horrific usage of toxic drugs and toxic therapies that can not only harm you, perhaps for life or even kill you before your time. When this happened to me, no toxic drugs or false diagnoses that never existed were applied to me. It was handwritten on yellow notepaper by me. Probably in this day and time; the way psychiatry, et. al; works it would be dangerous and lead to negative more harmful consequences than the actual self-harm itself. Only if you saw a private counselor, of the grid, so to speak, might it work.
Since then I have been critically harmed and damaged by these mental illness zealots who said I had a diseases/disorders I never had (I am no expert; but I am not under the thought that self-harm means you have an alleged diagnosable disease/disorder.) and drugged me so horribly that eventually I got to a point my body almost shut down through a sleep I almost did not wake up from. Now, I am in the slow and steady state of withdrawal and healing; relearning my whole self; including my brain and body. My body is not always as happy as it used to be before the drugs; but, each day I get a little better. My mind is mostly very good; but one thing I am learning and which was hidden from me; is there is a uniqueness to my brain that must be honored and that when I operate from that uniqueness; I do better and am happier. etc. But, of course this all hid from me for their own self-interest; not mine. What happened to me worked until the paper died and the toxic drugs and therapy got forced onto me. Now off all that toxic junk, I don’t need a contract or anything. I just need me and God. Thank you.
I don’t support any psychological “interventions”. But if they’re pinning their hopes on “brief psychological interventions that require minimal expertise to deliver” they ain’t going nowhere.