A practitioner review of 18 randomised controlled trials identifies the therapeutic elements most commonly found in interventions that reduce suicide attempts and self-harm among adolescents. The findings highlight key strategies that can inform and guide clinical practice.
Suicide and Self-Harm in Adolescents: A Growing Concern
Suicide remains one of the leading causes of death among adolescents worldwide (World Health Organization, 2018). In many countries, both suicide attempts and non-suicidal self-injury are increasing, with notable rises in presentations to emergency services following self-harm (Centers for Disease Control and Prevention, 2020; Witt et al., 2021). The problem particularly affects minoritised groups: for instance, suicide rates have been found to be particularly high among Native American and Alaskan Native adolescents in the United States and are increasing among Black and Latinx youth (Curtin & Hedegaard, 2019; Congressional Black Caucus Emergency Taskforce, 2019). Similar trends have been reported in the United Kingdom (Farooq et al., 2021).
Despite the growing need for effective interventions, few treatments have demonstrated clear and consistent benefits in reducing suicide attempts or self-harm in young people. Dialectical Behaviour Therapy (DBT) is the only approach that currently meets Level 1 criteria for reducing self-harm in adolescents across multiple trials (McCauley et al., 2018; Mehlum et al., 2014), though other promising interventions continue to be evaluated (Santamarina-Perez et al., 2020; Witt et al., 2021).
To better understand what works in practice, Meza and colleagues (2023) conducted a comprehensive review of the treatment elements shared across interventions with demonstrated benefits. They aimed to identify features that clinicians might prioritise, regardless of therapeutic model or setting.
Rates of adolescent suicide and self-harm are rising. Understanding which treatment components are most effective is a clinical priority.
What Makes an Intervention Effective?
This practitioner review examined 18 randomised controlled trials focused on reducing suicide and self-harm in adolescents aged 12–18. Each trial involved a manualized intervention, and interventions were grouped into those with significant effects on outcomes and those without. The authors identified 27 treatment elements across three domains: format (how treatment was delivered), process (how content was approached), and content (what skills or knowledge were targeted).
Format Elements
A clear pattern emerged regarding the structure of effective interventions. Most successful treatments provided a combination of individual sessions for the young person and structured involvement of parents or caregivers. These sessions often included shared therapeutic work between the young person and their family, creating space for joint problem-solving and safety planning. This combination was less frequently observed in interventions that did not show clinical benefit.
Additionally, some effective interventions offered round-the-clock phone coaching to help young people and families respond to moments of acute distress. While this level of support may not be feasible in all settings, it was notably absent in trials where interventions did not improve outcomes.
Process Elements
Several core therapeutic processes were more common in effective interventions. These included:
Building a strong therapeutic alliance with both the young person and their caregivers (Hawley & Garland, 2008; McCarty & Weisz, 2007)
- Using an individualised case formulation to tailor treatment (NICE, 2011)
- Actively addressing the young person’s concerns and priorities early in therapy
- Monitoring self-harm thoughts and behaviours over time
- Maintaining an explicit focus on safety and the development of a shared safety plan
Content Elements
Skills training formed the foundation of most effective interventions. Common targets included:
- Emotional regulation and distress tolerance (Asarnow et al., 2020)
- Social and communication skills
- Behavioural activation and impulse control (Grigoryan & Jurcik, 2020)
- Cognitive restructuring techniques
- Safety planning and lethal means counselling (National Action Alliance for Suicide Prevention, 2020; SAMHSA, 2020)
These skills were typically introduced in therapy sessions and reinforced through homework and monitoring. Importantly, in interventions that included caregiver involvement, parents were often taught the same strategies, equipping them to model and reinforce skills at home.
Effective treatments focus on practical skill-building, caregiver involvement, and ongoing safety monitoring.
Translating Findings into Clinical Practice
Meza and colleagues’ (2023) review suggests that clinicians supporting young people at risk of suicide or self-harm may benefit from focusing less on selecting a specific manualised model and more on ensuring that core treatment elements are delivered. These elements include:
- Combining individual therapy with structured caregiver involvement
- Building and maintaining a strong therapeutic alliance
- Adapting the treatment plan to individual needs through case formulation
- Integrating skills training in emotional regulation, communication, and problem-solving
- Embedding self-harm monitoring and collaborative safety planning
- Including discussions with families about restricting access to lethal means
In trials that specifically reported reductions in suicide attempts, the presence of 24/7 crisis coaching and a sustained commitment to safety planning stood out. While resource-intensive, these features may guide service development or point toward the value of digital tools to support out-of-session care.
Carefully selected treatment elements can inform scalable, evidence-informed responses to youth self-harm and suicide risk.
Conclusions
This review by Meza et al. (2023) provides clinicians with guidance on the elements most commonly found in successful treatments for adolescent suicide and self-harm. Emphasising safety, involving caregivers, and delivering targeted skills training appear to be central to effective intervention. These findings offer a flexible framework that can support decision-making across diverse clinical settings.
NB this blog has been peer-reviewed
References
- Meza, J.I., Zullo, L., Vargas, S.M., Ougrin, D., & Asarnow, J.R. (2023). Practitioner Review: Common elements in treatments for youth suicide attempts and self‐harm. Journal of Child Psychology and Psychiatry, 64(10), 1409–1421.
- Asarnow, J.R., Tompson, M.C., Klomhaus, A.M., Babeva, K., Langer, D.A., & Sugar, C.A. (2020). Randomized controlled trial of family-focused treatment for child depression compared to individual psychotherapy: One-year outcomes. Journal of Child Psychology and Psychiatry, 61(6), 662–671. https://doi.org/10.1111/jcpp.13144
- Centers for Disease Control and Prevention. (2020). Web-based Injury Statistics Query and Reporting System (WISQARS). Available from: https://www.cdc.gov/injury/wisqars/
- Congressional Black Caucus Emergency Taskforce. (2019). Ring the Alarm: The Crisis of Black Youth Suicide in America.
- Curtin, S.C., & Hedegaard, H. (2019). Suicide rates for females and males by race and ethnicity: United States, 1999 and 2017.
- Farooq, B., Clements, C., Hawton, K., Geulayov, G., Casey, D., Waters, K., … & Kapur, N. (2021). Self-harm in children and adolescents by ethnic group: An observational cohort study. The Lancet Child & Adolescent Health, 5(11), 782–791. https://doi.org/10.1016/S2352-4642(21)00252-8
- Grigoryan, K., & Jurcik, T. (2020). Psychosocial predictors of non-suicidal self-injury (NSSI) in adolescents: Literature review. Mental Health, 16, 905–912.
- Hawley, K.M., & Garland, A.F. (2008). Working alliance in adolescent outpatient therapy: Youth, parent and therapist reports and associations with therapy outcomes. Child & Youth Care Forum, 37(2), 59–74. https://doi.org/10.1007/s10566-008-9050-x
- McCarty, C.A., & Weisz, J.R. (2007). Effects of psychotherapy for depression in children and adolescents: What we can (and can’t) learn from meta-analysis and component profiling. Journal of the American Academy of Child & Adolescent Psychiatry, 46(7), 879–886. https://doi.org/10.1097/chi.0b013e31805467b4
- McCauley, E., Berk, M.S., Asarnow, J.R., Adrian, M., Cohen, J., Korslund, K., … & Linehan, M.M. (2018). Efficacy of dialectical behavior therapy for adolescents at high risk for suicide. JAMA Psychiatry, 75(8), 777–785. https://doi.org/10.1001/jamapsychiatry.2018.1109
- Mehlum, L., Tørmoen, A.J., Ramberg, M., Haga, E., Diep, L.M., Laberg, S., … & Grøholt, B. (2014). Dialectical behavior therapy for adolescents with repeated suicidal and self-harming behavior: A randomized trial. Journal of the American Academy of Child & Adolescent Psychiatry, 53(10), 1082–1091. https://doi.org/10.1016/j.jaac.2014.07.003
- Meza, J.I., Zullo, L., Vargas, S.M., Ougrin, D., & Asarnow, J.R. (2023). Practitioner Review: Common elements in treatments for youth suicide attempts and self‐harm. Journal of Child Psychology and Psychiatry, 64(10), 1409–1421. https://doi.org/10.1111/jcpp.13780
- National Action Alliance for Suicide Prevention Lethal Means Stakeholder Group. (2020). Lethal Means & Suicide Prevention: A Guide for Clinicians.
- National Institute for Health and Clinical Excellence (NICE). (2011). Self-harm in over 8s: long-term management. NICE clinical guideline [CG133].
- Santamarina-Perez, P., Mendez, I., Singh, M.K., Miklowitz, D.J., Garcia-Lopez, L.J., Moreno, C., & Birmaher, B. (2020). Adapted dialectical behavior therapy for adolescents with a high risk of suicide in a community mental health setting. Psychiatry Research, 284, 112654. https://doi.org/10.1016/j.psychres.2019.112654
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- Witt, K.G., Hetrick, S.E., Rajaram, G., Hazell, P., Taylor Salisbury, T.L., Townsend, E., & Hawton, K. (2021). Interventions for self‐harm in children and adolescents. Cochrane Database of Systematic Reviews, 2021(3), CD013667. https://doi.org/10.1002/14651858.CD013667.pub2
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About the author
Sophie Mizrahi is Content and Events Producer at the Association for Child and Adolescent Mental Health (ACAMH). She holds a BSc in Psychology and a Postgraduate Diploma in Vocational and Career Development from Favaloro University in Buenos Aires, Argentina. Her career spans community-based programmes, where she led initiatives to support individuals, particularly young adults, in navigating transitions and making informed decisions about their personal and professional aspirations. She has also contributed to digital mental health projects and AI startups, with a focus on research and the development of mental health products. Her work consistently centres on expanding access to evidence-based mental health resources for professionals and the wider public.
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