Suicidality & Self-Harm
Cross-cutting. DSM-5-TR added billable codes for suicidal behavior (T14.91A / T14.91D, history Z91.51) and nonsuicidal self-injury (R45.88, history Z91.52) to Section II; suicidal behavior disorder and NSSI disorder themselves remain Section III conditions for further study
Suicidal ideation, planning, attempts, and non-suicidal self-injury. Not a diagnosis itself but a clinical priority cutting across many conditions. Safety planning, CAMS, and DBT have most evidence. Therapeutic relationship is critical.
Prevalence: ~5% of US adults had serious thoughts of suicide in the past year (5.5%, or 14.3 million people, NSDUH 2024)
Clinical Picture
Suicidality is not a diagnosis but a clinical emergency that cuts across all diagnostic categories. The therapist's task is to hold two things simultaneously: the urgency of safety and the dignity of the client's experience. Suicide is not simply a symptom to be managed: for the person experiencing it, it often represents the only perceived solution to unbearable pain. Effective treatment requires both immediate risk management and longer-term work on the underlying suffering. The evidence favors specific interventions (CAMS, DBT, safety planning) over 'treatment as usual', though it is worth knowing what that evidence measures: suicide deaths are rare enough that almost no trial is powered to detect a change in them, so the outcomes being compared are ideation and non-fatal suicidal behavior.
Treatment Considerations
The Collaborative Assessment and Management of Suicidality (CAMS) provides a structured framework that treats the client as a collaborator in understanding and managing their suicidality. DBT's specific suicide-prevention protocols (including chain analysis of suicidal crises and distress tolerance skills) have the strongest evidence. Safety planning (Stanley-Brown) is recommended across national suicide-prevention guidance and is a reasonable default whenever risk is present, though its own evidence rests largely on non-randomized studies. Counseling on access to lethal means belongs in every safety plan: reducing access to firearms and to stockpiled medication has clearer population-level effect than any psychotherapy, because most suicidal crises are short and method substitution is less common than intuition suggests. So-called no-suicide contracts are not an alternative; they have no evidence of protective effect and may increase risk, and the commitment-to-treatment statement is the recommended replacement. The absence of suicidal ideation doesn't mean the absence of risk: clinicians should assess for capability, means access, and protective factors. Therapists working with chronically suicidal clients need their own consultation and support.
10 Therapeutic Approaches
Sorted by evidence tier: guideline-recommended first, then RCT-supported, then emerging/limited evidence.
Related Clinical Vignettes
Sources & References
Prevalence data from NIMH, WHO, and DSM-5-TR field trial publications. Evidence tiers reflect guideline status (APA, NICE, VA/DoD, WHO) and meta-analytic findings as of early 2025. Individual modality citations are listed on each modality page. Full bibliography available on the Sources page.