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. Care includes assessment, collaborative safety planning where appropriate, and follow-up. Therapeutic relationship is critical.
Sources for the corrected statements:
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 a clinical priority across diagnoses, with urgency determined by assessment of the person's current state and circumstances. Current intent, recent suicidal behavior, access to means, and ability to maintain safety inform whether emergency intervention or another level of care is needed; suicidal thoughts alone do not establish that every presentation is an acute emergency. 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. Treatment evidence must be read for the population, intervention and outcome studied; findings about ideation or non-fatal suicidal behavior should not be presented as proof of fewer suicide deaths.
Sources for the corrected statements:
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. For children and young people with significant emotional dysregulation and frequent self-harm, NICE NG225 advises considering DBT adapted for adolescents, with attention to age and transitions between services. NICE NG225 advises considering a collaborative safety plan for people who have self-harmed. VA/DoD 2024 includes safety planning in routine care while finding insufficient evidence to recommend for or against it specifically for reducing attempts in people with recent suicidal ideation or a lifetime attempt history. A safety plan should address access to lethal means through collaborative steps to make the environment safer. No-suicide contracts do not have established protective efficacy and are not a substitute for a collaborative safety plan, assessment, and follow-up. Document practical coping steps, support and emergency contacts, and arrangements to reduce access to lethal means. 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.
Approaches and Evidence
Of 10 associated approaches, 8 have completed assessments for this topic, 0 have source checks awaiting assessment, and 2 have neither recorded yet. Each completed assessment states its population and rationale; source checks alone do not establish effectiveness. These categories describe different findings and review stages; they are not a ranking of treatments.
Guideline recommendation (4)
These assessments record a guideline recommendation for the stated population. Read the scope and rationale; a broad topic label does not make a recommendation applicable to everyone.
Cognitive Behavioral Therapy
Aaron Beck · 1964
Reviewed population: Suicide-focused CBT for adults with recent suicidal behavior or a history of self-directed violence; separately, CBT-informed care tailored to adults who self-harm.
VA/DoD 2024 weakly suggests suicide-focused CBT to reduce attempts in patients with suicidal behavior in the past six months (recommendation 5), and to reduce ideation in people with a history of self-directed violence (recommendation 6). NICE NG225 1.11.3 offers a CBT-informed intervention tailored to adults who self-harm. These are distinct populations and outcomes; they do not endorse every generic CBT protocol or establish fewer suicide deaths.
Reviewed
Guidelines and official sources (3)
3 clinical guideline checks
Read the recommendation and its scope. A source may discuss an approach without recommending it.
- Assessment and Management of Patients at Risk for Suicide
Recommendation for the stated population
VA/DoD weakly suggests suicide-focused CBT-based psychotherapy to reduce attempts in this population. Generic CBT is not interchangeable with a suicide-focused protocol.
Scope: Suicide-focused CBT-based psychotherapy for adults aged 18 and over with suicidal behavior within the past six months.
- Assessment and Management of Patients at Risk for Suicide
Recommendation for the stated population
VA/DoD weakly suggests suicide-focused CBT, including problem-solving-based psychotherapies. The ideation outcome differs from recommendation 5’s attempt outcome.
Scope: Adults aged 18 and over with a history of self-directed violence; reducing suicidal ideation.
- Self-harm: assessment, management and preventing recurrence (NG225)
Recommendation for the stated population
NICE says to offer a tailored intervention and explicitly names CBT and problem-solving therapy. This does not endorse every generic protocol or establish a reduction in suicide deaths.
Scope: Adults who have self-harmed; a structured, person-centred CBT-informed intervention tailored to their needs.
Dialectical Behavior Therapy for Adolescents
Alec Miller, Jill Rathus, Marsha Linehan · 2007
Reviewed population: Children and young people with significant emotional dysregulation and frequent self-harm, receiving adolescent-adapted DBT.
NICE NG225 1.11.4 advises considering DBT-A for this group, accounting for age and transitions between services. Its rationale reports benefit for repeated self-harm at treatment end, with no established effect at 12 months, and notes that evidence came from over-12s, mostly girls; the committee extrapolated to younger children and boys. This is narrower than all adolescent suicidality and does not establish fewer suicide deaths.
Reviewed
Guidelines and official sources (1)
1 clinical guideline check
Read the recommendation and its scope. A source may discuss an approach without recommending it.
- Self-harm: assessment, management and preventing recurrence (NG225)
Recommendation for the stated population
NICE says to consider DBT-A for this population, taking age and transitions between services into account. This is narrower than a recommendation for all adolescent suicidality.
Scope: Children and young people with significant emotional dysregulation and frequent self-harm.
Problem-Solving Therapy
D'Zurilla / Goldfried / Nezu · 1971
Reviewed population: Adults who self-harm receiving a tailored CBT-informed problem-solving intervention; suicide-focused problem-solving therapy for adults with a history of self-directed violence.
NICE NG225 1.11.3 explicitly includes problem-solving therapy within its offered CBT-informed intervention tailored to adults who self-harm. VA/DoD 2024 recommendation 6 weakly suggests suicide-focused CBT, including problem-solving-based therapies, to reduce ideation after self-directed violence. The scope is a tailored or suicide-focused intervention, not every generic PST programme. The VA recommendation concerns ideation and does not establish fewer suicide attempts or deaths for generic PST.
Reviewed
Guidelines and official sources (3)
3 clinical guideline checks
Read the recommendation and its scope. A source may discuss an approach without recommending it.
- Assessment and Management of Patients at Risk for Suicide
Recommendation for the stated population
VA/DoD includes problem-solving-based psychotherapies within its weak recommendation for suicide-focused CBT to reduce suicidal ideation. This recommendation concerns ideation and does not establish fewer suicide attempts or deaths for generic PST.
Scope: Suicide-focused, problem-solving-based CBT for adults aged 18 and over with a history of self-directed violence.
- Mental Health Gap Action Programme (mhGAP) guideline for mental, neurological and substance use disorders
Discussed in the source
WHO conditionally supports digital interventions based on approaches including problem-solving therapy, with low-certainty evidence. This is not a recommendation for every full problem-solving therapy program, and the reviewed trials did not establish benefit for attempts or deaths and were underpowered for those outcomes.
Scope: Digital support for people with suicidal thoughts.
- Self-harm: assessment, management and preventing recurrence (NG225)
Recommendation for the stated population
NICE says to offer a tailored intervention and explicitly names CBT and problem-solving therapy. This does not endorse every generic protocol or establish a reduction in suicide deaths.
Scope: Adults who have self-harmed; a structured, person-centred CBT-informed intervention tailored to their needs.
Safety Planning
Stanley / Brown · 2012
Reviewed population: Collaborative safety planning as part of care for people who have self-harmed; not a claim about a standalone plan preventing attempts.
NICE NG225 1.11.7–1.11.8 advises considering collaborative safety planning as part of care. WHO mhGAP 2023 SUI1 conditionally supports multicomponent or supported safety-planning-type interventions for thoughts or plans of self-harm in the past month or acts in the past year, with very low-certainty evidence; standalone evidence is insufficient. VA/DoD 2024 includes planning in routine care but recommendation 7 is inconclusive about reducing attempts in people with recent ideation or a lifetime attempt history. No studies of the Safety Planning Intervention and one crisis-response-planning trial met that VA review’s inclusion criteria. The guideline label describes scoped care recommendations, not proof that the original Safety Planning Intervention alone prevents attempts or deaths.
Reviewed
- NICE NG225 (2022), Recommendations 1.11.7–1.11.8 — collaborative safety planning
- NICE NG225 (2022), rationale — interventions for self-harm
- WHO mhGAP (2023), SUI1, p.108 — supported or multicomponent safety planning
- VA/DoD 2024, Recommendation 7, pp.53–54 — safety planning and attempts
- VA/DoD 2024, routine care IX.C.a, pp.31–32 — safety planning
Guidelines and official sources (4)
3 clinical guideline checks · 1 professional reference check
Read the recommendation and its scope. A source may discuss an approach without recommending it.
- Assessment and Management of Patients at Risk for Suicide
Insufficient evidence for or against
Recommendation 7 is neutral because evidence is insufficient for this outcome. The guideline also incorporates safety planning in routine care; these statements need to be read together. No Safety Planning Intervention studies and one crisis-response-planning trial met this review’s inclusion criteria; this is not a statement that no SPI research exists.
Scope: Reducing attempts in adults aged 18 and over with recent suicidal ideation and/or a lifetime attempt history.
- Study Evaluates Prevalence of Four Recommended Practices for Suicide Prevention
Discussed in the source
The Joint Commission article describes formal safety planning as expert-recommended practice and distinguishes it from explicit National Patient Safety Goal requirements.
Scope: Hospital suicide-prevention and discharge practices.
- Mental Health Gap Action Programme (mhGAP) guideline for mental, neurological and substance use disorders
Recommendation for the stated population
WHO conditionally supports considering safety-planning-type interventions that include several components or follow-up/support, with very low-certainty evidence. It found insufficient evidence to recommend safety planning as a stand-alone intervention.
Scope: People with thoughts or plans of self-harm in the past month, or acts of self-harm in the past year.
- Self-harm: assessment, management and preventing recurrence (NG225)
Recommendation for the stated population
NICE says to consider a plan with the person. This practice recommendation draws on committee experience and supporting qualitative/component evidence; it does not independently prove that a standalone plan prevents attempts.
Scope: Collaborative safety planning as part of care for people who have self-harmed.
Randomized studies (2)
These assessments describe randomized studies in the stated population. Randomized studies may include pilot or null findings; this label alone does not establish benefit.
Compassion-Focused Therapy
Paul Gilbert · 2005
Reviewed population: Girls aged 16–19 engaging in nonsuicidal self-injury in one Iranian pilot; separately, Nigerian adults with newly diagnosed HIV and suicidal ideation.
Small studies report random allocation and direct self-injury or suicidal-ideation outcomes. The 2026 NSSI abstract describes random allocation but also calls the design quasi-experimental; full allocation methods were not verified. It reports short-term improvement versus no intervention. The 2020 HIV study contains serious statistical-reporting inconsistencies. This record identifies reported randomized research, not established efficacy or prevention of suicide attempts or deaths.
Reviewed
Mentalization-Based Treatment
Fonagy / Bateman · 2004
Reviewed population: Adolescents presenting with self-harm and depression; separately, adults with borderline personality disorder in structured outpatient care.
Direct randomized studies measure self-harm, including a positive 12-month MBT-A trial. A brief adolescent group feasibility trial found no added benefit, and an adult BPD trial produced mixed comparative results. The tier identifies randomized research, not consistent superiority or proof of reduced suicide mortality; results depend on population and MBT format.
Reviewed
Guideline evidence inconclusive (2)
The named guideline review found insufficient evidence to recommend for or against the specified use, population and outcomes. This is a completed guideline assessment, not a finding of ineffectiveness or a review of the entire literature.
Collaborative Assessment and Management of Suicidality
David Jobes · 2006
Reviewed population: Adults at suicide risk in the VA/DoD care context; CAMS for reducing suicidal ideation.
VA/DoD 2024 recommendation 8 found insufficient evidence to recommend for or against CAMS for reducing suicidal ideation. This does not mean CAMS is ineffective or lacks randomized studies. The guideline describes a small pooled ideation benefit compared with alternative interventions, but no statistically clear benefit in the military/Veteran subgroup; some smaller comparisons with usual care found no differences, and study quality and modified delivery limit interpretation. It does not establish prevention of suicide deaths. VA/DoD’s evidence search ended on 15 March 2023; later studies were not reviewed in this assessment.
Reviewed
Guidelines and official sources (2)
1 clinical guideline check · 1 professional reference check
Read the recommendation and its scope. A source may discuss an approach without recommending it.
- Assessment and Management of Patients at Risk for Suicide
Insufficient evidence for or against
The 2024 guideline finds insufficient evidence for or against CAMS for reducing suicidal ideation. Inclusion in the guideline is not a positive recommendation. The guideline describes a small pooled ideation benefit versus alternative interventions but no statistically clear benefit in military/Veteran samples, with limitations in study quality and delivery.
Scope: Adults aged 18 and over at risk of suicide; CAMS for reducing suicidal ideation.
- Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth
Discussed in the source
SAMHSA describes CAMS but distinguishes assessment-tool validation from youth treatment efficacy. Its dated evidence statement should not be read as a current review of all youth trials.
Scope: Youth assessment and suicide-focused care; source published in 2020.
Dialectical Behavior Therapy
Marsha Linehan · 1993
Reviewed population: Adults at suicide risk across diagnoses in the VA/DoD review; separate positive guidance applies to women with BPD and recurrent self-harm.
VA/DoD 2024 recommendation 9 found insufficient evidence for or against DBT for suicidal ideation, attempts or suicide death in its broader adult population. This does not refute the narrower NICE CG78 1.3.4.5 recommendation to consider comprehensive DBT for women with BPD when reducing recurrent self-harm is a priority, assessed separately under personality disorders. DBT-A and digital DBT-based support have different recommendations. Combined self-harm outcomes are not equivalent to suicide attempts or deaths. VA/DoD’s evidence search ended on 15 March 2023; later studies were not reviewed in this assessment.
Reviewed
Guidelines and official sources (4)
4 clinical guideline checks
Read the recommendation and its scope. A source may discuss an approach without recommending it.
- Borderline personality disorder: recognition and management (CG78)
Recommendation for the stated population
NICE says to consider a comprehensive DBT programme for this specified population. This does not establish a recommendation for every personality disorder or every presentation.
Scope: Women with BPD for whom reducing recurrent self-harm is a priority.
- Assessment and Management of Patients at Risk for Suicide
Insufficient evidence for or against
The 2024 guideline finds insufficient evidence for or against DBT for these outcomes. This recommendation is separate from NICE’s BPD recommendation.
Scope: Adults aged 18 and over at risk of suicide; DBT for reducing suicidal ideation, suicide attempts or suicide.
- Self-harm: assessment, management and preventing recurrence (NG225)
Discussed in the source
NICE says to consider the adolescent adaptation, DBT-A, for this specified self-harm population. This does not grade every DBT programme or suicide-related outcome.
Scope: Children and young people with significant emotional dysregulation and frequent self-harm
- Mental Health Gap Action Programme (mhGAP) guideline for mental, neurological and substance use disorders
Discussed in the source
WHO conditionally supports digital interventions based on approaches including DBT, with low-certainty evidence. This is not a recommendation for every full DBT program, and the reviewed trials did not establish benefit for attempts or deaths and were underpowered for those outcomes.
Scope: Digital support for people with suicidal thoughts.
Assessment not yet completed (2)
No completed assessment or source check for this topic is recorded yet.
Compassionate Mind Training
Paul Gilbert · 2005
Psychological First Aid
National Child Traumatic Stress Network / NCTSN · 2006
Additional Source References (2)
These source checks also address this topic. They are listed separately from the catalogue associations above. Read each source’s scope and direction; a mention may concern a related intervention or a neutral recommendation.
Internet-Delivered Cognitive Behavioral Therapy
Guidelines and official sources (2)
2 clinical guideline checks
Read the recommendation and its scope. A source may discuss an approach without recommending it.
- Assessment and Management of Patients at Risk for Suicide
Discussed in the source
VA/DoD weakly supports this digital-intervention category for short-term ideation, but finds insufficient evidence for reducing attempts or suicide. This does not endorse every CBT app.
Scope: Adults aged 18 and over at risk of suicide; self-guided digital interventions containing CBT-based content; short-term suicidal-ideation outcomes.
- Mental Health Gap Action Programme (mhGAP) guideline for mental, neurological and substance use disorders
Discussed in the source
WHO conditionally supports digital interventions based on approaches including CBT, with low-certainty evidence. This is not a recommendation for every full CBT program, and the reviewed trials did not establish benefit for attempts or deaths and were underpowered for those outcomes.
Scope: Digital support for people with suicidal thoughts.
Ketamine-Assisted Psychotherapy
Guidelines and official sources (1)
1 clinical guideline check
Read the recommendation and its scope. A source may discuss an approach without recommending it.
- Assessment and Management of Patients at Risk for Suicide
Discussed in the source
VA/DoD weakly supports ketamine infusion for short-term ideation reduction; evidence for preventing attempts or suicide is insufficient. KAP is not separately recommended.
Scope: Adjunctive ketamine infusion in adults aged 18 and over with major depression and suicidal ideation; medication rather than KAP psychotherapy.
Cases Featuring Associated Approaches
These teaching cases share approach links with this topic. They may illustrate a different presenting concern.
Reading This Page
Why are these approaches listed with Suicidality & Self-Harm?
The catalogue associates 10 approaches and 0 frameworks with this topic. These links support learning and comparison; association alone is not a treatment recommendation or evidence of effectiveness.
How should I read the evidence assessments?
Assessments are specific to the population and scope stated on each card. They include a rationale, source links, and a review date. An overall review of an approach does not automatically apply to this condition, and a randomized-study label does not by itself mean that a study found benefit.
What does "Assessment not yet completed" mean?
A condition-specific assessment has not been recorded. Approaches with checked sources appear in a separate assessment-pending group; a checked source can support, oppose, or discuss an intervention without recommending it. Neither pending group means that no research exists or that the approach is ineffective. Frameworks are shown separately.
Sources and Review Scope
Source links and dates on assessment cards apply to the stated population and rationale. The clinical overview and prevalence text above are separate authored content; an approach's evidence label does not verify those statements. Recorded narrative notes and citations remain available on individual modality pages, with their review status identified. The bibliography provides further reading.