Systemic family therapy is not superior to treatment as usual in reducing subsequent acts of self-harm in adolescents who have a history of the disorder, a new study published in Lancet Psychiatry suggests.


Investigators led by David J. Cottrell, foundation chair in child and adolescent psychiatry, Leeds Institute of Health Sciences, United Kingdom, compared a manual-based family therapy intervention to more generalized therapies in young people who had self-harmed at least twice.

The researchers found no significant difference between the groups with respect to rates of hospitalization for repetition of self-harm. "Clinicians are therefore still unable to recommend a clear, evidence-based intervention to reduce repeated self-harm in adolescents," the authors write.

"Self-harm in adolescents is a global public health problem," the authors write, but a "single effective intervention has not been identified." They note that previous studies that included "strong family involvement and substantial treatment dose" showed "significant reductions in self-harm events."

Because family factors, such as parent-child interaction, perceived support, expressed emotion, experience of abuse, parental conflict, and parental mental health, are "associated with self-harm in children and adolescents," a therapeutic approach that draws on and mobilizes the existing strengths and resources of the child and family is "a logical potential intervention after self-harm."

The Self-Harm Intervention: Family Therapy (SHIFT) trial was designed to investigate a "new form" of family therapy for self-harm. It was conducted to "investigate the clinical effectiveness and cost-effectiveness of family therapy for adolescents who self-harm."

Treatment, as usual, was "diverse," with the most common modality being supportive therapy or counseling. Other interventions included cognitive-behavioral therapy, family work (discussion meetings with families without formal family therapy), and formal systemic family therapy.

Participants (n = 832) included children and adolescents aged 11 to 17 years, who had been referred to Child and Adolescent Mental Health Services (CAMHS) for self-harm following at least two prior episodes. Participants were randomly allocated to receive either family therapy (n = 415) or treatment as usual (n = 417).

The researchers measured suicidal ideation, quality of life, depression, mental health, family functioning, self-harm, emotional traits, health economics, and engagement with therapy. Assessments were administered at baseline and at 3, 6, 12, and 18 months after random group assignments.

The outcomes included repetition of self-harm leading to hospital attendance during the 12 and 18 months following group assignment, cost per self-harm event averted by family therapy, characteristics of self-harm episodes, suicidal ideation, quality of life, depression, overall mental health and emotional and behavioral difficulties.

As determined on the basis of the Suicide Attempt Self-Injury Interview, 62% of participants met criteria for nonsuicidal self-injury. However, only 60% of participants in the family therapy group and 45% in the treatment-as-usual group were available at 12 months.

At the 18-month follow-up, 27% of all participants had been hospitalized after repeated self-harm: 28% of the family-therapy group, and 25% of the treatment-as-usual group. Repeated self-harm was less common in males and in participants aged 15 years or younger.

The proportions of patients who repeated self-harm were higher in the subgroups who were referred to CAMHS via hospital, as compared to those referred via the community, and in participants with an index episode that combined self-injury with poisoning, in comparison to either method alone.

Participants often engaged in a different method of self-harm than the one they used in the index event. More than half of participants who had self-injured at their index episode subsequently engaging in self-poisoning.

In participants who reported difficulty talking about feelings, the risk for hospital attendance for repeat self-harm was increased in the family therapy group, compared to the treatment-as-usual group. In participants who reported being able to discuss feelings easily, the risk was decreased in the family therapy group, compared to the treatment-as-usual group.

Participants and their caregivers in the family therapy group reported significantly better outcomes on several elements of general emotional and behavioral difficulties, as measured by the Strengths and Difficulties Questionnaire, "suggesting that family therapy had a significant positive effect on general mental health, even if this did not translate into reduced repetition of self-harm," the authors note.