• Bipolar Disorder
  • Therapy Center
  • When To See a Therapist
  • Types of Therapy
  • Best Online Therapy
  • Best Couples Therapy
  • Best Family Therapy
  • Managing Stress
  • Sleep and Dreaming
  • Understanding Emotions
  • Self-Improvement
  • Healthy Relationships
  • Student Resources
  • Personality Types
  • Guided Meditations
  • Verywell Mind Insights
  • 2024 Verywell Mind 25
  • Mental Health in the Classroom
  • Editorial Process
  • Meet Our Review Board
  • Crisis Support

What Is Problem-Solving Therapy?

Arlin Cuncic, MA, is the author of The Anxiety Workbook and founder of the website About Social Anxiety. She has a Master's degree in clinical psychology.

intervention and problem solving in counseling brainly

Daniel B. Block, MD, is an award-winning, board-certified psychiatrist who operates a private practice in Pennsylvania.

intervention and problem solving in counseling brainly

Verywell / Madelyn Goodnight

Problem-Solving Therapy Techniques

How effective is problem-solving therapy, things to consider, how to get started.

Problem-solving therapy is a brief intervention that provides people with the tools they need to identify and solve problems that arise from big and small life stressors. It aims to improve your overall quality of life and reduce the negative impact of psychological and physical illness.

Problem-solving therapy can be used to treat depression , among other conditions. It can be administered by a doctor or mental health professional and may be combined with other treatment approaches.

At a Glance

Problem-solving therapy is a short-term treatment used to help people who are experiencing depression, stress, PTSD, self-harm, suicidal ideation, and other mental health problems develop the tools they need to deal with challenges. This approach teaches people to identify problems, generate solutions, and implement those solutions. Let's take a closer look at how problem-solving therapy can help people be more resilient and adaptive in the face of stress.

Problem-solving therapy is based on a model that takes into account the importance of real-life problem-solving. In other words, the key to managing the impact of stressful life events is to know how to address issues as they arise. Problem-solving therapy is very practical in its approach and is only concerned with the present, rather than delving into your past.

This form of therapy can take place one-on-one or in a group format and may be offered in person or online via telehealth . Sessions can be anywhere from 30 minutes to two hours long. 

Key Components

There are two major components that make up the problem-solving therapy framework:

  • Applying a positive problem-solving orientation to your life
  • Using problem-solving skills

A positive problem-solving orientation means viewing things in an optimistic light, embracing self-efficacy , and accepting the idea that problems are a normal part of life. Problem-solving skills are behaviors that you can rely on to help you navigate conflict, even during times of stress. This includes skills like:

  • Knowing how to identify a problem
  • Defining the problem in a helpful way
  • Trying to understand the problem more deeply
  • Setting goals related to the problem
  • Generating alternative, creative solutions to the problem
  • Choosing the best course of action
  • Implementing the choice you have made
  • Evaluating the outcome to determine next steps

Problem-solving therapy is all about training you to become adaptive in your life so that you will start to see problems as challenges to be solved instead of insurmountable obstacles. It also means that you will recognize the action that is required to engage in effective problem-solving techniques.

Planful Problem-Solving

One problem-solving technique, called planful problem-solving, involves following a series of steps to fix issues in a healthy, constructive way:

  • Problem definition and formulation : This step involves identifying the real-life problem that needs to be solved and formulating it in a way that allows you to generate potential solutions.
  • Generation of alternative solutions : This stage involves coming up with various potential solutions to the problem at hand. The goal in this step is to brainstorm options to creatively address the life stressor in ways that you may not have previously considered.
  • Decision-making strategies : This stage involves discussing different strategies for making decisions as well as identifying obstacles that may get in the way of solving the problem at hand.
  • Solution implementation and verification : This stage involves implementing a chosen solution and then verifying whether it was effective in addressing the problem.

Other Techniques

Other techniques your therapist may go over include:

  • Problem-solving multitasking , which helps you learn to think clearly and solve problems effectively even during times of stress
  • Stop, slow down, think, and act (SSTA) , which is meant to encourage you to become more emotionally mindful when faced with conflict
  • Healthy thinking and imagery , which teaches you how to embrace more positive self-talk while problem-solving

What Problem-Solving Therapy Can Help With

Problem-solving therapy addresses life stress issues and focuses on helping you find solutions to concrete issues. This approach can be applied to problems associated with various psychological and physiological symptoms.

Mental Health Issues

Problem-solving therapy may help address mental health issues, like:

  • Chronic stress due to accumulating minor issues
  • Complications associated with traumatic brain injury (TBI)
  • Emotional distress
  • Post-traumatic stress disorder (PTSD)
  • Problems associated with a chronic disease like cancer, heart disease, or diabetes
  • Self-harm and feelings of hopelessness
  • Substance use
  • Suicidal ideation

Specific Life Challenges

This form of therapy is also helpful for dealing with specific life problems, such as:

  • Death of a loved one
  • Dissatisfaction at work
  • Everyday life stressors
  • Family problems
  • Financial difficulties
  • Relationship conflicts

Your doctor or mental healthcare professional will be able to advise whether problem-solving therapy could be helpful for your particular issue. In general, if you are struggling with specific, concrete problems that you are having trouble finding solutions for, problem-solving therapy could be helpful for you.

Benefits of Problem-Solving Therapy

The skills learned in problem-solving therapy can be helpful for managing all areas of your life. These can include:

  • Being able to identify which stressors trigger your negative emotions (e.g., sadness, anger)
  • Confidence that you can handle problems that you face
  • Having a systematic approach on how to deal with life's problems
  • Having a toolbox of strategies to solve the issues you face
  • Increased confidence to find creative solutions
  • Knowing how to identify which barriers will impede your progress
  • Knowing how to manage emotions when they arise
  • Reduced avoidance and increased action-taking
  • The ability to accept life problems that can't be solved
  • The ability to make effective decisions
  • The development of patience (realizing that not all problems have a "quick fix")

Problem-solving therapy can help people feel more empowered to deal with the problems they face in their lives. Rather than feeling overwhelmed when stressors begin to take a toll, this therapy introduces new coping skills that can boost self-efficacy and resilience .

Other Types of Therapy

Other similar types of therapy include cognitive-behavioral therapy (CBT) and solution-focused brief therapy (SFBT) . While these therapies work to change thinking and behaviors, they work a bit differently. Both CBT and SFBT are less structured than problem-solving therapy and may focus on broader issues. CBT focuses on identifying and changing maladaptive thoughts, and SFBT works to help people look for solutions and build self-efficacy based on strengths.

This form of therapy was initially developed to help people combat stress through effective problem-solving, and it was later adapted to address clinical depression specifically. Today, much of the research on problem-solving therapy deals with its effectiveness in treating depression.

Problem-solving therapy has been shown to help depression in: 

  • Older adults
  • People coping with serious illnesses like cancer

Problem-solving therapy also appears to be effective as a brief treatment for depression, offering benefits in as little as six to eight sessions with a therapist or another healthcare professional. This may make it a good option for someone unable to commit to a lengthier treatment for depression.

Problem-solving therapy is not a good fit for everyone. It may not be effective at addressing issues that don't have clear solutions, like seeking meaning or purpose in life. Problem-solving therapy is also intended to treat specific problems, not general habits or thought patterns .

In general, it's also important to remember that problem-solving therapy is not a primary treatment for mental disorders. If you are living with the symptoms of a serious mental illness such as bipolar disorder or schizophrenia , you may need additional treatment with evidence-based approaches for your particular concern.

Problem-solving therapy is best aimed at someone who has a mental or physical issue that is being treated separately, but who also has life issues that go along with that problem that has yet to be addressed.

For example, it could help if you can't clean your house or pay your bills because of your depression, or if a cancer diagnosis is interfering with your quality of life.

Your doctor may be able to recommend therapists in your area who utilize this approach, or they may offer it themselves as part of their practice. You can also search for a problem-solving therapist with help from the American Psychological Association’s (APA) Society of Clinical Psychology .

If receiving problem-solving therapy from a doctor or mental healthcare professional is not an option for you, you could also consider implementing it as a self-help strategy using a workbook designed to help you learn problem-solving skills on your own.

During your first session, your therapist may spend some time explaining their process and approach. They may ask you to identify the problem you’re currently facing, and they’ll likely discuss your goals for therapy .

Keep In Mind

Problem-solving therapy may be a short-term intervention that's focused on solving a specific issue in your life. If you need further help with something more pervasive, it can also become a longer-term treatment option.

Get Help Now

We've tried, tested, and written unbiased reviews of the best online therapy programs including Talkspace, BetterHelp, and ReGain. Find out which option is the best for you.

Shang P, Cao X, You S, Feng X, Li N, Jia Y. Problem-solving therapy for major depressive disorders in older adults: an updated systematic review and meta-analysis of randomized controlled trials .  Aging Clin Exp Res . 2021;33(6):1465-1475. doi:10.1007/s40520-020-01672-3

Cuijpers P, Wit L de, Kleiboer A, Karyotaki E, Ebert DD. Problem-solving therapy for adult depression: An updated meta-analysis . Eur Psychiatry . 2018;48(1):27-37. doi:10.1016/j.eurpsy.2017.11.006

Nezu AM, Nezu CM, D'Zurilla TJ. Problem-Solving Therapy: A Treatment Manual . New York; 2013. doi:10.1891/9780826109415.0001

Owens D, Wright-Hughes A, Graham L, et al. Problem-solving therapy rather than treatment as usual for adults after self-harm: a pragmatic, feasibility, randomised controlled trial (the MIDSHIPS trial) .  Pilot Feasibility Stud . 2020;6:119. doi:10.1186/s40814-020-00668-0

Sorsdahl K, Stein DJ, Corrigall J, et al. The efficacy of a blended motivational interviewing and problem solving therapy intervention to reduce substance use among patients presenting for emergency services in South Africa: A randomized controlled trial . Subst Abuse Treat Prev Policy . 2015;10(1):46. doi:doi.org/10.1186/s13011-015-0042-1

Margolis SA, Osborne P, Gonzalez JS. Problem solving . In: Gellman MD, ed. Encyclopedia of Behavioral Medicine . Springer International Publishing; 2020:1745-1747. doi:10.1007/978-3-030-39903-0_208

Kirkham JG, Choi N, Seitz DP. Meta-analysis of problem solving therapy for the treatment of major depressive disorder in older adults . Int J Geriatr Psychiatry . 2016;31(5):526-535. doi:10.1002/gps.4358

Garand L, Rinaldo DE, Alberth MM, et al. Effects of problem solving therapy on mental health outcomes in family caregivers of persons with a new diagnosis of mild cognitive impairment or early dementia: A randomized controlled trial . Am J Geriatr Psychiatry . 2014;22(8):771-781. doi:10.1016/j.jagp.2013.07.007

Noyes K, Zapf AL, Depner RM, et al. Problem-solving skills training in adult cancer survivors: Bright IDEAS-AC pilot study .  Cancer Treat Res Commun . 2022;31:100552. doi:10.1016/j.ctarc.2022.100552

Albert SM, King J, Anderson S, et al. Depression agency-based collaborative: effect of problem-solving therapy on risk of common mental disorders in older adults with home care needs . The American Journal of Geriatric Psychiatry . 2019;27(6):619-624. doi:10.1016/j.jagp.2019.01.002

By Arlin Cuncic, MA Arlin Cuncic, MA, is the author of The Anxiety Workbook and founder of the website About Social Anxiety. She has a Master's degree in clinical psychology.

10 Best Problem-Solving Therapy Worksheets & Activities

Problem solving therapy

Cognitive science tells us that we regularly face not only well-defined problems but, importantly, many that are ill defined (Eysenck & Keane, 2015).

Sometimes, we find ourselves unable to overcome our daily problems or the inevitable (though hopefully infrequent) life traumas we face.

Problem-Solving Therapy aims to reduce the incidence and impact of mental health disorders and improve wellbeing by helping clients face life’s difficulties (Dobson, 2011).

This article introduces Problem-Solving Therapy and offers techniques, activities, and worksheets that mental health professionals can use with clients.

Before you continue, we thought you might like to download our three Positive Psychology Exercises for free . These science-based exercises explore fundamental aspects of positive psychology, including strengths, values, and self-compassion, and will give you the tools to enhance the wellbeing of your clients, students, or employees.

This Article Contains:

What is problem-solving therapy, 14 steps for problem-solving therapy, 3 best interventions and techniques, 7 activities and worksheets for your session, fascinating books on the topic, resources from positivepsychology.com, a take-home message.

Problem-Solving Therapy assumes that mental disorders arise in response to ineffective or maladaptive coping. By adopting a more realistic and optimistic view of coping, individuals can understand the role of emotions and develop actions to reduce distress and maintain mental wellbeing (Nezu & Nezu, 2009).

“Problem-solving therapy (PST) is a psychosocial intervention, generally considered to be under a cognitive-behavioral umbrella” (Nezu, Nezu, & D’Zurilla, 2013, p. ix). It aims to encourage the client to cope better with day-to-day problems and traumatic events and reduce their impact on mental and physical wellbeing.

Clinical research, counseling, and health psychology have shown PST to be highly effective in clients of all ages, ranging from children to the elderly, across multiple clinical settings, including schizophrenia, stress, and anxiety disorders (Dobson, 2011).

Can it help with depression?

PST appears particularly helpful in treating clients with depression. A recent analysis of 30 studies found that PST was an effective treatment with a similar degree of success as other successful therapies targeting depression (Cuijpers, Wit, Kleiboer, Karyotaki, & Ebert, 2020).

Other studies confirm the value of PST and its effectiveness at treating depression in multiple age groups and its capacity to combine with other therapies, including drug treatments (Dobson, 2011).

The major concepts

Effective coping varies depending on the situation, and treatment typically focuses on improving the environment and reducing emotional distress (Dobson, 2011).

PST is based on two overlapping models:

Social problem-solving model

This model focuses on solving the problem “as it occurs in the natural social environment,” combined with a general coping strategy and a method of self-control (Dobson, 2011, p. 198).

The model includes three central concepts:

  • Social problem-solving
  • The problem
  • The solution

The model is a “self-directed cognitive-behavioral process by which an individual, couple, or group attempts to identify or discover effective solutions for specific problems encountered in everyday living” (Dobson, 2011, p. 199).

Relational problem-solving model

The theory of PST is underpinned by a relational problem-solving model, whereby stress is viewed in terms of the relationships between three factors:

  • Stressful life events
  • Emotional distress and wellbeing
  • Problem-solving coping

Therefore, when a significant adverse life event occurs, it may require “sweeping readjustments in a person’s life” (Dobson, 2011, p. 202).

intervention and problem solving in counseling brainly

  • Enhance positive problem orientation
  • Decrease negative orientation
  • Foster ability to apply rational problem-solving skills
  • Reduce the tendency to avoid problem-solving
  • Minimize the tendency to be careless and impulsive

D’Zurilla’s and Nezu’s model includes (modified from Dobson, 2011):

  • Initial structuring Establish a positive therapeutic relationship that encourages optimism and explains the PST approach.
  • Assessment Formally and informally assess areas of stress in the client’s life and their problem-solving strengths and weaknesses.
  • Obstacles to effective problem-solving Explore typically human challenges to problem-solving, such as multitasking and the negative impact of stress. Introduce tools that can help, such as making lists, visualization, and breaking complex problems down.
  • Problem orientation – fostering self-efficacy Introduce the importance of a positive problem orientation, adopting tools, such as visualization, to promote self-efficacy.
  • Problem orientation – recognizing problems Help clients recognize issues as they occur and use problem checklists to ‘normalize’ the experience.
  • Problem orientation – seeing problems as challenges Encourage clients to break free of harmful and restricted ways of thinking while learning how to argue from another point of view.
  • Problem orientation – use and control emotions Help clients understand the role of emotions in problem-solving, including using feelings to inform the process and managing disruptive emotions (such as cognitive reframing and relaxation exercises).
  • Problem orientation – stop and think Teach clients how to reduce impulsive and avoidance tendencies (visualizing a stop sign or traffic light).
  • Problem definition and formulation Encourage an understanding of the nature of problems and set realistic goals and objectives.
  • Generation of alternatives Work with clients to help them recognize the wide range of potential solutions to each problem (for example, brainstorming).
  • Decision-making Encourage better decision-making through an improved understanding of the consequences of decisions and the value and likelihood of different outcomes.
  • Solution implementation and verification Foster the client’s ability to carry out a solution plan, monitor its outcome, evaluate its effectiveness, and use self-reinforcement to increase the chance of success.
  • Guided practice Encourage the application of problem-solving skills across multiple domains and future stressful problems.
  • Rapid problem-solving Teach clients how to apply problem-solving questions and guidelines quickly in any given situation.

Success in PST depends on the effectiveness of its implementation; using the right approach is crucial (Dobson, 2011).

Problem-solving therapy – Baycrest

The following interventions and techniques are helpful when implementing more effective problem-solving approaches in client’s lives.

First, it is essential to consider if PST is the best approach for the client, based on the problems they present.

Is PPT appropriate?

It is vital to consider whether PST is appropriate for the client’s situation. Therapists new to the approach may require additional guidance (Nezu et al., 2013).

Therapists should consider the following questions before beginning PST with a client (modified from Nezu et al., 2013):

  • Has PST proven effective in the past for the problem? For example, research has shown success with depression, generalized anxiety, back pain, Alzheimer’s disease, cancer, and supporting caregivers (Nezu et al., 2013).
  • Is PST acceptable to the client?
  • Is the individual experiencing a significant mental or physical health problem?

All affirmative answers suggest that PST would be a helpful technique to apply in this instance.

Five problem-solving steps

The following five steps are valuable when working with clients to help them cope with and manage their environment (modified from Dobson, 2011).

Ask the client to consider the following points (forming the acronym ADAPT) when confronted by a problem:

  • Attitude Aim to adopt a positive, optimistic attitude to the problem and problem-solving process.
  • Define Obtain all required facts and details of potential obstacles to define the problem.
  • Alternatives Identify various alternative solutions and actions to overcome the obstacle and achieve the problem-solving goal.
  • Predict Predict each alternative’s positive and negative outcomes and choose the one most likely to achieve the goal and maximize the benefits.
  • Try out Once selected, try out the solution and monitor its effectiveness while engaging in self-reinforcement.

If the client is not satisfied with their solution, they can return to step ‘A’ and find a more appropriate solution.

3 positive psychology exercises

Download 3 Free Positive Psychology Exercises (PDF)

Enhance wellbeing with these free, science-based exercises that draw on the latest insights from positive psychology.

Download 3 Free Positive Psychology Tools Pack (PDF)

By filling out your name and email address below.

Positive self-statements

When dealing with clients facing negative self-beliefs, it can be helpful for them to use positive self-statements.

Use the following (or add new) self-statements to replace harmful, negative thinking (modified from Dobson, 2011):

  • I can solve this problem; I’ve tackled similar ones before.
  • I can cope with this.
  • I just need to take a breath and relax.
  • Once I start, it will be easier.
  • It’s okay to look out for myself.
  • I can get help if needed.
  • Other people feel the same way I do.
  • I’ll take one piece of the problem at a time.
  • I can keep my fears in check.
  • I don’t need to please everyone.

Worksheets for problem solving therapy

5 Worksheets and workbooks

Problem-solving self-monitoring form.

Answering the questions in the Problem-Solving Self-Monitoring Form provides the therapist with necessary information regarding the client’s overall and specific problem-solving approaches and reactions (Dobson, 2011).

Ask the client to complete the following:

  • Describe the problem you are facing.
  • What is your goal?
  • What have you tried so far to solve the problem?
  • What was the outcome?

Reactions to Stress

It can be helpful for the client to recognize their own experiences of stress. Do they react angrily, withdraw, or give up (Dobson, 2011)?

The Reactions to Stress worksheet can be given to the client as homework to capture stressful events and their reactions. By recording how they felt, behaved, and thought, they can recognize repeating patterns.

What Are Your Unique Triggers?

Helping clients capture triggers for their stressful reactions can encourage emotional regulation.

When clients can identify triggers that may lead to a negative response, they can stop the experience or slow down their emotional reaction (Dobson, 2011).

The What Are Your Unique Triggers ? worksheet helps the client identify their triggers (e.g., conflict, relationships, physical environment, etc.).

Problem-Solving worksheet

Imagining an existing or potential problem and working through how to resolve it can be a powerful exercise for the client.

Use the Problem-Solving worksheet to state a problem and goal and consider the obstacles in the way. Then explore options for achieving the goal, along with their pros and cons, to assess the best action plan.

Getting the Facts

Clients can become better equipped to tackle problems and choose the right course of action by recognizing facts versus assumptions and gathering all the necessary information (Dobson, 2011).

Use the Getting the Facts worksheet to answer the following questions clearly and unambiguously:

  • Who is involved?
  • What did or did not happen, and how did it bother you?
  • Where did it happen?
  • When did it happen?
  • Why did it happen?
  • How did you respond?

2 Helpful Group Activities

While therapists can use the worksheets above in group situations, the following two interventions work particularly well with more than one person.

Generating Alternative Solutions and Better Decision-Making

A group setting can provide an ideal opportunity to share a problem and identify potential solutions arising from multiple perspectives.

Use the Generating Alternative Solutions and Better Decision-Making worksheet and ask the client to explain the situation or problem to the group and the obstacles in the way.

Once the approaches are captured and reviewed, the individual can share their decision-making process with the group if they want further feedback.

Visualization

Visualization can be performed with individuals or in a group setting to help clients solve problems in multiple ways, including (Dobson, 2011):

  • Clarifying the problem by looking at it from multiple perspectives
  • Rehearsing a solution in the mind to improve and get more practice
  • Visualizing a ‘safe place’ for relaxation, slowing down, and stress management

Guided imagery is particularly valuable for encouraging the group to take a ‘mental vacation’ and let go of stress.

Ask the group to begin with slow, deep breathing that fills the entire diaphragm. Then ask them to visualize a favorite scene (real or imagined) that makes them feel relaxed, perhaps beside a gently flowing river, a summer meadow, or at the beach.

The more the senses are engaged, the more real the experience. Ask the group to think about what they can hear, see, touch, smell, and even taste.

Encourage them to experience the situation as fully as possible, immersing themselves and enjoying their place of safety.

Such feelings of relaxation may be able to help clients fall asleep, relieve stress, and become more ready to solve problems.

We have included three of our favorite books on the subject of Problem-Solving Therapy below.

1. Problem-Solving Therapy: A Treatment Manual – Arthur Nezu, Christine Maguth Nezu, and Thomas D’Zurilla

Problem-Solving Therapy

This is an incredibly valuable book for anyone wishing to understand the principles and practice behind PST.

Written by the co-developers of PST, the manual provides powerful toolkits to overcome cognitive overload, emotional dysregulation, and the barriers to practical problem-solving.

Find the book on Amazon .

2. Emotion-Centered Problem-Solving Therapy: Treatment Guidelines – Arthur Nezu and Christine Maguth Nezu

Emotion-Centered Problem-Solving Therapy

Another, more recent, book from the creators of PST, this text includes important advances in neuroscience underpinning the role of emotion in behavioral treatment.

Along with clinical examples, the book also includes crucial toolkits that form part of a stepped model for the application of PST.

3. Handbook of Cognitive-Behavioral Therapies – Keith Dobson and David Dozois

Handbook of Cognitive-Behavioral Therapies

This is the fourth edition of a hugely popular guide to Cognitive-Behavioral Therapies and includes a valuable and insightful section on Problem-Solving Therapy.

This is an important book for students and more experienced therapists wishing to form a high-level and in-depth understanding of the tools and techniques available to Cognitive-Behavioral Therapists.

For even more tools to help strengthen your clients’ problem-solving skills, check out the following free worksheets from our blog.

  • Case Formulation Worksheet This worksheet presents a four-step framework to help therapists and their clients come to a shared understanding of the client’s presenting problem.
  • Understanding Your Default Problem-Solving Approach This worksheet poses a series of questions helping clients reflect on their typical cognitive, emotional, and behavioral responses to problems.
  • Social Problem Solving: Step by Step This worksheet presents a streamlined template to help clients define a problem, generate possible courses of action, and evaluate the effectiveness of an implemented solution.

If you’re looking for more science-based ways to help others enhance their wellbeing, check out this signature collection of 17 validated positive psychology tools for practitioners. Use them to help others flourish and thrive.

intervention and problem solving in counseling brainly

17 Top-Rated Positive Psychology Exercises for Practitioners

Expand your arsenal and impact with these 17 Positive Psychology Exercises [PDF] , scientifically designed to promote human flourishing, meaning, and wellbeing.

Created by Experts. 100% Science-based.

While we are born problem-solvers, facing an incredibly diverse set of challenges daily, we sometimes need support.

Problem-Solving Therapy aims to reduce stress and associated mental health disorders and improve wellbeing by improving our ability to cope. PST is valuable in diverse clinical settings, ranging from depression to schizophrenia, with research suggesting it as a highly effective treatment for teaching coping strategies and reducing emotional distress.

Many PST techniques are available to help improve clients’ positive outlook on obstacles while reducing avoidance of problem situations and the tendency to be careless and impulsive.

The PST model typically assesses the client’s strengths, weaknesses, and coping strategies when facing problems before encouraging a healthy experience of and relationship with problem-solving.

Why not use this article to explore the theory behind PST and try out some of our powerful tools and interventions with your clients to help them with their decision-making, coping, and problem-solving?

We hope you enjoyed reading this article. Don’t forget to download our three Positive Psychology Exercises for free .

  • Cuijpers, P., Wit, L., Kleiboer, A., Karyotaki, E., & Ebert, D. (2020). Problem-solving therapy for adult depression: An updated meta-analysis. European P sychiatry ,  48 (1), 27–37.
  • Dobson, K. S. (2011). Handbook of cognitive-behavioral therapies (3rd ed.). Guilford Press.
  • Dobson, K. S., & Dozois, D. J. A. (2021). Handbook of cognitive-behavioral therapies  (4th ed.). Guilford Press.
  • Eysenck, M. W., & Keane, M. T. (2015). Cognitive psychology: A student’s handbook . Psychology Press.
  • Nezu, A. M., & Nezu, C. M. (2009). Problem-solving therapy DVD . Retrieved September 13, 2021, from https://www.apa.org/pubs/videos/4310852
  • Nezu, A. M., & Nezu, C. M. (2018). Emotion-centered problem-solving therapy: Treatment guidelines. Springer.
  • Nezu, A. M., Nezu, C. M., & D’Zurilla, T. J. (2013). Problem-solving therapy: A treatment manual . Springer.

' src=

Share this article:

Article feedback

What our readers think.

Saranya

Thanks for your information given, it was helpful for me something new I learned

Let us know your thoughts Cancel reply

Your email address will not be published.

Save my name, email, and website in this browser for the next time I comment.

Related articles

Variations of the empty chair

The Empty Chair Technique: How It Can Help Your Clients

Resolving ‘unfinished business’ is often an essential part of counseling. If left unresolved, it can contribute to depression, anxiety, and mental ill-health while damaging existing [...]

intervention and problem solving in counseling brainly

29 Best Group Therapy Activities for Supporting Adults

As humans, we are social creatures with personal histories based on the various groups that make up our lives. Childhood begins with a family of [...]

Free Therapy Resources

47 Free Therapy Resources to Help Kick-Start Your New Practice

Setting up a private practice in psychotherapy brings several challenges, including a considerable investment of time and money. You can reduce risks early on by [...]

Read other articles by their category

  • Body & Brain (49)
  • Coaching & Application (58)
  • Compassion (25)
  • Counseling (51)
  • Emotional Intelligence (23)
  • Gratitude (18)
  • Grief & Bereavement (21)
  • Happiness & SWB (40)
  • Meaning & Values (26)
  • Meditation (20)
  • Mindfulness (44)
  • Motivation & Goals (45)
  • Optimism & Mindset (34)
  • Positive CBT (30)
  • Positive Communication (21)
  • Positive Education (47)
  • Positive Emotions (32)
  • Positive Leadership (19)
  • Positive Parenting (16)
  • Positive Psychology (34)
  • Positive Workplace (37)
  • Productivity (17)
  • Relationships (44)
  • Resilience & Coping (38)
  • Self Awareness (21)
  • Self Esteem (38)
  • Strengths & Virtues (32)
  • Stress & Burnout Prevention (34)
  • Theory & Books (46)
  • Therapy Exercises (37)
  • Types of Therapy (64)

Salene M. W. Jones Ph.D.

Cognitive Behavioral Therapy

Solving problems the cognitive-behavioral way, problem solving is another part of behavioral therapy..

Posted February 2, 2022 | Reviewed by Ekua Hagan

  • What Is Cognitive Behavioral Therapy?
  • Find a therapist who practices CBT
  • Problem-solving is one technique used on the behavioral side of cognitive-behavioral therapy.
  • The problem-solving technique is an iterative, five-step process that requires one to identify the problem and test different solutions.
  • The technique differs from ad-hoc problem-solving in its suspension of judgment and evaluation of each solution.

As I have mentioned in previous posts, cognitive behavioral therapy is more than challenging negative, automatic thoughts. There is a whole behavioral piece of this therapy that focuses on what people do and how to change their actions to support their mental health. In this post, I’ll talk about the problem-solving technique from cognitive behavioral therapy and what makes it unique.

The problem-solving technique

While there are many different variations of this technique, I am going to describe the version I typically use, and which includes the main components of the technique:

The first step is to clearly define the problem. Sometimes, this includes answering a series of questions to make sure the problem is described in detail. Sometimes, the client is able to define the problem pretty clearly on their own. Sometimes, a discussion is needed to clearly outline the problem.

The next step is generating solutions without judgment. The "without judgment" part is crucial: Often when people are solving problems on their own, they will reject each potential solution as soon as they or someone else suggests it. This can lead to feeling helpless and also discarding solutions that would work.

The third step is evaluating the advantages and disadvantages of each solution. This is the step where judgment comes back.

Fourth, the client picks the most feasible solution that is most likely to work and they try it out.

The fifth step is evaluating whether the chosen solution worked, and if not, going back to step two or three to find another option. For step five, enough time has to pass for the solution to have made a difference.

This process is iterative, meaning the client and therapist always go back to the beginning to make sure the problem is resolved and if not, identify what needs to change.

Andrey Burmakin/Shutterstock

Advantages of the problem-solving technique

The problem-solving technique might differ from ad hoc problem-solving in several ways. The most obvious is the suspension of judgment when coming up with solutions. We sometimes need to withhold judgment and see the solution (or problem) from a different perspective. Deliberately deciding not to judge solutions until later can help trigger that mindset change.

Another difference is the explicit evaluation of whether the solution worked. When people usually try to solve problems, they don’t go back and check whether the solution worked. It’s only if something goes very wrong that they try again. The problem-solving technique specifically includes evaluating the solution.

Lastly, the problem-solving technique starts with a specific definition of the problem instead of just jumping to solutions. To figure out where you are going, you have to know where you are.

One benefit of the cognitive behavioral therapy approach is the behavioral side. The behavioral part of therapy is a wide umbrella that includes problem-solving techniques among other techniques. Accessing multiple techniques means one is more likely to address the client’s main concern.

Salene M. W. Jones Ph.D.

Salene M. W. Jones, Ph.D., is a clinical psychologist in Washington State.

  • Find a Therapist
  • Find a Treatment Center
  • Find a Psychiatrist
  • Find a Support Group
  • Find Online Therapy
  • United States
  • Brooklyn, NY
  • Chicago, IL
  • Houston, TX
  • Los Angeles, CA
  • New York, NY
  • Portland, OR
  • San Diego, CA
  • San Francisco, CA
  • Seattle, WA
  • Washington, DC
  • Asperger's
  • Bipolar Disorder
  • Chronic Pain
  • Eating Disorders
  • Passive Aggression
  • Personality
  • Goal Setting
  • Positive Psychology
  • Stopping Smoking
  • Low Sexual Desire
  • Relationships
  • Child Development
  • Self Tests NEW
  • Therapy Center
  • Diagnosis Dictionary
  • Types of Therapy

May 2024 magazine cover

At any moment, someone’s aggravating behavior or our own bad luck can set us off on an emotional spiral that threatens to derail our entire day. Here’s how we can face our triggers with less reactivity so that we can get on with our lives.

  • Emotional Intelligence
  • Gaslighting
  • Affective Forecasting
  • Neuroscience

RACGP

Issues by year

Advertising

Volume 41, Issue 9, September 2012

Problem solving therapy Use and effectiveness in general practice

Problem solving therapy has been described as pragmatic, effective and easy to learn. It is an approach that makes sense to patients and professionals, does not require years of training and is effective in primary care settings. 1 It has been described as well suited to general practice and may be undertaken during 15–30 minute consultations. 2

Problem solving therapy takes its theoretical base from social problem solving theory which identifies three distinct sequential phases for addressing problems: 3

  • discovery (finding a solution)
  • performance (implementing the solution)
  • verification (assessing the outcome).

Initially, the techniques of social problem solving emerged in response to empirical observations including that people experiencing depression exhibit a reduced capacity to resolve personal and social problems. 4,5 Problem solving therapy specifically for use in primary care was then developed. 6

Problem solving therapy has been shown to be effective for many common mental health conditions seen by GPs, including depression 7–9 and anxiety. 10,11 Most research has focused on depression. In randomised controlled trials, when delivered by appropriately trained GPs to patients experiencing major depression, PST has been shown to be more effective than placebo and equally as effective as antidepressant medication (both tricyclics and selective serotonin reuptake inhibitors [SSRIs]). 7,8 A recent meta-analysis of 22 studies reported that for depression, PST was as effective as medication and other psychosocial therapies, and more effective than no treatment. 9 For patients experiencing anxiety, benefit from PST is less well established. It has been suggested it is most effective with selected patients experiencing more severe symptoms who have not benefited from usual GP care. 10 Problem solving therapy may also assist a group of patients often seen by GPs: those who feel overwhelmed by multiple problems but who have not yet developed a specific diagnosis.

Although PST has been shown to be beneficial for many patients experiencing depression, debate continues about the mechanism(s) through which the observed positive impact of PST on patient affect is achieved. Two mechanisms have been proposed: the patient improves because they achieve problem resolution, or they improve because of a sense of empowerment gained from PST skill development. 12 Perhaps both factors play a part in achieving the benefits of PST as a therapeutic intervention. The observed benefit of PST for patients experiencing anxiety may be due to problem resolution and consequent reduction in distress from anticipatory concern about the identified but unsolved problem.

It is important to note that, while in the clinical setting we may find ourselves attempting to solve problems for patients and to advise them on what we think they should do, 13 this is not PST. Essential to PST, as an evidence based therapeutic approach, is that the clinician helps the patient to become empowered to learn to solve problems for themselves. The GP's role is to work through the stages of PST in a structured, sequential way to determine and to implement the solution selected by the patient. These stages have been described previously. 14 Key features of PST are summarised in Table 1 .

Using PST in general practice

Using PST, like any other treatment approach, depends on identifying patients for whom it may be useful. Patients experiencing a symptom relating to life difficulties, including relationship, financial or employment problems, which are seen by the patient in a realistic way, may be suitable for PST. Frequently, such patients feel overwhelmed and at times confused by these difficulties. Encouraging the patient to clearly define the problem(s) and deal with one problem at a time can be helpful. To this end, a number of worksheets have been developed. A simple, single page worksheet is shown in Figure 1 . A typical case study in which PST may be useful is presented in Table 2 . By contrast, patients whose thinking is typically characterised by unhelpful negative thought patterns about themself or their world may more readily benefit from cognitive strategies that challenge unhelpful negative thought patterns (such as cognitive behaviour therapy [CBT]). 15 Some problems not associated with an identifiable implementable solution, including existential questions related to life meaning and purpose, may not be suitable for PST. Identification of supportive and coping strategies along with, if appropriate, work around reframing the question may be more suitable for such patients.

Problem solving therapy may be used with patients experiencing depression who are also on antidepressant medication. It may be initiated with medication or added to existing pharmacotherapy. Intuitively, we might expect enhanced outcomes from combined PST and pharmacotherapy. However, research suggests this does not occur, with PST alone, medication alone and a combination of PST and medication each resulting in a similar patient outcomes.8 In addition to GPs, PST may be provided by a range of health professionals, most commonly psychologists. General practitioners may find they have a role in reinforcing PST skills with patients who developed their skills with a psychologist, especially if all Better Access Initiative sessions with the psychologist have been utilised.

The intuitive nature of PST means its use in practice is often straightforward. However, this is not always the case. Common difficulties using PST with patients and potential solutions to these difficulties have previously been discussed by the author 14 and are summarised in Table 3 . Problem solving therapy may also have a role in supporting marginalised patients such as those experiencing major social disadvantage due to the postulated mechanism of action of empowerment of patients to address symptoms relating to life problems. 12 of action includes empowerment of patients to address symptom causing life problems. Social and cultural context should be considered when using PST with patients, including conceptualisation of a problem, its significance to the patient and potential solutions.

General practitioners may be concerned that consultations that include PST will take too much time. 13 However, Australian research suggests this fear may not be justified with many GPs being able to provide PST to a simulated patient with a typical presentation of depression in 20 minutes. 15 Therefore, the concern over consultation duration may be more linked to established patterns of practice than the use of PST. Problem solving therapy may add an increased degree of structure to complex consultations that may limit, rather than extend, consultation duration.

Figure 1. Problem solving therapy patient worksheet

PST skill development for GPs

Many experienced GPs have intuitively developed valuable problem solving skills. Learning about PST for such GPs often involves refining and focusing those skills rather than learning a new skill from scratch. 13 A number of practical journal articles 16 and textbooks 10 that focus on developing PST skills in primary care are available. In addition, PST has been included in some interactive mental health continuing medical education for GPs. 17 This form of learning has the advantage of developing skills alongside other GPs.

Problem solving therapy is one of the Medicare supported FPS available to GPs. It is an approach that has developed from a firm theoretical basis and includes principles that will be familiar to many GPs. It can be used within the constraints of routine general practice and has been shown, when provided by appropriately skilled GPs, to be as effective as antidepressant medication for major depression. It offers an additional therapeutic option to patients experiencing a number of the common mental health conditions seen in general practice, including depression 7–9 and anxiety. 10,11

Conflict of interest: none declared.

  • Gask L. Problem-solving treatment for anxiety and depression: a practical guide. Br J Psychiatry 2006;189:287–8. Search PubMed
  • Hickie I. An approach to managing depression in general practice. Med J Aust 2000;173:106–10. Search PubMed
  • D'Zurilla T, Goldfried M. Problem solving and behaviour modification. J Abnorm Psychol 1971;78:107–26. Search PubMed
  • Gotlib I, Asarnow R. Interpersonal and impersonal problem solving skills in mildly and clinically depressed university students. J Consult Clin Psychol 1979;47:86–95. Search PubMed
  • D'Zurilla T, Nezu A. Social problem solving in adults. In: Kendall P, editor. Advances in cognitive-behavioural research and therapy. New York: Academic Press, 1982. p. 201–74. Search PubMed
  • Hegel M, Barrett J, Oxman T. Training therapists in problem-solving treatment of depressive disorders in primary care: lessons learned from the: "Treatment Effectiveness Project". Fam Syst Health 2000;18:423–35. Search PubMed
  • Mynors-Wallis LM, Gath DH, Lloyd-Thomas AR, Tomlinson D. Randomised control trial comparing problem solving treatment with Amitryptyline and placebo for major depression in primary care. BMJ 1995;310:441–5. Search PubMed
  • Mynors-Wallis LM, Gath DH, Day A, Baker F. Randomised controlled trial of problem solving treatment, antidepressant medication, and combined treatment for major depression in primary care. BMJ 2000;320:26–30. Search PubMed
  • Bell A, D'Zurilla. Problem-solving therapy for depression: a meta-analysis. Clin Psychol Rev 2009;29:348–53. Search PubMed
  • Mynors-Wallis L Problem solving treatment for anxiety and depression. Oxford: OUP, 2005. Search PubMed
  • Seekles W, van Straten A, Beekman A, van Marwijk H, Cuijpers P. Effectiveness of guided self-help for depression and anxiety disorders in primary care: a pragmatic randomized controlled trial. Psychiatry Res 2011;187:113–20. Search PubMed
  • Mynors- Wallis L. Does problem-solving treatment work through resolving problems? Psychol Med 2002;32:1315–9. Search PubMed
  • Pierce D, Gunn J. GPs' use of problem solving therapy for depression: a qualitative study of barriers to and enablers of evidence based care. BMC Fam Pract 2007;8:24. Search PubMed
  • Pierce D, Gunn J. Using problem solving therapy in general practice. Aust Fam Physician 2007;36:230–3. Search PubMed
  • Pierce D, Gunn J. Depression in general practice, consultation duration and problem solving therapy. Aust Fam Physician 2011;40:334–6. Search PubMed
  • Blashki G, Morgan H, Hickie I, Sumich H, Davenport T. Structured problem solving in general practice. Aust Fam Physician 2003;32:836–42. Search PubMed
  • SPHERE a national mental health project. Available at www.spheregp.com.au [Accessed 17 April 2012]. Search PubMed

Also in this issue: Psychological strategies

AFP Cover - Psychological strategies

Professional

Printed from Australian Family Physician - https://www.racgp.org.au/afp/2012/september/problem-solving-therapy © The Australian College of General Practitioners www.racgp.org.au

intervention and problem solving in counseling brainly

Search form

intervention and problem solving in counseling brainly

  • Table of Contents
  • Troubleshooting Guide
  • A Model for Getting Started
  • Justice Action Toolkit
  • Best Change Processes
  • Databases of Best Practices
  • Online Courses
  • Ask an Advisor
  • Subscribe to eNewsletter
  • Community Stories
  • YouTube Channel
  • About the Tool Box
  • How to Use the Tool Box
  • Privacy Statement
  • Workstation/Check Box Sign-In
  • Online Training Courses
  • Capacity Building Training
  • Training Curriculum - Order Now
  • Community Check Box Evaluation System
  • Build Your Toolbox
  • Facilitation of Community Processes
  • Community Health Assessment and Planning

7. Developing an Intervention

This toolkit provides supports for developing core components of a community intervention and adapting them to fit the context.

  • Statement of the community problem/goal to be addressed
  • Specific behaviors of whom that need to change
  • Improvements in community-level outcomes that should result   Related resources : Proclaiming Your Dream: Developing Vision and Mission Statements Creating Objectives  
  • Direct observation of the problem or goal
  • Conducting behavioral surveys
  • Interviewing key people in the community
  • Reviewing archival or existing records   Related resources : Developing a Plan for Identifying Local Needs and Resources Collecting Information About the Problem Conducting Surveys Conducting Interviews Using Public Records and Archival Data  
  • Targets of change or prioritized groups for whom behaviors or outcomes should change
  • Agents of change or those implementing the intervention   Related resources : Identifying Targets and Agents of Change: Who Can Benefit and Who Can Help  
  • Personal contacts - Who will you speak with about what?
  • Interviews - What questions will you ask of whom about the problem or goal and possible interventions?
  • Focus groups - From what groups will you seek what kinds of information?
  • Community forums - What public situations would present an opportunity for you to discuss the problem or goal, and how will you use the opportunity?
  • Concerns surveys - What questions of whom will you ask about the problem or goal and potential solutions?   Related resources : An Introduction to the Problem Solving Process Analyzing Root Causes of Problems The "But Why?" Technique Conducting Interviews Conducting Focus Groups Conducting Public Forums and Listening Sessions Conducting Concerns Surveys  
  • Those for whom the current situation is a problem. Who is affected by the issue, problem, or goal?
  • The negative (positive) consequences for those directly affected and the broader community. What effect does the problem or issue have on the lives of those affected?
  • Personal and environmental factors to be influenced (i.e., people's experience and history; knowledge and skills; barriers and opportunities; social support and caring relationships; living conditions that put them at risk for or protect them from experiencing certain problems).
  • The behavior or lack of behavior that causes or maintains the problem. What behaviors of whom would need to change for the problem (or goal) to be eliminated (addressed).
  • Who benefits and how from the situation staying the same (economically, politically).
  • The conditions that need to change for the issue to be resolved (e.g., skills, opportunities, financial resources, trusting relationships).
  • The appropriate level at which the problem or goal should be addressed (e.g., by individuals, families, neighborhoods, city or county government), and whether the organization has the capacity to influence such changes).   Related resources : Defining and Analyzing the Problem Collecting Information About the Problem Identifying Targets and Agents of Change: Who Can Benefit and Who Can Help Understanding Risk and Protective Factors: Their Use in Selecting Potential Targets and Promising Strategies for Interventions Identifying Strategies and Tactics for Reducing Risks Creating Objectives  
  • A description of what success would look like. How will the community or group be different if the intervention is successful?
  • Those goals the intervention is targeted to accomplish. How will you know if your intervention is successful?
  • The specific objectives the intervention will achieve. What will change by how much and by when?   Related resources : Creating Objectives  
  • Potential or promising “best practices” for your situation (consider various available databases and lists of “best” or evidence-based practices)
  • How strong is the evidence that each potential “best practice” caused the observed improvement? (Rather than other associated conditions or potential influences)
  • Whether the “best practice” could achieve the desired results in your community
  • Whether the conditions (e.g., time, money, people, technical assistance) that affect success for the “best practice” are present
  • (Based on the assessment) The “best practice” or evidence-based approach to be tried in your situation (Note: If no “best practices” are known or appropriate to your situation, follow the steps below to design or adapt another intervention.)   Related resources : Generating and Choosing Solutions Criteria for Choosing Promising Practices and Community Interventions  
  • Providing information and enhancing skills (e.g., conduct a public information campaign to educate people about the problem or goal and how to address it)
  • Modifying access, barriers, exposures, and opportunities (e.g., increase availability of affordable childcare for those entering work force; reduce exposures to stressors)
  • Enhancing services and supports (e.g., increase the number of centers that provide health care)
  • Changing the consequences (e.g., provide incentives to develop housing in low-income areas)
  • Modifying policies and broader systems (e.g., change business or public policies to address the goal)   Related resources : Creating Objectives Developing an Action Plan Providing Information and Enhancing Skills Modifying Access, Barriers, and Opportunities Changing the Physical and Social Environment Enhancing Support, Incentives, and Resources Changing Policies  
  • Identify the mode of delivery through which each component and element of the intervention will be delivered in the community (e.g., workshops for skill training).   Related resources : Developing an Action Plan Putting Your Solution into Practice  
  • Indicate how you will adapt the intervention or "best practice" to fit the needs and context of your community (e.g., differences in resources, cultural values, competence, language).   Related resources : Adapting Community Interventions for Different Cultures and Communities Designing Community Interventions    
  • What specific change or aspect of the intervention will occur?
  • Who will carry it out?
  • When the intervention will be implemented or how long it will be maintained?
  • Resources (money and staff) needed/ available?
  • Who should know what about this?   Related resources : Developing an Action Plan  
  • Test the intervention and with whom
  • Assess the quality of implementation of the intervention
  • Assess results and consequences or side effects
  • Collect and use feedback to adapt and improve the intervention  
  • Implement the intervention, and monitor and evaluate the process (e.g., quality of implementation, satisfaction) and outcomes (e.g., attainment of objectives).   Related resources : A Framework for Program Evaluation: A Gateway to the Tools  

Library homepage

  • school Campus Bookshelves
  • menu_book Bookshelves
  • perm_media Learning Objects
  • login Login
  • how_to_reg Request Instructor Account
  • hub Instructor Commons

Margin Size

  • Download Page (PDF)
  • Download Full Book (PDF)
  • Periodic Table
  • Physics Constants
  • Scientific Calculator
  • Reference & Cite
  • Tools expand_more
  • Readability

selected template will load here

This action is not available.

Social Sci LibreTexts

3.1: Interventions and Problem Solving

  • Last updated
  • Save as PDF
  • Page ID 43048

  • Vera Kennedy
  • West Hills College Lemoore

\( \newcommand{\vecs}[1]{\overset { \scriptstyle \rightharpoonup} {\mathbf{#1}} } \)

\( \newcommand{\vecd}[1]{\overset{-\!-\!\rightharpoonup}{\vphantom{a}\smash {#1}}} \)

\( \newcommand{\id}{\mathrm{id}}\) \( \newcommand{\Span}{\mathrm{span}}\)

( \newcommand{\kernel}{\mathrm{null}\,}\) \( \newcommand{\range}{\mathrm{range}\,}\)

\( \newcommand{\RealPart}{\mathrm{Re}}\) \( \newcommand{\ImaginaryPart}{\mathrm{Im}}\)

\( \newcommand{\Argument}{\mathrm{Arg}}\) \( \newcommand{\norm}[1]{\| #1 \|}\)

\( \newcommand{\inner}[2]{\langle #1, #2 \rangle}\)

\( \newcommand{\Span}{\mathrm{span}}\)

\( \newcommand{\id}{\mathrm{id}}\)

\( \newcommand{\kernel}{\mathrm{null}\,}\)

\( \newcommand{\range}{\mathrm{range}\,}\)

\( \newcommand{\RealPart}{\mathrm{Re}}\)

\( \newcommand{\ImaginaryPart}{\mathrm{Im}}\)

\( \newcommand{\Argument}{\mathrm{Arg}}\)

\( \newcommand{\norm}[1]{\| #1 \|}\)

\( \newcommand{\Span}{\mathrm{span}}\) \( \newcommand{\AA}{\unicode[.8,0]{x212B}}\)

\( \newcommand{\vectorA}[1]{\vec{#1}}      % arrow\)

\( \newcommand{\vectorAt}[1]{\vec{\text{#1}}}      % arrow\)

\( \newcommand{\vectorB}[1]{\overset { \scriptstyle \rightharpoonup} {\mathbf{#1}} } \)

\( \newcommand{\vectorC}[1]{\textbf{#1}} \)

\( \newcommand{\vectorD}[1]{\overrightarrow{#1}} \)

\( \newcommand{\vectorDt}[1]{\overrightarrow{\text{#1}}} \)

\( \newcommand{\vectE}[1]{\overset{-\!-\!\rightharpoonup}{\vphantom{a}\smash{\mathbf {#1}}}} \)

Social issues impair social functioning and negatively impact the lives of individuals, groups, and organizations (Bruhn and Rebach 2007). People effected by a particular social issue may face a variety of obstacles and challenges associated with the problem including labeling, stigma, discrimination, and isolation. Sociological practitioners work to address the problem by changing the social setting, arrangement, norms, and behaviors surrounding the issue and the people involved. A sociological practitioner may serve as the facilitator of this social change, a broker by acting on the behalf of others for change, or a clinician by providing direct services or help to change the situation of individuals and families.

There are six approaches most commonly used by sociological and other professional practitioners, communities, and clients to address social problems and create change. To resolve or improve situations, different problems require different approaches based on the client needs and social resources available to them. Each sociological approach incorporates a different level of analysis to assess the problem with a specific focal area of intervention. When social change requires different levels of analysis, sociological approaches must identify and explore multiple solutions across continuums. Not all approaches result in an expeditious solution. Sociological approaches and interventions take planning and time to implement and can take years to gain permanent change or improve people’s lives.

Process of Intervention

Regardless of approach, sociologists follow an incremental process of intervention to remedy a social problem. Each sociological approach includes a process of intervention that includes an assessment, planning, implementation, and evaluation phase. There are no timelines of completion defined within each phase. Rather the sociological practitioner, clients, and other impacted individuals or groups set deadlines and completion parameters based on context and need.

The first phase examines the social problem and needs of those it impairs. This is an investigative stage to gather information and understand the situation to define the problem (Bruhn and Rebach 2007). A sociological practitioner must first identify the presenting problem and client(s). The presenting problem refers to the client’s perspective of the problem as they see it in their own words (Bruhn and Rebach 2007). The assessment is a discovery phase of the history and evolution of the problem within the geographic region to find out who is seeking help and why. The assessment also helps determine the role or involvement of the sociological practitioner in the intervention.

An assessment is a case study guided by the nature of the problem and clients (Bruhn and Rebach 2007). Data collection may include interviews, focus groups, surveys, and secondary analysis (e.g., analytic data, educational records, criminal records, medical files, etc.). Findings and results are presented and discussed with clients and other involved parties to formulate solutions and objectives of intervention.

image82.png

The next stage in the process is to plan the steps for achieving intervention objectives. The plan is a formal (written) agreement among interventionists (including the sociological practitioner) and client(s) outlining the objectives and roles and responsibilities of each person involved. The plan will include observable, measurable objectives that include: 1) subject and verb stating the condition to achieve, 2) amount or percentage of reduction or improvement of the condition, and 3) timeframe or deadline for completion (Bruhn and Rebach 2007). Both process and outcome objectives must be delineated in the plan. Process objectives will focus on program operations or services, and outcome objectives concentrate on the results of the intervention against baseline data (i.e., data collected prior to intervention). Interventionists and clients work together to develop a plan so everyone has an equal voice and understanding of their duties, obligations, and work to complete in the implementation phase.

Consider a social problem you would like to address in your community. Conduct secondary analysis of the issue to identify the presenting problem, clientele, and existing community services. Explore nonprofit and public agencies in your community working on the problem you chose to help you gather information.

After completing your analysis, draft four observable, measurable objectives of intervention for the problem and population you wish to address. Two objectives must focus on process and two on outcomes. All outcomes must include a verb and subject stating the condition to achieve, amount or percentage of reduction or improvement of the condition, and timeframe or deadline for completion.

The third phase in the process centers on implementation. In this stage, the plan commences according to the steps outlined in the formal agreement. Implementation puts the plan into action by following the proposed sequence and schedule. This phase engages strategies in order to accomplish objectives. For example, solving chronic poverty in your community might require employing several strategies such as improving K-12 education, increasing higher education enrollments and job skills training, providing access to health care, and developing employment opportunities. During the implementation phase, interventionists and collaborators will initiate and work on each strategy for change.

The final phase in the process of intervention is evaluation. Sociologists use evaluation to find out if a program, service, or intervention works (Steele and Price 2008). There are two types of evaluation. A process or formative evaluation gathers information to help improve or change a program, service, or intervention. Did everything occur and work according to plan? Sociological practitioners work with clients to determine program strengths, weaknesses, and areas of improvement to strengthen or adapt the program (Steele and Price 2008). An outcome or summative evaluation measures the impact of the program, service, or intervention on clients or participants. Were benchmarks achieved or changes made? Practitioners measure changes in clients over the duration of their participation from start to completion. The impact evaluation determines if change occurred, any unintended outcomes, and the long-term effects.

image35.png

Evaluation is an ongoing task tracking program progress from beginning to end (Bruhn and Rebach 2007). Interventionists and practitioners must monitor the program continuously to ensure the service or intervention is advancing toward change, and adjustments or alternatives are deployed to increase effectiveness in a timely manner. The goal of evaluation is to know why a program, service, or intervention succeeded or failed to reform or adapt present and future support and solutions. Evaluation is a mechanism of continual improvement by regularly providing information and identifying unintended consequences.

Evaluation requires both quantitative and qualitative data (see page 5) using a variety of data collection methods and tools to gather information (e.g., tests, questionnaires, archival data, etc.). Data collection tools vary from program to program, sometimes tools exist to conduct an evaluation, and other times practitioners must develop them (Viola and McMahon 2010). Practitioners lead in the development of data collection protocols, tools, and instruments for review by participants (e.g., clients and community members) before they are ready to use.

As a contributing member of an evaluation team, sociological practitioners (see page 3) must be aware of role-conflict . It is imperative to avoid role-conflict in a participatory evaluation model. In other words, practitioners must be aware of their role within the evaluative context or situation as to whether one is serving as a researcher, practitioner, or interventionist (i.e., clinical sociologist). It is difficult to implement the scientific method (process and procedures) in the field within the standards of academic research when serving as a practitioner (Bruhn and Rebach 2007). Sociological practitioners or interventionists do not always have control over the evaluation research, study environment, or time to complete an evaluative study as prescribed by the scientific method.

The Workforce Internship Networking (WIN) Center at West Hill College Lemoore in California connects and supports students and alumni by providing employment, occupational readiness, and job placement information and resources to advance personal career goals. The WIN Center provides a space for employers and students to connect. At the WIN Center, students and alumni receive skills training, employment and internship application assistance, and support in creating a professional profile.

  • Describe why it might be important to evaluate the WIN Center.
  • Considering the importance of evaluating college campus programs, how often would you recommend evaluating the WIN Center’s programs and services? What should the evaluation examine?
  • What role could program monitoring play in the overall evaluation of the WIN Center?
  • If you were responsible for overseeing program monitoring and the evaluation of the WIN Center, what data would you collect to assess its impact?

In addition, evaluations may cause tension between practitioners (interventionists) and evaluation associates. Interventionists are responsible for providing data and keeping records while implementing program activities. Conflicting demands for an interventionists’ time and energy during the program implementation process may lead to a delay in gathering and sharing data with evaluators. Evaluation is not always equally valued, and some interventionists may consider evaluation unimportant or a threat to their work or process resulting in uncooperative behavior or interest.

U.S. flag

An official website of the United States government

The .gov means it's official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

  • Publications
  • Account settings
  • Browse Titles

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Cover of Evidence reviews for psychological and psychosocial interventions

Evidence reviews for psychological and psychosocial interventions

Evidence review J

NICE Guideline, No. 225

  • Copyright and Permissions
  • Psychological and psychosocial interventions

Review question

What psychological and psychosocial interventions (including safety plans and electronic health-based interventions) are effective for people who have self-harmed?

Introduction

People who self-harm or engage in suicidal behaviour are often in distress and may benefit from effective psychological or psychosocial support to help reduce distress and repeat self-harm or suicide in the future. There is often limited availability of psychological and psychosocial interventions targeted for this group of people and they may be excluded from generic psychological therapy services. Determining which interventions are effective for children and young people and for adults is therefore important so that evidence-based psychological and psychosocial interventions can be commissioned and offered. The aim of this review is to find out what psychological and psychosocial interventions are effective for people who have self-harmed.

Summary of the protocol

See Table 1 for a summary of the Population, Intervention, Comparison and Outcome (PICO) characteristics of this review.

Table 1. Summary of the protocol (PICO table).

Summary of the protocol (PICO table).

For further details see the review protocol in appendix A .

Methods and process

During the development of this guideline, two registered Cochrane protocols were identified which matched the committee’s intended PICOs. The Cochrane protocols differed from the committee’s intended population in that the Cochrane protocols excluded studies that included people who had self-harmed who had a neurodevelopmental disorder or learning difficulty, however no studies were identified that were excluded from the reviews on these grounds alone.

The Cochrane review team completed two reviews investigating the effectiveness of psychosocial interventions in adults ( Witt 2021a ) and psychosocial and pharmacological interventions in children and young people (CYP) ( Witt 2021b ) during guideline development and presented their results to the guideline committee, which used them to make recommendations. Cochrane’s methods are closely aligned to standard NICE methods, minor deviations (the use of GRADE only on main outcomes with no overall quality rating for those with zero events in either arm, summary of findings tables instead of full GRADE tables, defining primary and secondary outcomes as opposed to critical and important and including countries from a broader range of income categories than the majority of the other reviews in the guideline) relevant to the topic area were highlighted to the committee and taken into account in discussions of the evidence.

Declarations of interest were recorded according to NICE’s conflicts of interest policy .

Effectiveness evidence

Included studies.

Two Cochrane reviews ( Witt 2021a , Witt 2021b ) including 83 randomised controlled trials were considered in this report. Of the studies included in these reviews, 76 were from the review investigating psychosocial interventions for adults (Allard 1992, Amadéo 2015, Andreoli 2015, Armitage 2016, Bateman 2009, Beautrais 2010, Bennewith 2002, Brown 2005, Carter 2005, Cedereke 2002, Clarke 2002, Crawford 2010, Davidson 2014, Dubois 1999, Evans 1999a, Evans 1999b, Fleischmann 2008, Gibbons 1978, Gratz 2006, Gratz 2014, Grimholt 2015, Guthrie 2001, Gysin-Maillart 2016, Hassanian-Moghaddam 2011, Hatcher 2011, Hatcher 2015, Hatcher 2016, Hawton 1981, Hawton 1987, Harned 2014, Husain 2014, Hvid 2011, Kapur 2013, Kawanishi 2014, Liberman 1981, Lin 2020, Linehan 1991, Linehan 2006, Linehan 2015, Marasinghe 2012, McAuliffe 2014, McMain 2009, McMain 2017, McLeavey 1994, Morgan 1993, Morthorst 2012, Mouaffak 2015, Mousavi 2015, Mousavi 2017, Naidoo 2014, O’Connor 2015, O’Connor 2017 , O’Connor 2020, Owens 2020 , Patsiokas 1985, Priebe 2012 , Sahin 2018, Salkovskis 1990, Slee 2008, Sreedaran 2020, Stewart 2009, Tapolaa 2010, Torhorst 1987, Torhorst 1988, Turner 2000, Tyrer 2003 , Vaiva 2006, Vaiva 2018, Van der Sande 1997, Van Heeringen 1995, Walton 2020, Wang 2016, Waterhouse 1990, Wei 2013, Weinberg 2006, Welu 1977), and 17 studies were from the review investigating pharmacological and psychosocial interventions for children (Asarnow 2017, Cooney 2010, Cotgrove 1995, Cottrell 2018 , Donaldson 2005, Green 2011 , Griffiths 2019, Harrington 1998 , Hazell 2009, McCauley 2018, Mehlum 2014, Ougrin 2011, Rossouw 2012, Santamarina-Pérez 2020, Sinyor 2020, Spirito 2002, Wood 2001a). These reviews were used for recommendation making by the committee, as they were considered sufficiently relevant, high quality and up to date.

The Cochrane reviews are summarised in Table 2 , however full details of the Cochrane reviews including methods are available in the review of Psychosocial interventions for self-harm in adults and the review of Interventions for self-harm in children and adolescents .

See the Cochrane reviews for the literature search strategies for the adults review and the CYP review , study selection flow charts for the adults review and the CYP review , forest plots in the adults review and the CYP review and summary of findings tables for the adults review and the CYP review .

Excluded studies

See the lists of excluded studies in the Cochrane adults review and the CYP review with reasons for their exclusions.

Summary of included studies

Summaries of the studies that were included in this review are presented in Table 2 .

Table 2. Summary of included studies.

Summary of included studies.

See the Cochrane adults review and CYP review for characteristics of studies tables.

Summary of the evidence

  • Comparison 1.1: Individual-based CBT-based psychotherapy versus TAU or another comparator. This intervention was more effective for ‘repetition of self-harm’ at post-intervention (low certainty of the evidence according to GRADE criteria), as well as at 6, 12, and 24-month follow-up, and for ‘frequency of self-harm repetition’ by the 6 and 12-month assessments. CBT-based psychotherapy had no effect on ‘frequency of self-harm repetition’ by the post-intervention assessment, nor on ‘time to self-harm repetition’.
  • Comparison 1.2: Group-based CBT-based psychotherapy versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ at post-intervention (moderate certainty of the evidence according to GRADE criteria), nor by the 6 or 12-month assessment, and no evidence of effect on ‘frequency of self-harm repetition’ by the 12-month assessment.
  • Comparison 2.1: Standard DBT versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ at post-intervention (very low certainty of the evidence according to GRADE criteria), nor by the 12-month assessment. DBT was more effective for ‘frequency of self-harm repetition’ by the post-intervention assessment, but there was no evidence of effect by the 6-month assessment,
  • Comparison 2.2: DBT group-based skills training versus TAU or another comparator. There was no evidence of effect for this intervention only compared to standard DBT for ‘suicide reattempts’ or ‘NSSI’ at post-intervention (moderate certainty of the evidence according to GRADE criteria), nor by the 12-month assessment, and no evidence of effect on ‘frequency of suicide reattempts’ or ‘frequency of episodes of NSSI’ at the post-intervention or 12-month assessments, nor on ‘time to first suicide attempt’.
  • Comparison 2.3: DBT individual therapy versus TAU or another comparator. There was no evidence of effect for this intervention only compared to standard DBT for ‘suicide reattempts’ or ‘NSSI’ at post-intervention (moderate certainty of the evidence according to GRADE criteria), nor by the 12-month assessment, and no evidence of effect on ‘frequency of suicide reattempts’ or ‘frequency of episodes of NSSI’ at the post-intervention or 12-month assessments, nor on ‘time to first suicide attempt’.
  • Comparison 2.4: DBT prolonged exposure protocol versus TAU or another comparator. There was no evidence of effect for this intervention compared to standard DBT for ‘repetition of self-harm’ at post-intervention (moderate certainty of the evidence according to GRADE criteria), nor by the 6-month assessment, and no evidence of effect on ‘frequency of self-harm repetition’ at the post-intervention or 6-month assessments.
  • Comparison 3: MBT versus TAU or another comparator. This intervention was more effective for ‘repetition of self-harm’ by the conclusion of the 18-month treatment period (high certainty of the evidence according to GRADE criteria), and for ‘frequency of self-harm repetition’ by the post-intervention assessment.
  • Comparison 4: Emotion-regulation psychotherapy versus TAU or another comparator. This intervention was more effective for ‘repetition of self-harm’ by the post-intervention assessment (moderate certainty of the evidence according to GRADE criteria), but there was no evidence of effect on ‘frequency of self-harm repetition’ by the post-intervention assessment.
  • Comparison 5: Psychodynamic psychotherapy versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the post-intervention assessment (moderate certainty of the evidence according to GRADE criteria). Psychodynamic psychotherapy was more effective for ‘time to repetition of self-harm’.
  • Comparison 6: Case management versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the post-intervention assessment (low certainty of the evidence according to GRADE criteria), nor by the 12-month assessment. There were conflicting data about the effectiveness of case management for ‘time to self-harm repetition’.
  • Comparison 7: Structured GP follow-up versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the post-intervention assessment, either according to hospital records or emergency medical records (low certainty of the evidence according to GRADE criteria).Structured GP follow-up was less effective for ‘episodes of self-poisoning’ by the post-intervention assessment, but there was no evidence of effect on ‘episodes of self-cutting’ or ‘other methods of self-harm’ by the post-intervention assessment.
  • Comparison 8.1: Brief Collaborative Assessment and Management of Suicidality (CAMS)-based intervention versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the 12-month assessment, nor for ‘frequency of self-harm repetition’ by the 12-month assessment.
  • Comparison 8.2: Brief guided Integrated Motivational-Volitional-focused intervention versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the 6-month assessment, nor for ‘frequency of self-harm repetition’ by the 6-month assessment or ‘time to self-harm repetition’.
  • Comparison 8.3: Brief self-guided Integrated Motivational-Volitional-focused intervention versus TAU or another comparator. Data on frequency of self-harm could not be disaggregated from data on frequency of suicidal ideation and therefore could not be included in the review.
  • Comparison 8.4: Brief alcohol-focused intervention versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the 6-month assessment.
  • Comparison 9.1: Emergency cards versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the post-intervention assessment (low certainty of the evidence according to GRADE criteria), nor by the 12-month assessment, and no evidence of effect on ‘frequency of self-harm repetition’ by the 12-month assessment, nor on ‘time to self-harm repetition’.
  • Comparison 9.2: Coping cards versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the post-intervention assessment (moderate certainty of the evidence according to GRADE criteria). Coping cards were more effective for ‘time to self-harm repetition’.
  • Comparison 9.3: GP letters versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the 12-month assessment, nor for ‘time to self-harm repetition’.
  • Comparison 9.4: Postcards versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the post-intervention assessment (very low certainty of the evidence according to GRADE criteria), nor by the 12-month assessment, and no evidence of effect for ‘frequency of self-harm repetition’ by the post-intervention or 12-month assessments.
  • Comparison 9.5: Telephone contact versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the post-intervention assessment (low certainty of the evidence according to GRADE criteria), nor by the 12 or 24-month assessment, and no evidence of effect for ‘frequency of self-harm repetition’ by the post-intervention assessment.
  • Comparison 9.6: Telephone contact combined with emergency cards and letters versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the post-intervention assessment (moderate certainty of the evidence according to GRADE criteria), and no evidence of effect for ‘frequency of self-harm repetition’ by the post-intervention assessment, nor for ‘time to self-harm repetition’.
  • Comparison 9.7: Telephone-based psychotherapy versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the post-intervention assessment (low certainty of the evidence according to GRADE criteria), nor by the 6 and 12-month assessments.
  • Comparison 10: Provision of information and support versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the 12-month post-intervention assessment (very low certainty of the evidence according to GRADE criteria). Provision of information and support was less effective for ‘frequency of self-harm repetition’ by the 6-month assessment.
  • Comparison 11: Other multimodal interventions versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the post-intervention assessment (very low certainty of the evidence according to GRADE criteria), nor for ‘time to self-harm repetition’. Provision of information and support was more effective for ‘frequency of self-harm repetition’ at the post-intervention assessment.
  • Comparison 12.1: Continuity of care by the same therapist versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the 12-month assessment.
  • Comparison 12.2: Interpersonal problem-solving therapy versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the 12-month assessment.
  • Comparison 12.3: Behaviour therapy versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the 24-month assessment.
  • Comparison 12.4: Intensive in- and outpatient treatment versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the 12-month assessment, nor on ‘frequency of self-harm repetition’ or ‘time to self-harm repetition’.
  • Comparison 12.5: General hospital management versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the post-intervention assessment (moderate certainty of the evidence according to GRADE criteria), nor by the 4-month assessment,
  • Comparison 12.6: Intensive outpatient treatment versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the 4 or 24-month assessment, nor on ‘frequency of self-harm repetition’.
  • Comparison 12.7: Home-based psychotherapy and telephone contact versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the 12-month assessment.
  • Comparison 12.8: Long-term therapy versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the post-intervention assessment (low certainty of the evidence according to GRADE criteria).
  • Comparison 1: Individual CBT-based psychotherapy (for example CBT, PST) compared to TAU or other comparator. There was no evidence of effect for this intervention compared to alternative psychotherapy for ‘repetition of self-harm’ at post-intervention (low certainty of the evidence according to GRADE criteria).
  • Comparison 2: DBT-A compared to TAU or another comparator. This intervention was more effective for ‘repetition of self-harm’ at post-intervention (high certainty of the evidence according to GRADE criteria), but there was no evidence of effect by the 12-month assessment when compared to alternative psychotherapy, nor for ‘frequency of self-harm repetition’ by the post-intervention or 12-month assessments.
  • Comparison 3: MBT-A compared to TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ at post-intervention (very low certainty of the evidence according to GRADE criteria), nor by the 6-month assessment.
  • Comparison 4: Group-based psychotherapy versus TAU or other comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the 12 or 24-month assessments.
  • Comparison 5: Enhanced assessment approaches versus TAU or other comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the 6 or 12-month assessments.
  • Comparison 6: Compliance enhancement approaches versus TAU or other comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the 6-month assessment.
  • Comparison 7: Family interventions compared to TAU or other comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ at post-intervention (moderate certainty of the evidence according to GRADE criteria), nor by the 18-month assessment, and no evidence of effect for ‘time to self-harm repetition’ by the post-intervention or 18-month assessments.
  • Comparison 8: Remote contact interventions versus TAU or other comparator. There was no evidence of effect for emergency cards for ‘repetition of self-harm’ by the 12-month assessment.

See the Cochrane adults review and the CYP review for summary of findings tables and full results, including all primary and secondary outcomes and sub-group analyses.

Economic evidence

A single economic search was undertaken for all topics included in the scope of this guideline. Nine economic studies were identified which were relevant to this question. Of the studies, 4 evaluated psychosocial interventions for adults ( Byford 2003 , O’Connor 2017 , Owens 2020 , and Priebe 2012 ), and 5 studies evaluated psychosocial interventions for CYP ( Byford 1999 , Cottrell 2018 , Green 2011 , Haga 2018 , Wijana 2021 ).

See the literature search strategy in appendix B and economic study selection flow chart in appendix G .

Economic studies not included in the guideline economic literature review are listed, and reasons for their exclusion are provided in appendix J .

Summary of included economic evidence

  • One UK study ( Byford 2003 ) on the cost-effectiveness and cost-utility of manual-assisted cognitive behaviour therapy (CBT-MACT) versus TAU alone.
  • One UK study ( O’Connor 2017 ) on the cost-effectiveness of a brief psychological intervention (volitional help-sheet) combined with TAU versus TAU alone.
  • One UK study ( Owens 2020 ) on the cost-utility of problem solving therapy combined with TAU versus TAU alone.
  • One UK study ( Priebe 2012 ) on the cost-effectiveness of dialectical behaviour therapy (DBT) versus TAU.

See the economic evidence tables in appendix H . See Table 3 to Table 6 for the economic evidence profiles of the included studies.

  • One UK study ( Byford 1999 ) on the cost-effectiveness of a social work intervention combined with TAU versus TAU alone.
  • One UK study ( Cottrell 2018 ) on the cost-utility of family therapy (FT) versus TAU.
  • One UK study ( Green 2011 ) on the cost-effectiveness of a manual-based developmental group psychotherapy programme combined with TAU versus TAU alone.
  • One study from Norway ( Haga 2018 ) on the cost-effectiveness of DBT for adolescents versus enhanced usual care.

One further study was identified as eligible for the review ( Wijana 2021 ). However, this study was characterised by very serious limitations and it has not been considered in decision making.

See the economic evidence tables in appendix H . See Table 7 to Table 10 for the economic evidence profiles of the included studies.

Economic evidence profiles for adults who have self-harmed

Table 3. Economic evidence profiles for cognitive behaviour therapy in adults who have self-harmed.

Economic evidence profiles for cognitive behaviour therapy in adults who have self-harmed.

Table 4. Economic evidence profile for volitional help-sheet in adults who have self-harmed.

Economic evidence profile for volitional help-sheet in adults who have self-harmed.

Table 5. Economic evidence profile for problem solving therapy in adults who have self-harmed.

Economic evidence profile for problem solving therapy in adults who have self-harmed.

Table 6. Economic evidence profile for dialectical behaviour therapy for adults who have self-harmed.

Economic evidence profile for dialectical behaviour therapy for adults who have self-harmed.

Economic evidence profiles for children and young people who have self-harmed

Table 7. Economic evidence profile for social work intervention in children and young people who have self-harmed.

Economic evidence profile for social work intervention in children and young people who have self-harmed.

Table 8. Economic evidence profile for family therapy in children and young people who have self-harmed.

Economic evidence profile for family therapy in children and young people who have self-harmed.

Table 9. Economic evidence profile for manual-based developmental group psychotherapy programmes in children and young people who have self-harmed.

Economic evidence profile for manual-based developmental group psychotherapy programmes in children and young people who have self-harmed.

Table 10. Economic evidence profiles for dialectical behaviour therapy in children and young people who have self-harmed.

Economic evidence profiles for dialectical behaviour therapy in children and young people who have self-harmed.

Economic model

Two cost-utility analyses were developed to assist the committee decision making in this area of the guideline, as the available economic evidence assessed a limited number of interventions, was often inconclusive or not applicable to the NICE decision-making context. Moreover, existing economic evidence was based on single studies, whereas the guideline was informed by systematic reviews and meta-analyses of RCTs of psychological and psychosocial therapies for children and adults who have self-harmed. One economic analysis aimed to evaluate the relative cost-effectiveness of CBT-informed psychological intervention in addition to TAU versus TAU alone for adults who self-harm; the other economic analysis aimed to evaluate the cost-effectiveness of DBT-A relative to enhanced TAU for children who self-harm. Both interventions were shown to be effective following meta-analyses of RCTs ( Witt 2021a , Witt 2021b ). This section provides a summary of the methods employed and the results of the economic analyses. See appendix I for full details.

Each economic analysis utilised a hybrid model, comprising a 6-month decision-tree, followed by a 3-state Markov model (repeat self-harm - RSH, noRSH and death) that lasted 4.5 years. The time horizon of each model was 5 years. This period was considered to be long enough to capture longer-term costs and effects of treatment, without significant extrapolation over the course of RSH. Both analyses adopted the perspective of the NHS and personal social services (PSS), and used the QALY as the measure of outcome. For both analyses, costs consisted of intervention costs and costs of health and social care services incurred by adults or children who have self-harmed, as relevant. The cost year was 2020.

Efficacy data were obtained from the two Cochrane reviews and meta-analyses that informed this area of the guideline ( Witt 2021a , Witt 2021b ). Other clinical data were obtained from cohort studies or RCTs conducted in the UK. Utility data were based on published evidence. Resource use data relating to the delivery of the interventions were based on the trials included in the meta-analyses that informed the guideline economic models, supplemented by the committee’s expert advice, so that resource use reflects optimal routine practice in the UK. Other health and social care costs incurred by people who have self-harmed were taken from cohort studies or RCTs conducted in the UK. National unit costs were used. Model input parameters were synthesised in a probabilistic analysis. This approach allowed more comprehensive consideration of the uncertainty characterising the input parameters and captured the non-linearity characterising the economic model structure. A number of deterministic sensitivity analyses were also carried out. Results were expressed in the form of incremental cost-effectiveness ratios (ICERs).

According to the base-case results of the cost-utility analysis concerning CBT-informed psychological intervention for adults who self-harm, the ICER of CBT-based psychotherapy added to TAU versus TAU was £9,088/QALY, which is below the lower NICE threshold of £20,000 per QALY. Alternative scenarios tested included increased intensity in the delivery of the CBT-based psychotherapy, different unit costs of health professionals delivering the intervention, alternative utility data, changes in the health and social care costs incurred by adults who self-harm, and changes in the baseline risk of RSH. Delivery of the CBT-informed psychological intervention remained likely to be cost effective in adults who self-harm in most scenarios tested, suggesting confidence in the model’s results.

According to the base-case results of the economic model on the cost-effectiveness of DBT-A versus enhanced TAU for children and young people at risk of RSH, the ICER for DBT-A versus enhanced TAU was £268,601/QALY, which is well above the lower NICE threshold of £20,000 per QALY; therefore, DBT-A is not a cost-effective psychological therapy compared to the enhanced TAU. A number of alternative scenarios were explored, such as a different delivery mode of DBT-A, different unit costs of health professionals delivering the intervention, changes in utility data, as well as changes in the baseline risks of RSH or 26 intervention cost of DBT-A or health and social care costs incurred by children and young people at risk of RSH that would be required in order for the intervention to become cost-effective. Delivery of DBT-A remained unlikely to be cost effective in children and young people who are at risk of RHS under most plausible scenarios, suggesting confidence around models’ results when model assumptions varied. The only plausible (although highly unlikely in the general population of children and young people at risk of RSH) change in input parameters that would make DBT-A cost-effective was when the baseline risk of self-harm repetition was at least 69%, which would be reflecting the healthcare circumstances and needs of a particular sub-group of CYP who RSH, such as those CYP at very high risk of self-harm recurrence over time, such as CYP with significant emotional dysregulations who have frequent episodes of self-harm.

Evidence statements

Psychological and psychosocial interventions for adults who have self-harmed.

  • Evidence from the guideline cost-utility analysis suggests that CBT-informed psychological intervention for adults who have self-harmed is likely to be cost-effective when added to TAU versus TAU alone from a UK NHS and personal social services perspective. The economic analysis is directly applicable to the NICE decision-making context and is characterised by minor limitations.
  • Evidence from a cost-utility analysis conducted alongside a RCT ( Byford 2003 , N=397) suggests that a manual-assisted cognitive behaviour therapy (MACT) is likely to be cost-effective compared with TAU in adults who have self-harmed in the UK. The study is directly applicable to the UK but has potentially serious limitations.
  • Evidence from a cost-effectiveness analysis conducted alongside a RCT ( O’Connor 2017 , N=518) suggests that brief psychological intervention (a volitional help-sheet) combined with TAU is likely to be cost-effective compared with TAU alone in adults who have self-harmed in the UK, as it was found to be more effective and less costly than TAU alone at 6 months follow-up. The study is directly applicable to the UK and has minor limitations.
  • Evidence from a cost-utility analysis conducted alongside a RCT ( Owens 2020 , N=62) suggests that cognitive behaviour based-psychotherapy (problem-solving therapy) added onto TAU is likely to be cost-effective compared with TAU alone in adults who have self-harmed in the UK, as it was found to be more effective and less costly than TAU alone. The study is directly applicable to the UK but has potentially serious limitations.
  • Evidence from a cost-effectiveness analysis conducted alongside a RCT ( Priebe 2012 , N=80) was inconclusive regarding the cost-effectiveness of dialectical behaviour therapy (DBT) compared with TAU in adults with borderline personality disorder who have self-harmed in the UK. This is because DBT was found to be more effective and more costly than TAU, but no QALYs were estimated and therefore a judgement needs to be made on whether the extra benefit is worth the extra cost. The study is partially applicable to the NICE decision-making context and is characterised by potentially serious limitations.

Psychological and psychosocial interventions for CYP who have self-harmed

  • Evidence from a cost-effectiveness analysis conducted alongside a RCT ( Byford 1999 , N=162) suggests that a home-based social work intervention may be potentially cost-effective compared with TAU in CYP who have self-harmed in the UK, as no statistically significant differences in costs or outcomes were found between the two interventions, however, costs were slightly lower for the intervention compared with TAU. The study is directly applicable to the NICE decision-making context but is characterised by potentially serious limitations.
  • Evidence from a cost-utility analysis conducted alongside a RCT ( Cottrell 2018 , N=832) suggests that family therapy is unlikely to be cost-effective compared with enhanced TAU in CYP referred to CAMHS (children and adolescent mental health services) after self-harm in the UK over 18 months, but may become cost-effective over 5 years. The study is directly applicable to the UK and is characterised by minor limitations.
  • Evidence from a cost-effectiveness analysis conducted alongside a RCT ( Green 2011 , N=364) is inconclusive regarding the cost-effectiveness of a manual-based developmental group psychotherapy programme combined with TAU versus TAU alone in CYP referred to CAMHS (children and adolescent mental health services) after self-harm in the UK. This is because the intervention was found to be more effective and more costly than TAU, but no QALYs were estimated and therefore a judgement needs to be made on whether the extra benefit is worth the extra cost. The study is partially applicable to the NICE decision-making context because, although it was conducted in the UK, no QALYs were estimated, and is characterised by minor limitations.
  • Evidence from the guideline cost-utility analysis suggests that dialectical behavioural therapy (DBT-A) for CYP who have self-harmed is not cost-effective from a NHS and personal social services perspective, compared to enhanced TAU. The economic analysis is directly applicable to the UK and is characterised by minor limitations.
  • Evidence from a cost-effectiveness analysis carried out alongside a RCT ( Haga 2018 , N=77) from Norway suggests that dialectical behaviour therapy for adolescents (DBT-A) is cost-effective compared with enhanced TAU in CYP who self-harmed, mostly people with borderline personality disorder, in Norway, as it is more effective and less costly than enhanced TAU. The study is partially applicable to the UK and is characterised by potentially serious limitations.

The committee’s discussion and interpretation of the evidence

The outcomes that matter most.

The Cochrane protocols’ primary outcome was occurrence of repeated self-harm within a maximum follow-up period of 2 years, which the committee agreed is critical as it is a direct measure of any differential effectiveness associated with the psychosocial intervention. All other outcomes listed in the Cochrane protocol (treatment adherence; depression; hopelessness; general functioning; social functioning; suicidal ideation; suicide) were agreed to be important outcomes by the committee. The committee agreed that treatment adherence would indicate the patient’s satisfaction with the intervention and ultimately determine its success. Depression, hopelessness, and suicidal ideation were agreed to be important outcomes as they are measures of well-being which may capture long-term health-related outcomes associated with the effectiveness of interventions. The committee agreed that general functioning and social functioning were also important as measures of how successful the intervention is at reducing the impact of self-harm on the person’s day-to-day life and ability to build and maintain relationships. Suicide was also agreed by the committee to be a direct measure of any differential effectiveness associated with the pharmacological intervention.

The quality of the evidence

When Cochrane assessed the evidence using GRADE methodology it was found to range from high to very low quality, with most of the evidence being moderate or low quality. Where evidence was downgraded it was mainly due to imprecision of the effect size (where the 95% confidence intervals for the pooled effect included the null value), risk of bias as per Cochrane RoB 2.0 (due to bias in the randomisation process, deviations from the intended interventions, missing outcome data, measurement of the outcome, and/ or selection of the reported results), and in some cases, significant heterogeneity between studies as indicated by the I2 value. In 1 case, evidence was downgraded due to suspicion of publication bias.

The committee discussed the evidence presented by Cochrane which showed that although the evidence base remained somewhat uncertain regarding the effectiveness of most psychological and psychosocial interventions with regards to self-harm repetition in both adults and CYP, there was limited emerging evidence of low and high quality respectively which showed individual cognitive behavioural therapy (CBT) and dialectic behavioural therapy for adolescents (DBT-A) had positive effects on repetition of self-harm in their respective cohorts.

There was evidence about the effectiveness of a number of longer term and brief psychological interventions but it was unclear whether they were effective for key populations (such as men or people who repeatedly self-harm). The committee made a research recommendation on the effectiveness of psychological interventions in these populations.

Benefits and harms

The committee agreed, based on their knowledge and experience, that all treatment should be planned according to the psychosocial assessment, as assessment can indicate the suitability of potential treatments. The committee also discussed the fact that self-harm is often associated with coexisting conditions such as depression or anxiety, and agreed that planning treatment for self-harm in isolation of these other factors could lead to an inappropriate care pathway, or a lowered chance of recovery. The committee discussed the various coexisting conditions that are frequently associated with self-harm, and agreed there were a number of NICE guidelines that clinicians should be aware of, so they can understand when a patient may have coexisting conditions and how these might interact with self-harm. This would allow clinicians to appropriately plan treatment for patients according to their overall needs and not any one factor in isolation, prioritising any coexisting conditions to ensure the most appropriate intervention is provided for the individual and to promote person-centred care.

The committee agreed that overall, the evidence showed a beneficial effect of psychological and psychosocial therapies on various outcomes and therefore psychological or psychosocial therapy generally should be recommended for children and adults who have self-harmed. In particular, for adults there was evidence from 20 trials that showed psychological interventions informed by CBT had positive effects on repetition of self-harm at longer follow-up assessments, as well as small beneficial effects on depression, hopelessness, and suicidal ideation over time. However, the committee acknowledged that the evidence from the Cochrane review was flawed due to the wide interpretation of ‘CBT-based psychotherapies’ which included therapeutic elements not necessarily typical to CBT, such as problem-solving therapy. The categorisation of all interventions throughout the evidence review was indistinct with some of the comparisons including therapies which overlapped across different interventions. However, the evidence did show a potential benefit of psychological interventions which were structured, person-centred, time-limited, and informed by cognitive behavioural therapy. The recommendation that a CBT-informed psychological intervention should be offered to people who self-harm was therefore based on the evidence that this had a positive effect on reducing repeat self-harm at long-term follow-up. The committee agreed other treatment modalities might be effective in adults who have self-harmed as long as they meet these principles. The committee discussed the evidence from the qualitative review on involving families and carers in management of self-harm (Evidence Report D) which showed that long waiting times for treatment was often a barrier to help-seeking, and agreed based on this evidence as well as their own experience that treatment should be offered as soon as possible to people who had self-harmed. The committee discussed whether the specific period of within 72 hours of assessment should be recommended, but ultimately agreed that without specific evidence, and based on their knowledge that it can be unfeasible to start longer term treatment within that timeframe, the timeframe should be nonspecific. However, the committee still wanted to acknowledge the potential negative effects of delaying treatment on repeat self-harm and suicide based on their knowledge and experience, and therefore agreed on the recommendation that treatment should start without delay. The recommendation regarding the number of sessions was based on the committee’s discussion of the cost-effectiveness evidence, as outlined below, however the committee agreed it was important to highlight the fact that some people may need more than 10 sessions, to ensure people receive the person-centred care they need and to enhance their experience of services. Additionally, any psychological or psychosocial interventions should be tailored to the individual’s needs and preferences, based on the committee’s knowledge and experience that enabling service users to make informed decisions about and have input on their own care has a beneficial effect on the person’s satisfaction and likelihood to engage with services.

There were limited data from 1 trial which showed mentalisation-based therapy (MBT) had positive effects on absolute repetition of self-harm and frequency of self-harm at post-intervention, while data from 2 trials showed emotion-regulation psychotherapy in a group setting also had positive effects on absolute repetition of self-harm at post-intervention specifically for women diagnosed with borderline personality disorder. The evidence of effects for standard dialectical behaviour therapy (DBT) on frequency of self-harm repetition in adults was uncertain. Finally, there was no evidence of an effect of self-harm repetition for remote contact interventions, case management, information and support, and other multimodal interventions. The committee agreed that the evidence allowed them to make recommendations for CBT-informed psychological interventions, however on the basis of such an uncertain evidence base for MBT, emotion-regulation psychotherapy and DBT, the committee could not make specific recommendations for these interventions for adults.

For children and young people, there was high-certainty evidence from 4 trials that DBT-A had a positive effect on repetition of self-harm in adolescents at post-intervention but an uncertain evidence base for other therapies: Cochrane reported low-certainty evidence regarding whether CBT had a positive effect on repetition of self-harm at post-intervention; very low-certainty evidence regarding whether MBT-A had a positive effect on repetition of self-harm at post-intervention; no evidence of effect on repetition of self-harm at post-intervention for family therapy; no evidence of effect on repetition of self-harm for compliance enhancement approaches, group-based psychotherapy, a remote contact intervention (emergency cards), or for therapeutic assessment. The committee agreed that the evidence for DBT-A allowed them to make recommendations for this therapy, however the committee could not make specific recommendations for any other therapies on the basis of such an uncertain evidence base. Therefore, the recommendation to consider offering DBT-A to children and young people was based on the evidence showing DBT-A has a positive effect on reduced repetition of self-harm in adolescents. However, the committee agreed they could not make a strong recommendation because the evidence was limited by the fact that participants in studies which showed this effect had all self-harmed more than once, were all between the ages of 12 and 18 years and were mostly female, and there was no evidence of effect of DBT-A on repeat self-harm by 12-month follow-up. The committee discussed whether the evidence could be extrapolated to children under the age of 12 and agreed, based on their knowledge and expertise, that DBT-A was likely to be similarly effective in children due to the fact that DBT-A would be carried out by very specialised staff members for children under the age of 12. The committee agreed that the lack of evidence of for children under 12 years was likely to be more reflective of the small trial sizes and nature of the sample rather than representative of the effect of DBT-A on this age group. Additionally, there was no evidence showing potential harms of DBT-A for adolescents, and the committee agreed offering DBT-A to children under 12 carried similarly low risk of harm. On the other hand, the committee agreed that not providing a therapeutic intervention to children under the age of 12 could allow for self-harm to become a coping mechanism, or otherwise repeated behaviour in the patient. They therefore agreed that DBT-A should be recommended for both children and young people despite the lack of evidence for children, to reduce the rates of repeat self-harm and suicide in this age group. However, the committee agreed they could not be sure that DBT-A would be similarly effective for children and young people who did not frequently self-harm, so they could not extrapolate the evidence any further to other populations. The recommendation was also based on the committee’s discussion of the cost-effectiveness evidence, as outlined below, however there was insufficient evidence for the committee to define how frequent self-harm would have to be to determine whether the person should receive DBT-A. The committee also agreed they could not further define how DBT-A should be provided as per the recommendation for CBT, due to the lack of robustness in the evidence base.

The committee acknowledged the weak evidence base meant that interventions other than CBT-informed psychological interventions for adults or DBT-A for children and young people might be appropriate depending on the results of the person’s psychosocial assessment. They agreed the recommendation to plan treatment according to the person’s assessment and any coexisting comorbidities would ensure this was taken into consideration to ensure the person received the right intervention for them.

The committee agreed that any therapy offered should be delivered by staff with training in the relevant therapy and who are receiving appropriate supervision, to ensure the competence of the professional delivering the training allows for the needs of the person to be met and for the treatment to be tailored for people who self-harm. The committee agreed further limitations on which staff could deliver therapies were unnecessary and could result in implementation difficulties and delays in treatment provision.

The committee agreed that any intervention should be delivered in a collaborative way with the individual and should focus on the positive effects of therapies, based on their knowledge that a strength-based approach would have the effect of finding solutions rather than focusing on potential problems for the person.

Although safety planning was not analysed as a standalone intervention in the Cochrane psychological interventions review, the committee agreed that safety planning is an important aspect of care for people who have self-harmed that is already commonly used in current practice as an adjunct to another intervention such as CBT, based on their experience and expertise. The committee’s understanding of the importance of safety plans is supported by the qualitative evidence in the review for specialist staff skills (see Evidence Report P), in which specialist staff identified safety planning as a technique that can help people manage self-harm. The committee discussed the benefits of safety planning, which they agreed equipped people who had self-harmed with the ability to identify and use their strengths and sources of support to overcome crisis moments and prevent the thought, temptation, and accessibility of self-harm. The committee discussed whether to make a strong recommendation despite the low quality of the available evidence as assessed with GRADE CERQual, because safety planning is increasingly offered to people who have self-harmed as a part of existing practice. However, the committee agreed that a stronger recommendation for safety planning would overprivilege the evidence and imply the existence of strong data where they currently do not exist. Evidence about the benefits and harms of safety planning would be necessary to confidently make a strong recommendation. The committee agreed based on their knowledge and expertise that one of the most important aspects of safety planning was reducing lethal means access, because access to means is consistently recognised as a risk factor in suicide research. The committee thought that this should always be done in collaboration with the person to protect the individual’s autonomy and dignity in moments of crisis, which could increase service user satisfaction and lower distress. Three studies included in the Cochrane review explicitly used safety planning as a part of the intervention (Armitage 2016b; Gysin-Maillart 2016; Lin 2020); the committee considered the components of these safety-planning interventions and discussed their merits. The plans in these studies included identifying the following: long-term goals; potential crisis situations; individual warning signs; personal safety strategies (such as reinforcing positive thinking, rewarding not self-harming, seeking out social support, taking medication). The committee agreed it was important for people who had self-harmed to be able to recognise warning signs so they could proactively put their safety plan into action and prevent a potential crisis that could lead to self-harm. In order to prevent self-harm upon recognising warning signs, the committee agreed it was important for professionals to help people who have self-harmed develop coping strategies to minimise distress and lower the rates of self-harm, however the committee agreed these coping strategies should be individualised to ensure generic advice which might not be helpful for the individual is not given. The committee also agreed that consideration should be given to any potential barriers to enacting these strategies, as well as problem-solving to ensure the person is equipped to deal with these barriers as they come up. Qualitative evidence from both staff skills reviews showed that people who had self-harmed, as well as specialist and non-specialist staff, identified the ability to help patients develop coping strategies as an important skill for professionals to have. The quality of this evidence was low in the specialist review but moderate in the non-specialist review. The committee also discussed the benefits of helping people to identify social contacts and settings they could seek out in a crisis, because they agreed distraction was a useful technique that could lower the distress of the person and reduce the urge to self-harm in the moment, based on their experience. The qualitative review on support needs of people who had self-harmed (see Evidence Report A) found moderate quality evidence that people who had self-harmed identified family members and friends as important sources of emotional and/or practical support. The committee therefore recommended such contacts be identified as part of a safety plan because this support could be invaluable during a crisis to prevent self-harm. The committee discussed the fact that participants in the Gysin-Maillart study were given crisis cards with contact details for private and professional helpers who could be contacted in case of a crisis, and agreed that safety plans should include contact details for these services so the person can access spontaneous support and care in a crisis. In particular, the committee agreed that out-of-hours services were important based on their knowledge that often people need help in the evenings or at night when some services may not be accessible, rendering them useless to people who need them. Furthermore, the committee agreed that there were situations where a person might need to talk to services without it being an emergency, and added that these services should available to people regardless of their levels of distress/state of emergency. They agreed this would help prevent self-harm proactively rather than waiting until the person was in crisis.

The process of safety planning was seen as a therapeutic element in itself by the committee as their experience showed it had the benefits of allowing the person to feel listened to, understood, and validated. All three studies in the Cochrane review that explicitly used safety planning as a part of the intervention implemented collaborative decision-making with the person, which the committee agreed would improve the patient’s engagement with services based on their knowledge and expertise. The committee discussed how the safety plan should be provided to the person and agreed that the person should have a copy of the plan to hold, as this would emphasise the collaborative aspect of the safety plan and allow it to be more accessible to the person in a crisis. If the safety plan is not accessible, the committee agreed based on their knowledge and expertise that this would reduce its efficacy, especially if the person was too distressed to remember their plan. This could defeat the purpose of the safety plan and lead to repeat self-harm. The committee also discussed the importance of social connectedness as a protective factor against self-harm based on their expertise, and agreed that care plans should therefore be shared with family members/ carers and other professionals when appropriate.

The committee discussed their concern that the avoidance of offering appropriate psychological or psychosocial interventions based on availability or resource implication could have a significant harmful effect on the people who had self-harmed for whom these therapies should normally be offered. They also discussed the fact that some people do not receive appropriate interventions in current practice based on their demographic or certain comorbidities such as a diagnosis of borderline personality disorder. The committee agreed that such interventions should always be available to all people who have self-harmed, based on their expertise that this can reduce the likelihood of services not being offered to people who need them, in turn potentially reducing the rates of repeat self-harm or suicide.

Cost effectiveness and resource use

The committee noted that 9 relevant papers had been identified in the literature review of published economic evidence on this topic ( Byford 1999 , Byford 2003 , Cottrell 2018 , Green 2011 , Haga 2018 , O’Connor 2017 , Owens 2020 , Priebe 2012 , Wijana 2021 ); of these, Wijana 2021 was characterised by very serious limitations and was not considered further when formulating recommendations. Moreover, 2 bespoke economic analyses were undertaken for this area of the guideline.

One guideline economic analysis aimed to evaluate the relative cost-effectiveness of CBT-informed psychological intervention in addition to treatment as usual (TAU) versus TAU alone for adults who self-harm; the other guideline economic analysis aimed to evaluate the cost-effectiveness of DBT-A relative to enhanced TAU for children and young people (CYP) who self-harm. Both economic models were cost-utility analyses (CUA) that adopted the perspective of the NHS and personal social services (PSS). The committee agreed that both economic analyses are directly applicable to the NICE decision-making context and are characterised by minor limitations.

Of the 8 economic studies identified with the review of economic evidence and considered by the committee, 4 evaluated psychological and psychosocial interventions for adults ( Byford 2003 , O’Connor 2017 , Owens 2020 , and Priebe 2012 ), and 4 studies evaluated psychological and psychosocial interventions for CYP ( Byford 1999 , Cottrell 2018 , Green 2011 , and Haga 2018 ). The committee considered this economic evidence to be directly relevant to the guideline’s decision-making, with the exception of three studies ( Green 2011 , Haga 2018 , and Priebe 2012 ), because they either were conducted outside the UK, or they did not use the QALY as the measure of outcome and therefore assessment of the cost-effectiveness of interventions was not straightforward. Most studies included in the review were cost-effectiveness analyses ( Byford 1999 , Green 2011 , Haga 2018 , O’Connor 2017 , Priebe 2012 ), or CUAs ( Byford 2003 , Cottrell 2018 , and Owens 2020 ). All economic evaluations included were undertaken alongside clinical trials, however, most of the studies did adopt a relatively long-term time frame to reflect the long-term costs and benefits of psychological and psychosocial interventions for people who self-harmed; the time horizon in 5 studies was > 1 year ( Byford 2003 , Cottrell 2018 , Green 2011 , Haga 2018 , and Priebe 2012 ), whereas only three studies used a time horizon shorter than 1 year ( Byford 1999 , O’Connor 2017 , and Owens 2020 ). Some of the studies were characterised by potentially serious methodological limitations ( Byford 1999 , Byford 2003 , Haga 2018 , Priebe 2012 , Owens 2020 ).

Based on the findings of the Cochrane systematic reviews on interventions for adults and CYP who self-harmed, the committee considered CBT-informed psychological intervention for adults and DBT-A for CYP as potential candidates for recommendation, as these were the only interventions with adequate evidence suggesting these are effective. Hence, these interventions were prioritised for economic modelling.

The committee agreed that overall, according to the findings of the economic analysis, the CBT-informed psychological intervention is likely to be cost-effective in the treatment of adults who self-harm. The committee noted that the results of the economic analysis indicated that a CBT-informed psychological intervention was cost-effective if it was delivered in up to 10 sessions, after examining a number of alternative scenarios in sensitivity analysis. However, use of alternative utility data (that suggested narrower gains in utility following a reduction in self-harming behaviour) in combination with 8–10 sessions or with a lower excess NHS cost for people who repeat self-harm within 6 months relative to those who don’t resulted in the intervention becoming not cost-effective. Nevertheless, the committee expressed the view that these analyses reflected relatively extreme scenarios regarding the data used, where a narrow range of utility values was combined with either a large number of psychological therapy sessions or with a NHS excess cost that was likely lower that the usual cost incurred by people who self-harm.

Based on the findings of the economic model and supplemented by the results of the clinical review, the committee pointed out the potential vital role of CBT-informed psychological intervention in the management of self-harm recurrence in adults who self-harm, while ensuring NHS resources are used efficiently. Therefore, they agreed to make a strong (offer) recommendation, to ensure the widespread use of CBT-informed psychological intervention for care management of adults who had self-harmed across NHS services. Based on their expertise, the results of the clinical review and the base-case and sensitivity analysis of the respective guideline economic model, they recommended that CBT-informed psychological intervention be typically delivered over a range between 4 and 10 individual sessions. The committee noted that more than 10 individual sessions of CBT-informed psychological intervention are unlikely to be cost-effective at the NICE lower cost-effectiveness threshold, nevertheless, they expressed the view that, for a minority of people who self-harm, more than 10 sessions may be essential for their improvement, and therefore decided to include in the recommendation the option of more sessions for some adults, dependent on their individual needs, in order to cover the whole population of adults who self-harm.

The committee discussed the findings of the second guideline economic analysis performed on this topic. They noted that findings suggested that DBT-A for CYP who have self-harmed is not cost-effective from a NHS and personal social services perspective, compared to enhanced TAU. Therefore, based on their expertise, the results of the clinical review and the DBT-A economic model, they recognised that recommending a typical mode of delivery of the DBT-A intervention for the whole population of CYP who self-harm was not an efficient use of resources. However, they acknowledged the important role likely to be played by DBT-A in the management of self-harm recurrence in a number of subgroups of CYP who self-harm, such as those CYP with significant emotional dysregulations who have frequent episodes of self-harm. For this reason, they agreed to make a weaker (‘consider’) recommendation to ensure that DBT-A is used for care management of CYP with significant emotional dysregulations who have frequent episodes of self-harm.

The recommendations should increase the number of people receiving psychological interventions after an episode of self-harm, and reduce the number of people denied appropriate interventions because of limited or no availability. In turn, this should reduce repeat self-harm and suicide, and improve satisfaction and engagement with services.

The committee acknowledged that the recommendations for CBT-informed psychological intervention for adults and DBT-A for CYP are likely to increase overall costs related to the provision of psychological interventions to people who self-harm, if CBT-informed psychological interventions and DBT A are offered to more service users. There is also a likely resource impact depending on how many centres do not currently offer these therapies. The committee advised that for services that do not currently offer these therapies, training and additional staffing may be needed for these interventions to be available to all eligible service users.

Recommendations supported by this evidence review

This evidence review supports recommendations 1.11.1 to 1.11.9 and research recommendation 4: the effectiveness of specific psychological interventions, including digital vs face-to face. Other evidence supporting these recommendations can be found in the evidence reviews on involving families and carers (evidence report D).

References – included studies

Effectiveness.

Byford 1999

Byford 2003

Cottrell 2018

O’Connor 2017

Priebe 2012

Wijana 2021

Harrington 1998

Mehlum 2016

Appendix A. Review protocols

Review protocol for review question: what psychological and psychosocial interventions (including safety plans and electronic health-based interventions) are effective for people who have self-harmed.

See the Cochrane review protocols for Psychosocial interventions for self-harm in adults and Interventions for self-harm in children and adolescents .

Appendix B. Literature search strategies

Literature search strategies for review question: What psychological and psychosocial interventions (including safety plans and electronic health-based interventions) are effective for people who have self-harmed? (PDF, 364K)

Appendix C. Results of the search

Results of the search for review question: what psychological and psychosocial interventions (including safety plans and electronic health-based interventions) are effective for people who have self-harmed.

See Results of the search – figure 1 from the Cochrane review of Psychosocial interventions for self-harm in adults and Results of the search – figure 1 from the Cochrane review of Interventions for self-harm in children and adolescents .

Appendix D. Characteristics of studies tables

Characteristics of studies tables for review question: what psychological and psychosocial interventions (including safety plans and electronic health-based interventions) are effective for people who have self-harmed.

See the Characteristics of included studies tables from the Cochrane review of Psychosocial interventions for self-harm in adults and the Characteristics of included studies tables from the Cochrane review of Interventions for self-harm in children and adolescents .

Appendix E. Data and analyses

Data and analyses for review question: what psychological and psychosocial interventions (including safety plans and electronic health-based interventions) are effective for people who have self-harmed.

See the Data and analyses tables from the Cochrane review of Psychosocial interventions for self-harm in adults and the Data and analyses tables from the Cochrane review of Interventions for self-harm in children and adolescents .

Appendix F. Summary of findings tables

Summary of findings tables for review question: what psychological and psychosocial interventions (including safety plans and electronic health-based interventions) are effective for people who have self-harmed.

See the Summary of findings tables from the Cochrane review of Psychosocial interventions for self-harm in adults and the Summary of findings tables from the Cochrane review of Interventions for self-harm in children and adolescents .

Appendix G. Economic evidence study selection

Study selection for review question: What psychological and psychosocial interventions (including safety plans and electronic health-based interventions) are effective for people who have self-harmed? (PDF, 23K)

Appendix H. Economic evidence tables

Economic evidence tables for review question: What psychological and psychosocial interventions (including safety plans and electronic health-based interventions) are effective for people who have self-harmed? (PDF, 413K)

Appendix I. Economic model

Economic models for review question: what psychological and psychosocial interventions (including safety plans and electronic health-based interventions) are effective for people who have self-harmed.

The committee and the guideline health economist identified the choice of psychological interventions in people who have self-harmed as an area with potentially major resource implications. Many economic evaluations in this area have been identified in the review of economic evidence for this topic. Most of this evidence was considered to have potentially serious limitations ( Byford 1999 , Byford 2003 , Owens 2020 and Priebe 2012 ), though many studies were judged of higher methodological quality ( Cottrell 2018 , Green 2011 , Haga 2018 , and O’Connor 2017 ). When discussing this evidence, the committee noted that available economic evidence assessed a limited number of interventions and was often inconclusive or not applicable to the NICE decision-making context. Moreover, existing economic evidence was based on single studies, whereas the guideline was informed by two large systematic reviews and meta-analyses of RCTs of psychological and psychosocial therapies for children and adults who have self-harmed. Therefore, 2 bespoke economics models were developed, which were informed by Cochrane systematic reviews and meta-analyses, to increase the evidence base in order to assist the committee decision making for this area of the guideline. One economic analysis aimed to evaluate the relative cost-effectiveness of cognitive behavioural therapy (CBT)-informed psychological intervention in addition to TAU versus TAU alone for adults who repeated self-harm (RSH); the other economic analysis aimed to evaluate the cost-effectiveness of dialectical behavioural therapy adapted for adolescents (DBT-A) relatively to enhanced treatment as usual (TAU) for children and young people (CYP) who RSH; both analyses were placed in the UK. The models are described below (‘ CBT-informed psychological intervention for adults who have self-harmed ’, ‘ DBT-A for children and young people who have self-harmed ’).

CBT-informed psychological intervention for adults who have self-harmed

Objective of economic modelling.

The Cochrane systematic review of clinical evidence ( Witt 2021a ) demonstrated that CBT-informed psychological intervention in addition to treatment as usual (TAU) for adults who RSH is effective in reducing the repetition of self-harm episodes when compared with TAU alone; in addition, the existing clinical evidence was deemed adequate to inform exploratory bespoke economic modelling. Based on these considerations, an economic model was developed to assess the relative cost-effectiveness of CBT-informed psychological intervention in addition to TAU versus TAU alone for adults who RSH in the UK.

Economic modelling methods

The study population of the economic model comprised adults with a hospital presentation for self-harming in the prior six months; furthermore, people included in the economic model may have repeated single or multiple self-harm episodes in the past. The age of the population at the start of the model was 29 years, in accordance with a large UK-based prospective cohort study; 56% of the model’s population were women ( Cooper 2013 , Cooper 2015 ). The starting age of the cohort and its gender composition were needed in order to estimate mortality risks in the cohort over the time horizon of the economic analysis.

Intervention

The economic analysis considered CBT-informed psychological intervention as this was the only intervention that was shown to be effective in reducing the number of future RSH episodes according to the Cochrane systematic review and meta-analysis of the clinical evidence ( Witt 2021a ). The characteristics of CBT-informed psychological intervention in terms of effectiveness and resource use (healthcare professional time, and number of sessions delivered), were determined by the findings of the Cochrane systematic review and meta-analysis that informed the review question and economic analysis, supplemented by the committee’s expert opinion.

TAU was described as treatment provided by community mental health teams (CMHT) to adults who RSH after initial hospital management. As TAU was provided in both treatment arms, it was not costed.

Scope of the economic model

The economic analysis adopted the perspective of the NHS and personal social services (PSS), as recommended by NICE ( NICE 2020 ). The measure of outcome was the Quality Adjusted Life Year (QALY), which incorporated utilities associated with repetition of self-harm health-related quality of life (HRQoL). Costs to the NHS & PSS consisted of CBT-informed psychological intervention costs (healthcare professional time and number of sessions delivered as part of intervention) and use of health and social care services (including primary care, hospital medical care, emergency department presentations, inpatient psychiatric care, outpatient psychiatric care, psychotropic prescriptions, and social care) by adults who have self-harmed. The cost year was 2020.

Model structure

Figure 2 presents a schematic diagram of the hybrid decision-analytic model developed using Microsoft Office Excel 2013; it consisted of a simple decision tree lasting 6 months incorporating Markov nodes (represented by ‘M’ in Figure 2 – Part 1), and a Markov simulation model involving 3 health states (RSH, no RSH and death), which lasted 4.5 years with a 6-month cycle Figure 2 – Part 2). A 6-month cycle was used based on data availability and committee’s advice that this is an appropriate period over which to model RSH events. A half-cycle correction was applied.

The structure of the model, which aimed to simulate the natural history of the adult self-harming population, was driven by patterns of clinical practice in the UK and the availability of relevant data sources (see section ‘ Development and validation of the economic model ’ for further details). The model estimated the total costs and effects associated with the provision of CBT-informed psychological intervention to adults who RSH. According to the model structure, hypothetical cohorts of adults who RSH were either initiated on CBT-informed psychological intervention in addition to TAU or received TAU alone. Following care received, adults either RSH, did not RSH or died, with ‘death’ taken as the absorbing state ( Figure 2 ). Due to lack of long-term comparative clinical data, transitions between the ‘RSH’ and ‘no RSH’ health states in the Markov component of the model were assumed to be independent of the intervention received at the decision-tree part of the model. The transition probability to the death state depended on the RSH status of each person in the population.

The time horizon of the analysis was 5 years. This time frame was considered to be long enough to capture longer-term costs and effects of treatment, without significant extrapolation over the course of RSH.

Figure 2. Schematic structure of the economic model assessing the cost-effectiveness of CBT-informed psychological intervention for adults who RSH (PDF, 83K)

Cost input parameters

Intervention costs.

The intervention cost of CBT-informed psychological intervention was estimated by combining resource use associated with provision of CBT-informed psychological intervention with appropriate unit costs. It was assumed that the CBT-informed psychological intervention consisted of 6 sessions, which was the average intended number of sessions reported across studies informing the Cochrane systematic review and meta-analysis of clinical evidence ( Witt 2021a ). Based on this evidence and on the committee’s advice on patterns of attendance of adult patients to CBT-informed psychological intervention’s sessions in the UK, we estimated the proportions of people attending CBT-informed psychological intervention as reported in Table 13 . By weighing the intended number of sessions with their likely attendance rates we obtained the average number of attended CBT-informed psychological intervention sessions in the model, which is 4.725 (this is the mean number of sessions likely to be provided based on the attendance rates of service users). Each CBT session was assumed to last 55 minutes and to be provided by a health professional in NHS England Agenda for Change (AfC) Band 6, usually a mental health nurse. Each CBT-informed psychological intervention session was assumed to be delivered individually and face-to-face.

Table 13. People attending CBT-informed psychological intervention sessions 1 (PDF, 131K)

  • A Band 6 salary pay scale was used to estimate unit cost per hour worked by a professional delivering each session
  • All staff delivering CBT-informed psychological intervention were assumed to be mental health nurses, in order to estimate qualification costs
  • An additional training in CBT-informed psychological intervention was estimated to cost £2,000 according to the committee’s expert advice
  • The direct to indirect time of professionals delivering CBT-informed psychological intervention based on published estimates ( Curtis and Burns 2020 ) was considered when estimating unit costs of professionals involved in delivering CBT-informed psychological intervention.

Table 14. Unit cost of qualified mental health nurses, AfC band 6 (2020 prices) (PDF, 254K)

Details on the estimation of the cost of delivering CBT-informed psychological intervention (£396) are provided in Table 15 .

Table 15. Mean cost of delivery of the CBT-informed psychological intervention (PDF, 14K)

Healthcare costs associated with repeating self-harm

The estimation of costs incurred by an adult following an episode of RSH was based on a retrospective cost analysis by Sinclair (2011) , conducted in the UK. This study followed a cohort of self-harming patients presenting to a general hospital (n=150), mostly following an episode of deliberate self-poisoning (94% of the sample), and estimated their care cost from the perspective of the NHS and social care, which was divided into 6-month cost intervals. Among the 150 participants recruited in the study, 78 service users with available resource use in each period were analysed; the mean length of time in follow-up from their first ever episode of self-harm was 10.5 years (range 2–25 years). Resources measured in the study included primary care services, emergency department services, hospital (both medical and surgical) services such as inpatient bed days, outpatient consultations, laboratory investigations, inpatient and outpatient psychiatric care, psychotropic prescriptions, social service visits and social service residential placements. The cost estimate was based on a regression analysis that reported the cost coefficient incurred by people who had self-harmed between 6 months – 1 year ago compared with people who had self-harmed within the last 6 months. This 6-month cost difference between the two population subgroups, which was reported at £1,689 in 2004/05 prices, was applied as an additional cost incurred by people who self-harmed in the past 6 months in the model relative to those who did not self-harm in the past 6 months (thus the cost of people who did not self-harm in the past 6 months in the model was zero). This estimate was inflated to 2020 price year using Hospital and Community Health Services pay and price inflator up to 2016 and the NHS Cost Inflation Index after that and up to 2020 ( Curtis and Burns 2020 ); the 2020 price was £2,134.

Clinical input parameters

Clinical input parameters consisted of effectiveness data of repetition of self-harm associated with provision of CBT-based psychotherapy in addition to TAU compared with TAU alone; the 6-month risk of RSH in people who did RSH in the previous 6 months, which is the baseline risk of RSH in the model; and the 6-month risk of RSH in people who did not RSH in the previous 6 months.

Effectiveness data

Effectiveness data consisted of the risk ratio (RR) of RSH associated with provision of CBT-informed psychological intervention plus TAU to TAU alone. Data were derived from the Cochrane systematic review and meta-analysis of clinical evidence ( Witt 2021a ), which included 12 RCTs assessing the effectiveness of CBT-informed psychological intervention plus TAU relative to TAU alone in adults presenting to services following an episode of RSH, at 6 months follow-up.

By the six-month follow-up assessment, there was evidence of an effect for CBT-informed psychological intervention on repetition of self-harm (Odds Ratios [OR]: 0.52, 95% CI 0.38 to 0.70). Using the raw data, we estimated a RR of 0.66 (95% CI 0.53 to 0.82) ( Figure 3 ), which we subsequently combined with the absolute effect of TAU, in order to estimate the absolute effect of CBT-informed psychological intervention plus TAU.

Figure 3. Forest plot for CBT-informed psychological intervention plus TAU versus TAU for treatment of RSH in adults: risk ratio at 6 months follow-up. (PDF, 143K)

Other clinical data

The risk of self-harm repetition under TAU in people who had self-harmed within 6 months was estimated using data from Lilley 2008 . This UK-based prospective cohort study followed people who attended emergency departments following self-harm (n=7,344 aged 12 years or older) over 18-months and recorded episodes of repeat self-harm. Besides the overall rates of self-harm repetition, the study investigated the differences in repetition rate according to the method of self-harm used on the index episode, and the time from the index episode during the study.

During the study period, 10,498 visits to emergency department because of self-harm were reported. The study provided Kaplan–Meier curves, calculated using recurrent event analysis (where each repeat episode was treated as an index episode). The respective graph provided cumulative proportions of adults repeating self-harm at different time points over time. Using these data, it was possible to estimate the risk of RSH 6 months after the index episode, and also the risk of RSH between 6–12 months from the index episode. Data from the provided graph were extracted using appropriate software ( https://www.digitizeit.xyz/ ).

The risk of repeating self-harm after 6 months from a self-harm episode, as estimated from Lilley 2008 , was 0.288; this value was confirmed by the committee to be an accurate approximation of the 6-month risk of RSH in people who have self-harmed under TAU (baseline risk). This risk was used in the model twice: 1) as the baseline risk of RSH for people under TAU in the decision tree component; 2) as the 6-month transition probability in the Markov model component, for people who remain in the RSH state (that is, people who are already in the RSH state in the previous model cycle). The estimated risk of RSH between 6–12 months from the index episode in Lilley 2008 (that is, in people who did not RSH in the first 6 months after the index episode) was used to estimate the 6-month transition probability for people who move to the RSH state from the non-RSH state in the Markov model component; the estimated value was 0.074. This value was also validated by the committee. Based on Lilley 2008 , the estimated risk of RSH between 12–18 months from the indext episode was 0.058, suggesting a decrease in the risk over time. This difference in the risk for people who have not self-harmed for at least 6 months (0.074) versus the risk in those who have not self-harmed for at least 12 months (0.058) was considered to be too small to have any impact on the model findings and therefore, for simplicity, it was decided to use the higher figure of 0.074 for people who have not self-harmed in the last 6 months as a conservative higher estimate.

  • 6-month transition probability of moving to the RSH state from the non-RSH state (that is, people who have not RSH in the last 6 months, in the previous model cycle): 0.074
  • 6-month transition probability of remaining in the RSH state (that is, people who had RSH in the last 6 months, in the previous model cycle), including the risk of RSH in the first 6 months of the TAU arm: 0.288.

Mortality input parameters

People who have self-harmed have an increased mortality risk relative to the general population. A cohort study that followed individuals of all ages (n=30,950) presenting to emergency departments in the UK after deliberate self-poisoning or self-injury between 2000 and 2007 estimated the increased risk associated with self-harm; this study showed that all-cause mortality following hospital presentation for self-harm was more than twice that expected ( Bergen 2012 ). The increased likelihood of premature death after self-harm (standardised mortality ratio [SMR]) was 4.1 for males and 3.2 for females presented with self-harm relative to that of adults in the general population.

The SMRs of adults presented with RSH relative to adults in the general population was applied onto the most recent general mortality statistics for the population in England ( ONS 2020 ), to estimate the absolute mortality risk in people who self-harmed in the last 6 months (RSH state) relative to those who did not self-harm in the last 6 months (non-RSH state). Adults in the RSH state were assumed to be at increased mortality risk due to RSH only over the time during which they remained in the RSH state. Adults in the non-RSH state were assumed to carry the mortality risk of the general UK population. While in the decision-tree, all adults in the model were assumed to have an increased mortality risk, equal to that of the RSH state, regardless of their response to treatment, given that they were assumed to have self-harmed at model initiation.

Table 16 reports the 6-month mortality risks adopted at each 6-month period of the model.

Table 16. 6-month mortality probabilities for each 6-month model cycle in the study population (PDF, 57K)

Utility input parameters

In order to express outcomes in the form of QALYs, the health states of the economic model (RSH, non-RSH, death) needed to be linked to appropriate utility scores. Utility scores represent the HRQoL associated with specific health states on a scale usually from 0 (death) to 1 (perfect health); they are estimated using preference-based measures that capture people’s preferences on the HRQoL experienced in the health states under consideration.

To estimate QALYs for adults in the non-RSH state, the EQ-5D-derived utility value for adults aged 25–34 years in the general UK population was used (0.93 - Kind 1999 ). The utility value for adults who RSH was estimated using the EQ-5D-derived utility value reported in a UK study for 754 adolescents who self-harmed (0.68 - Tubeuf 2019 ). This study was a secondary analysis of a randomised controlled trial comparing family therapy with treatment as usual as an intervention for self-harming adolescents (Cottrel 2018). These EQ-5D-derived utility values were selected due to lack of more relevant data on adults and were presented to the committee when developing the economic model. The committee expressed the view that both values were overestimates of the utility relating to each of the two health states, as they noted that people who have previously self-harmed (even though they have not self-harmed over the previous 6 months) are unlikely to reach the utility value of the general population (0.93 - Kind 1999 ), and people who have recently self-harmed (in the last 6 months) are unlikely to have a utility as high as 0.68 ( Tubeuf 2019 )], but noted that the difference in utility values between the two health states of RSH and non-RSH (0.93–0.68=0.25) is probably reflective of changes in HRQoL between these two states, thus confirming the face validity of the differential utility data used in the model, both for adolescents and adults who have self-harmed. Alternative utility data reported in a recent UK economic evaluation were tested in a sensitivity analysis (utility values were 0.67 and 0.54 for non-RSH and RSH health states, respectively) ( Quinlivan 2019 ). The utility of 0.67 reflected the EQ-5D-based utility of ‘mental/behavioural problems’ or history of ‘mental/behavioural disorder’ in the UK, while the value of 0.54 reflected the utility of suicide attempt, according to 16 Dutch clinicians; the estimation of this second value does not meet NICE criteria for the estimation of utility values. When observing this evidence, the committee considered this difference in utility between the two health states to be very narrow and unlikely to be reflective of the true difference between the utility in the non-RSH and RSH health states; nevertheless, these data were still tested in sensitivity analysis to explore the impact of a potentially (even though unlikely) small change in HRQoL between the two health states on the results.

Discounting

Discounting at a rate of 3.5% was applied to costs and QALYs that accrued after the first year in the model, as per the NICE reference case ( NICE 2020 ).

Handling uncertainty and presentation of the results

Relative cost effectiveness between CBT-informed psychological intervention plus TAU vs TAU alone was estimated using the incremental cost-effectiveness ratio (ICER). The ICER was calculated using the following formula: ICER = ΔC / ΔE where ΔC is the difference in total costs between two treatment options and ΔE the difference in their effectiveness (QALYs). The ICER expresses the extra cost per extra unit of benefit (QALY) associated with one treatment option relative to its comparator. If an option has an ICER of up to £20,000–£30,000/QALY relative to its comparator (NICE lower and upper cost-effectiveness threshold, respectively) then the intervention is considered to be cost-effective ( NICE 2013 ). Estimation of such a ratio allowed consideration of whether the additional benefit was worth the additional cost when choosing one treatment option over another.

Model input parameters were synthesised in a probabilistic analysis. This means that the input parameters were assigned probability distributions (rather than being expressed as point estimates); this approach allowed more comprehensive consideration of the uncertainty characterising the input parameters. Subsequently, 10,000 iterations were performed, each drawing random values out of the distributions fitted onto the model input parameters. Results (mean costs and QALYs for each intervention) were averaged across the 10,000 iterations. This exercise provides more accurate estimates than those derived from a deterministic analysis (which utilises the mean value of each input parameter ignoring any uncertainty around the mean), by capturing the non-linearity characterising the economic model structure ( Briggs 2006 ).

In addition, alternative scenarios were tested in sensitivity analysis. Three categories of sensitivity analyses (SA) were performed: 1) Univariate SAs to assess the sensitivity of the results to variations in single input parameters; 2) Multivariate SAs to assess the sensitivity of the results to variations in combinations of input parameters; and 3) Threshold SAs to assess by how much specific parameter values would need to change, for the conclusions of the analysis to change. In each scenario, probabilistic analysis was conducted (and probability distributions were used for each altered parameter), in order to take uncertainty around mean values into account.

  • intensity and frequency of the CBT-informed psychological intervention: 1) extending the average number of intended sessions delivered as part of the CBT-informed psychological intervention; 2) varying the average length of each session; 3) assuming a different Band for health professionals delivering the intervention (AfC 7)
  • additional healthcare cost associated with self-harm repetition: change of ±50% in the value used in the base-case analysis, as this value reported in Sinclair (2011) had a wide standard deviation around the mean cost estimate
  • use of alternative utility weights for the RSH and no RSH health states (utility weights were 0.541 for RSH and 0.671 for no RSH - Quinlivan 2019 )
  • use of alternative utility data ( Quinlivan 2019 ) combined with 8 sessions of CBT-based psychological therapy. The ICER became £27,557/QALY.
  • use of alternative utility data ( Quinlivan 2019 ) combined with 10 sessions of CBT-based psychological therapy. The ICER became £46,203/QALY.
  • use of alternative utility data ( Quinlivan 2019 ) combined with a 50% reduction in the base-case extra cost associated with self-harm. The ICER became £32,498/QALY.
  • baseline risk of RSH
  • additional healthcare cost of RSH versus no RSH
  • difference in utility between RSH and no RSH health states

Table 17 provides information on the distributions assigned to input parameters in probabilistic sensitivity analyses.

Results of probabilistic analyses were presented in the form of cost effectiveness acceptability curves (CEACs), which demonstrated the probability of each of the 2 treatment options being the most cost effective at different levels of willingness-to-pay per QALY (that is, at different cost effectiveness thresholds the decision maker may set). Also, the cost effectiveness plane (CEP), which depicts the incremental costs and QALYs of CBT-informed psychological intervention plus TAU versus TAU alone (placed at the origin) was used to show the uncertainty around mean cost effectiveness outcomes of the model, represented as a cloud of points on the plane corresponding to the different 10,000 iterations of the economic model in the probabilistic analysis.

Table 17. Point estimates and probability distributions assigned to input parameters of the guideline economic model. (PDF, 386K)

Development and validation of the economic model

Please see for details about the methods followed to develop and validate the economic model ‘ Development and validation of the economic models ’.

Economic modelling results

Base-case analysis.

The average total costs from the 10,000 iterations were £2,283 and £2,424 per person for the TAU and CBT-informed psychological intervention plus TAU arms, respectively; the average incremental QALY was 0.02 for the CBT-informed psychological intervention + TAU compared to TAU alone ( Table 18 ). Accordingly, the average ICER was £9,088 per QALY gained, which is well below the lower NICE cost-effectiveness threshold of £20,000/QALY.

Table 18. Probabilistic cost effectiveness estimates for the CBT-based psychotherapy added to TAU compared with TAU at 5-years time horizon (PDF, 130K)

Figure 4 shows the cost effectiveness plane for the CBT-informed psychological intervention compared with TAU at 5-years based on 10,000 iterations. The diagonal line represents the willingness to pay per QALY threshold of £20,000. All the simulation estimates are on the right of the y-axis, showing that the CBT-informed psychological intervention is always more effective than TAU. Most of the ICERs are in the north-east quadrant (75% of the 10,000 iterations), where the CBT-informed psychological intervention results in higher costs compared with TAU. Of these, 51% are below the line showing the NICE threshold of £20,000 per QALY gained. In addition, the remaining estimates are in the south-east quadrant (25% of the 10,000 iterations), showing that, in those iterations, the CBT-informed psychological intervention + TAU led to lower costs compared with TAU alone; in these iterations the CBT-informed psychological intervention + TAU is dominant (this is, the intervention is both clinically superior and cost saving compared to the TAU). Overall, results suggest that the CBT-based psychotherapy added to TAU is likely to be cost effective compared to TAU alone, with a probability of 51% + 25% = 76%.

Figure 4. Cost effectiveness plane of CBT-informed psychological intervention added to TAU compared with TAU alone over a time horizon of 5 years (PDF, 444K)

A cost effectiveness acceptability curve of the CBT-informed psychological intervention compared with TAU alone is presented in Figure 5 . At a threshold of £20,000, the CBT-informed psychological intervention + TAU had a 76% chance of being cost effective, and this percentage increased to 92% when the threshold was £30,000. There is a positive relationship between the cost effectiveness threshold and the chance of CBT-informed psychological intervention being cost effective, and this is because the CBT-informed psychological intervention was, on average, more effective (in terms of QALY gains) than TAU, while either being cost saving or costing slightly more.

Figure 5. Cost effectiveness acceptability curves for the CBT-informed psychological intervention added to TAU compared with TAU alone over a 5 years’ time horizon (PDF, 472K)

Sensitivity analysis

To account for uncertainty in the incremental costs and QALYs estimation, a number of probabilistic univariate sensitivity analyses were conducted ( Table 19 ). The first sensitivity analyses included making different assumptions about the delivery of the CBT-informed psychological intervention: 1) varying the average number of sessions delivered, as defined earlier in the methods (section ‘ Handling uncertainty and presentation of the results ’); 2) Varying the average length of each CBT-informed psychological intervention from 50 to 65 minutes; 3) Assuming different healthcare professional’s salaries; 4) using alternative utility data from Quinlivan 2019 . By exploring these model’s assumptions, the delivery of the CBT-informed psychological intervention remained likely to be cost effective in adults who RSH at 5 years time horizon in all but one cases; it was unlikely to be cost effective when it was provided in more than 10 sessions ( Table 19 ). As for the base-case analyses, these results indicate the CBT-informed psychological intervention plus TAU is more effective than the TAU alone, and so, as the value placed on a QALY increases, the likelihood that the intervention is cost-effective rises.

Table 19. Probabilistic cost effectiveness estimates for the CBT-informed psychological intervention added to TAU compared with TAU alone – Univariate sensitivity analysis (PDF, 275K)

Besides univariate sensitivity analyses, multivariate sensitivity analyses were conducted to study the effect of using alternative utility weights combined 1) with an increase in the number of CBT-informed psychological intervention sessions and 2) with a 50% reduction in the excess NHS cost of RSH relative to RSH, on the results of the economic model ( Table 20 ). In none of these scenarios was CBT-informed psychological intervention found to be cost effective, using the NICE lower cost-effectiveness threshold of £20,000/QALY ( Table 20 ).

Table 20. Probabilistic cost effectiveness estimates for the CBT-informed psychological intervention added to TAU compared with TAU alone – Multivariate sensitivity analysis (PDF, 119K)

Finally, as suggested by the findings of the threshold sensitivity analysis ( Table 21 ), compared to TAU alone, CBT-informed psychological intervention plus TAU will remain cost effective if: 1) the baseline risk of RSH in the model population would be at least 21.5% (in the base-case analysis this value is 28.8 %); or the excess cost of RSH vs no RSH state would be at least £588 (instead of £2,133.53 with the base-case scenario); or the difference in utility between RSH and non-RSH state would be at least 0.10 (in base-case analysis this difference is 0.25)

Table 21. Cost effectiveness estimates for the CBT-informed psychological intervention added to TAU compared with TAU alone – Threshold sensitivity analysis (PDF, 230K)

The primary purpose of this economic model was to assess the relative cost-effectiveness of CBT-informed psychological intervention in addition to TAU versus TAU alone for adults who RSH. When considering a population of adults who RSH, our results suggest that the ICER for CBT-informed psychological intervention added to TAU was below the NICE threshold of £20,000 per QALY over 5 years. Secondly, starting with our base case economic scenario, we aimed to simulate costs and effectiveness data exploring a number of scenarios different from the base case; such as the intensive delivery of the CBT-informed psychological intervention, or considering the most relevant model’s assumptions (for example, NHS cost parameters, clinical input parameters, and QALY valuation). By exploring all these model’s assumptions, the delivery of the CBT-based psychotherapy remained likely to be cost effective in adults who RHS, suggesting confidence around both models’ results when model assumptions varied. The committee pointed all the above considerations out, when discussing the evidence and drafting the recommendations for this area of the guideline.

None of the analyses identified in the economic evidence review were focused on CBT-informed psychological intervention for people who RSH, except Byford (2003) . In this cost-utility analysis, which assessed the cost-effectiveness of manual-assisted cognitive behaviour therapy (MACT) relatively to TAU, MACT was found to be cheaper but slightly less effective than TAU, and, overall, more cost-effective than TAU. The results of this study are highly applicable to this guideline in terms of the population, healthcare system, interventions and outcomes considered ( Byford 2003 ). However, this study was considered to have potentially serious methodological limitations: the short-term time horizon, which was 12 months follow-up ( Tyrer 2003 ); in addition, the baseline and the relative intervention effects data were based on a single RCT ( Tyrer 2003 ).

Therefore, the present analysis makes an important contribution to the existing evidence on the cost effectiveness of CBT-informed psychological intervention(s) in people who RSH. It shows the cost-effectiveness CBT-informed psychological intervention added onto TAU compared to the TAU alone in the UK, using incremental costs per QALY gained as the primary outcome measure, adopting a longer-term analytical time horizon; and obtaining effectiveness data from the Cochrane review and meta-analysis of clinical evidence, which informed the guideline.

The model’s results should be interpreted in light of the information on the probabilities of repeating self-harm, since such data were based on a single, albeit large, study ( Lilley 2008 ). This was a prospective multicentre cohort analysis involving 10,498 consecutive episodes of self-harm at six English teaching hospitals, and its estimates of RSH are supported by alternative sources of evidence (such as Cooper 2015 ). The figures reported in Lilley 2008 were estimated from Kaplan–Meier curves which used recurrent event analysis (that is each repeat episode of self-harm treated as an index episode): the risk at 0–6 months was used to estimate the 6-month risk of remaining in the RSH state (that is, the 6-month risk of RSH in people who had self-harmed within the last 6 months); the risk at 6–12 months of the study was used to estimate the 6-month risk of moving to the RSH state from the non-RSH state (that is, the 6-month risk of RSH in people who had not self-harmed in the last 6 months). During the discussion of this evidence, the committee confirmed the face validity of these data, so, they agreed for these data to be used in the economic model.

The findings of the present model may be restricted by the paucity of self-harm related utility data. In the economic model, 2 different sets of utility data were used to reflect the health-related quality of life associated with RSH and no RSH. The first set of utility data (No RSH: 0.93 and RSH: 0.68; Kind 1999 and Tubeuf 2019 respectively) were considered by the committee to reflect the difference in utility between the two health states, although each value appeared to be an overestimate of the HRQoL in the respective health state. It is noted that this set of data has also been used in the base-case economic analysis described in McDaid 2022 , who estimated the cost-effectiveness of psychosocial assessment for individuals who present to hospital following self-harm in England. The second set of utility data does not meet NICE criteria for the estimation of utility values; in addition, the committee considered the difference in utility between the two health states too narrow (RSH: 0.54 and No RSH: 0.67 - Quinlivan 2019 ). Nevertheless, no alternative utility data were available, and therefore, after considering the available data, the committee advised that the first set of utility values be used in the base-case analysis, and the second set of utility data ( Quinlivan 2019 ) be investigated in sensitivity analysis.

Self-harm is strongly associated with mental health problems, and related utility values reflect the overall HRQoL of people experiencing/living with self-harm and other mental health problems, as it is not possible to isolate and represent separately HRQoL relating to self-harm and HRQoL relating to another mental-health problem. Similarly, people who have not self-harmed in the last 6 months (no RSH state), are expected to experience improvement in both their self-harming behaviour and associated mental health problems, and their HRQoL consequently reflects both improvements (as, again, it is not possible to isolate these from one another). Therefore, the utility values used in the model are assumed to reflect HRQoL related to self-harm that incorporates mental health problems or related improvements.

It is noted that the utility value of the no RSH state used in the base-case analysis is that of the general population in the UK, suggesting that the intervention has had a positive impact on other mental health problems. In sensitivity analysis, the utility value of the no RSH state reflects ‘mental/behavioural problem or history of mental disorder’. This is non-specific to the no RSH state and may also include improvement in other mental health problems (since it also incorporates the value of ‘history’ of a mental disorder). Therefore, the utility values of the no RSH state used both in base-case and sensitivity analysis reflect wider mental health improvements associated with this state, and not only improvements in self-harming behaviour.

Overall conclusions from the guideline economic analysis

The results of the guideline economic analysis suggest that individual CBT-informed psychological intervention is likely to be cost-effective in the treatment of adults who have RSH. When discussing the economic evidence, the committee acknowledged that these findings needed to be interpreted with some caution due to the limited evidence base characterising some of the models’ input parameters. Based on the findings of the economic model and supplemented by the results of the clinical review, the committee pointed out the vital role played by CBT-informed psychological intervention in the management of self-harm recurrence in adults, while ensuring NHS resources are used efficiently.

Bergen 2012

Briggs 2006

Cooper 2013

Cooper 2015

Curtis and Burns 2020

Davies 1998

Lilley 2008

McDaid 2022

Netten 1998

Norton 2018

Quinlivan 2019

Sinclair 2011

Tubeuf 2019

DBT-A for children and young people who have self-harmed

The Cochrane systematic review of clinical evidence ( Witt 2021b ) demonstrated that dialectical behavioural therapy adapted for adolescents (DBT-A) who repeated self-harm (RSH) is effective in reducing the repetition of self-harm episodes when compared with treatment as usual (TAU) or another comparator; in addition, the existing clinical evidence was deemed as adequate to inform exploratory bespoke economic modelling. Based on these considerations, an economic model was developed to assess the relative cost-effectiveness of DBT-A versus enhanced TAU for children and young people who have self-harmed in the UK.

The study population of the economic model comprised children and young people (CYP) with a hospital presentation for self-harming in the prior six months; furthermore, young people included in the economic model may have repeated single or multiple self-harm episodes in the past. The age of the population at the start of the model was 16 years, in accordance with a large UK-based prospective cohort study; 75% of the model’s population were women ( Hawton 2012 ). The starting age of the cohort and its gender composition were needed in order to estimate mortality risks in the cohort over the time horizon of the economic analysis.

The economic analysis considered DBT-A as this was the only intervention that was shown to be effective in reducing the number of future RSH episodes according to the Cochrane systematic review and meta-analysis of the clinical evidence ( Witt 2021b ). The characteristics of DBT-A in terms of effectiveness and resource use (healthcare professional time, and number of sessions delivered), were determined by the findings of the Cochrane systematic review and meta-analysis that informed the review question, supplemented by the committee’s expert opinion ( Witt 2021b ).

The comparator of the meta-analysis was ‘TAU or another comparator’. After reviewing the comparators in the studies included in the Cochrane meta-analysis that informed the guideline economic model, and following the committee’s expert advice, it was agreed that the comparator was equivalent, on average, to enhanced TAU. According to the committee’s expert opinion, enhanced TAU is expected to be diverse and delivered by a range of providers. In order to model the costs and outcomes of enhanced TAU, we considered enhanced TAU described in a clinical trial conducted in the UK ( Cottrell 2018 ) as treatment provided by children and adolescent mental health services (CAMHS) to children and young people who RSH after initial hospital management.

The economic analysis adopted the perspective of the NHS and personal social services (PSS), as recommended by NICE ( NICE 2020 ). The measure of outcome was the Quality Adjusted Life Year (QALY), which incorporated utilities associated with repetition of self-harm health-related quality of life (HRQoL). Costs to the NHS & PSS consisted of DBT-A and enhanced TAU-based intervention costs (healthcare professional time and number of sessions delivered as part of intervention) and use of health and social care services (including GP care, CAMHS, other primary care, hospital inpatient and outpatient care, emergency department presentations, physiotherapy, occupational therapy and social care) by children and young people who have self-harmed. The cost year was 2020.

Figure 6 presents a schematic diagram of the hybrid decision-analytic model developed using Microsoft Office Excel 2013; it consisted of a simple decision tree lasting 6 months incorporating Markov nodes (represented by ‘M’ in Figure 2 – Part 1), and a Markov simulation model involving 3 health states (RSH, no RSH and death due to suicide), which lasted 4.5 years with a 6-month cycle Figure 2 – Part 2). A 6-month cycle was used based on data availability and GC advice that this is an appropriate period over which to model RSH events. A half-cycle correction was applied.

The structure of the model, which aimed to simulate the natural history of the CYP self-harming population, was driven by patterns of clinical practice in the UK and the availability of relevant data sources (see section ‘ Development and validation of the economic model ’ for further details). The model estimated the total costs and effects associated with the provision of DBT-A and enhanced TAU for CYP who RSH. According to the model structure, hypothetical cohorts of CYP who RSH were either initiated on DBT-A or received enhanced TAU. Following care received, CYP either RSH, did not RSH or died by suicide, with ‘death’ taken as the absorbing state ( Figure 6 ). Due to lack of long-term comparative clinical data, transitions between the ‘RSH’ and ‘no RSH’ health states in the Markov component of the model were assumed to be independent of the intervention received at the decision-tree part of the model. The transition probability to the death by suicide state depended on the RSH status of each young person in the population.

Figure 6. Schematic structure of the economic model assessing the cost-effectiveness of DBT-A for children and young people who RSH (PDF, 195K)

Dialectical behaviour therapy costs

The intervention cost of DBT-A was estimated by combining resource use associated with provision of DBT-A with appropriate unit costs. It was assumed that DBT-A was a modular psychological treatment consisting of a combination of individual psychotherapy, group skills training, therapist consultation team, and telephone counselling. In our model, the DBT-A delivery mode consisted of 16 weekly sessions (60 minutes) of individual therapy, 16 weekly sessions (120 minutes) of skills training in a group format (2 therapists and 10 participants per group), 16 weekly sessions (120 minutes) of therapist consult team and out-of-hours counselling over the telephone as needed. Such assumptions on the DBT-A delivery mode were based on routine practice in the UK (according the advice of the committee) and the reported number and duration of sessions across studies informing the Cochrane review and meta-analysis of clinical evidence ( Witt 2021b ). Based on this evidence and on the committee’s advice on patterns of attendance of CYP to DBT-A’s individual psychotherapy sessions in the UK, we assumed the proportions of CYP attending DBT-A individual psychotherapy as reported in Table 22 . By weighing the intended number of individual psychotherapy sessions with their likely attendance rates we obtained the average number of attended DBT-A’s individual psychotherapy sessions in the model, which is 13.875 (this is the mean number of sessions likely to be provided based on the attendance rates of service users). This number was used in order to estimate the mean individual intervention cost. The number of therapist sessions per person attending group sessions was not altered from the intended number of 16 sessions, because the number of group sessions remains the same, whether a participant attends the full course of treatment or a lower number of sessions.

Table 22. People attending individual DBT-A sessions 1 (PDF, 243K)

  • A Band 7 salary pay scale was used to estimate unit cost per hour of the therapist delivering each session; unit costs of scientific and professional staff were used ( Table 23 )
  • The direct to indirect time of professionals delivering DBT-A based on published estimates ( Curtis and Burns 2020 ) was considered when estimating unit costs of professionals involved in delivering DBT-A ( Table 23 )
  • 2/3 of staff delivering DBT-A were assumed to be mental health nurses and 1/3 clinical psychologists; this assumption was used in order to estimate qualification costs
  • An additional training in DBT-A was estimated to cost £ 9,463, equal to a post-graduate diploma in DBT, as agreed with the committee

Table 23. Unit cost of health professional staff delivering DBT-A, AfC band 7 (2020 price) (PDF, 260K)

Therapist consult team sessions and telephone counselling were not costed, as they were delivered by healthcare professionals already involved in delivering individual psychotherapy and group skills training sessions, with no additional use of their time (these components are included in the professionals’ direct-to indirect time ratio of contact with patients). After combining resource use with unit costs estimated as described above, the mean cost per CYP receiving the DBT-A intervention was estimated to be £2,801 ( Table 24 ).

Table 24. DBT-A delivery mode and total cost (PDF, 14K)

Enhanced treatment as usual costs

Based on the committee’s advice, enhanced TAU for CYP who have self-harmed in the UK was assumed to be in line with the treatment as usual reported in a multicentre RCT and economic analysis conducted in the UK ( Cottrell 2018 ). This study assessed the effectiveness and cost-effectiveness of family therapy (FT) compared with TAU across 3 English regions. Therefore, enhanced TAU consisted of the care offered to CYP referred to children and adolescent mental health services (CAMHS) following self-harm, and included CAMHS services, telephone contacts and therapist’s supervision. Cottrell (2018) reports a cost of TAU in the UK of £ 875 at 6 months follow-up, in 2014 prices ( Table 25 ) . This estimate was inflated to 2020 price year using the NHS Cost Inflation Index after that and up to 2020 ( Curtis and Burns 2020 ); the 2020 price was £ 961.

Table 25. Average enhanced TAU cost at 6 moths follow-up (Cottrell 2018; 2014 prices) (PDF, 135K)

Healthcare costs associated with self-harm

The estimation of healthcare costs associated with the RSH and non-RSH health states incurred by CYP who had self-harmed in the past was based on the economic analysis published by Cottrell (2018) . This study estimated health and social care costs following an episode of self-harm from the perspective of the NHS and PSS. This UK study comprised a cohort of adolescents aged 11 to 17 years who self-harmed prior to assessment by the CAMHS team (n=832). Resources measured in the study included health community and social care services, hospital services, and medication use. Besides baseline, resource use data were collected at 6, 12 and 18 months converted into costs using unit cost figures from the British National Formulary (BNF), Personal Social Services Research Unit (PSSRU) and the Department of Health’s National Schedule of Reference Costs ( Cottrell 2018 ). The costing results were reported 2014/2015 prices in terms of healthcare costs associated with RSH within the previous 6 months and healthcare costs associated with no RSH within the previous 6 months ( Table 26 ). These estimates were inflated to 2020 price year using the NHS Cost Inflation Index after that and up to 2020 ( Curtis and Burns 2020 ); the resulting costs associated with using healthcare services were £1,859 for CYP who RHS and £807 for CYP who did no-RHS within the last 6 months.

Table 26. Average 6-month healthcare cost associated with self-harm (Cottrell 2018) (PDF, 136K)

Effectiveness data consisted of the risk ratio (RR) of RSH associated with provision of DBT-A to TAU or other comparator. Data were derived from the Cochrane systematic review and meta-analysis of clinical evidence, which included 4 RCTs ( Cooney 2010 , McCauley 2018 , Mehlum 2014 , and Santamarina-Pérez 2020 ) assessing the effectiveness of DBT-A relative to TAU in CYP presenting to services following an episode of RSH, at 6 months follow-up ( Witt 2021b ). As reported in the Cochrane review of clinical evidence, the evidence was deemed to be of high certainty, and there was no evidence of a difference by comparator (TAU versus enhanced TAU versus alternative psychotherapy), even though there were some concerns with regards to the overall risk of bias for all four trials ( Witt 2021b ).

By the six-month follow-up assessment, there was evidence of an effect for DBT-A on repetition of self-harm (Odds Ratios [OR]: 0.46, 95% CI 0.26 to 0.82). Using the raw data, we estimated a RR of 0.69 (95% CI 0.51 to 0.92) ( Figure 7 ), which we subsequently combined with the absolute effect of enhanced TAU, in order to estimate the absolute effect of DBT-A.

Figure 7. Forest plot for DBT-A versus enhanced TAU for treatment of RSH in CYP: risk ratio at 6 months follow-up. (PDF, 136K)

The baseline risk and the transition probabilities of self-harm repetition in CYP used in the model were estimated using data from Cottrell 2018 . This UK-based randomised controlled trial aimed to assess the effectiveness and cost-effectiveness of family therapy (FT) compared with treatment as usual (TAU) in adolescents aged 11 to 17 years who self-harmed prior to assessment by the CAMHS team (n=832) during the 18-month study period. Table 27 summaries the risks that have been used in the Markov model as transition probabilities between the RSH and the non-RSH states for the hypothetical cohort of CYP in a cycle time, plus the baseline probability of RSH in children and young people used in the decision tree part of the model ( Cottrell 2018 ).

Table 27. Baseline risk of RSH and 6-month transition probabilities of self-harm repetition in CYP (based on Cottrell 2018) (PDF, 29K)

Children and young people (CYP) who have repeated self-harm have an increased mortality risk due to suicide relative to the general population. A prospective cohort study followed children and young people aged 10–18 years presenting to emergency departments in the UK after non-fatal self-harm between 2000 and 2013 (n=9173 individuals who had 13,175 presentations for self-harm), to estimate the increased risk of suicide associated with self-harm. This study showed that in CYP the increased likelihood of premature death by suicide after self-harm was more than 30 times higher (standardised mortality ratio: 31.0, 95% CI 15.5 to 61.9) relative to that of CYP in the general population ( Hawton 2020 ).

Table 28 reports the 6-month mortality risks adopted at each 6-month period of the model. The standardised mortality ratios (SMRs) of CYP presented with RSH relative to CYP in the general population was applied onto the most recent age-specific suicide rate statistics for the population in England ( ONS 2020 ), to estimate the absolute mortality risk due to suicide in CYP who self-harmed in the last 6 months (RSH state) relative to those who did not self-harm in the last 6 months (non-RSH state). CYP in the RSH state were assumed to be at increased mortality risk due to RSH only over the time during which they remained in the RSH state. CYP in the non-RSH state were assumed to carry the mortality risk of the general UK population. While in the decision-tree, all children and young people in the model were assumed to have an increased mortality risk due to suicide following RSH, equal to that of the RSH state, regardless of their response to treatment, given that they were assumed to have self-harmed at model initiation.

Table 28. 6-month mortality by suicide probabilities for each 6-month model cycle in the study population (PDF, 154K)

In order to express outcomes in the form of QALYs, the health states of the economic model (RSH, non-RSH, death by suicide) needed to be linked to appropriate utility scores. Utility scores represent the HRQoL associated with specific health states on a scale usually from 0 (death) to 1 (perfect health); they are estimated using preference-based measures that capture people’s preferences on the HRQoL experienced in the health states under consideration.

To estimate QALYs for children and young people in the non-RSH state, the EQ-5D-derived utility value for young adults under 25 years of age in the general UK population was used (0.94 - Kind 1999 ). The utility value for children and young people who RSH was estimated using the EQ-5D-derived utility value reported in a UK study for 754 adolescents who self-harmed (0.68 - Tubeuf 2019 ). This study was a secondary analysis of a randomised controlled trial comparing family therapy with treatment as usual as an intervention for self-harming adolescents (Cottrel 2018). These EQ-5D-derived utility values were selected due to lack of more relevant data and were presented to the committee when developing the economic model. The committee expressed the view that both values were overestimates of the utility relating to each of the two health states, as they noted that people who have previously self-harmed (even though they have not self-harmed over the previous 6 months) are unlikely to reach the utility value of the general population (0.94 - Kind 1999 ), and people who have recently self-harmed (in the last 6 months) are unlikely to have a utility as high as 0.68 ( Tubeuf 2019 )], but noted that the difference in utility values between the two health states of RSH and non-RSH (0.93–0.68=0.25) is probably reflective of changes in HRQoL between these two states in children and young people, thus confirming the face validity of the differential utility data used in the model. Alternative utility data reported in a recent UK economic evaluation were tested in a sensitivity analysis (utility values were 0.76 and 0.80 for non-RSH and RSH health states, respectively) ( Cottrell 2018 ). These utility values were collected by administering the EQ-5D questionnaire to the sample of children and young people (n=832) included in the RCT at 6, 12, and 18 months follow-up. When observing this evidence, the committee considered this difference in utility between the two health states to be very narrow and unlikely to be reflective of the true difference between the utility in the non-RSH and RSH health states; nevertheless, these data were still tested in sensitivity analysis to explore the impact of a potentially (even though unlikely) small change in HRQoL between the two health states on the results.

Relative cost effectiveness between DBT-A vs enhanced TAU was estimated using the incremental cost-effectiveness ratio (ICER). The ICER was calculated using the following formula: ICER = ΔC / ΔE where ΔC is the difference in total costs between two treatment options and ΔE the difference in their effectiveness (QALYs). The ICER expresses the extra cost per extra unit of benefit (QALY) associated with one treatment option relative to its comparator. If an option has an ICER of up to £20,000–£30,000/QALY relative to its comparator (NICE lower and upper cost-effectiveness threshold, respectively) then the intervention is considered to be cost-effective ( NICE 2013 ). Estimation of such a ratio allowed consideration of whether the additional benefit was worth the additional cost when choosing one treatment option over another.

  • intensity and frequency of DBT-A: 1) extending the average number of intended sessions (individual psychotherapy and group skills training) delivered as part of the DBT-A intervention; 2) varying the average length of each DBT-A session; 3) assuming a different band for health professionals delivering the intervention
  • healthcare cost associated with self-harm: increasing/decreasing the values used in the base-case analysis by 50%, as for the costs associated with using healthcare services for CYP who RHS and for CYP who did not RHS
  • low DBT-A delivery costs: 1) reducing the average length of each individual psychotherapy session (50 minutes); 2) reducing the average length of each group skills training session (60 minutes); and 3) assuming a lower professional’s salary (AfC 6)
  • QALY valuation: using alternative utility weights to attach to the RHS and no RSH health states (utility weights were 0.76 for RSH and 0.80 for no RSH – Cottrell 2018 )
  • risk of RSH after having RSH, either the baseline risk of RSH in the model and the risk of RSH after RSH after post-intervention
  • healthcare cost associated with RSH versus no RSH
  • DBT-A delivery cost

Table 29 provides information on the distributions assigned to input parameters in probabilistic sensitivity analyses.

Results of probabilistic analyses were presented in the form of cost effectiveness acceptability curves (CEACs), which demonstrated the probability of each of the 2 treatment options being the most cost effective at different levels of willingness-to-pay per QALY (that is, at different cost effectiveness thresholds the decision maker may set). Also, the cost effectiveness plane (CEP), which depicts the incremental costs and QALYs of DBT-A versus enhanced TAU alone (placed at the origin) was used to show the uncertainty around mean cost effectiveness outcomes of the model, represented as a cloud of points on the plane corresponding to the different 10,000 iterations of the economic model in the probabilistic analysis.

Table 29. Point estimates and probability distributions assigned to input parameters of the guideline economic model. (PDF, 198K)

The average total costs from the 10,000 iterations were £8,494 and £10,292 per person for the enhanced TAU and DBT-A arms, respectively; the average incremental QALY was 0.01 for the DBT-A intervention compared to enhanced TAU ( Table 30 ). Accordingly, the average ICER was £268,601 per QALY gained, which is well above the NICE cost-effectiveness threshold of £20,000/QALY.

Table 30. Probabilistic cost effectiveness estimates for DBT-A compared with enhanced TAU at 5-years time horizon (PDF, 197K)

Figure 8 shows the cost effectiveness plane for DBT-A compared with enhanced TAU at 5-years based on 10,000 iterations. The diagonal line represents the willingness to pay per QALY threshold of £20,000. Nearly all the simulation estimates are on the right of the y-axis, showing that the DBT-A is most likely to be more effective than enhanced TAU. Also, almost all of the ICERs are in the north-east quadrant (99.5% of the 10,000 iterations), where DBT-A results in higher costs compared with enhanced TAU. Of these, just 2.5 % are below the line showing the NICE threshold of £20,000 per QALY gained. In addition, only 0.5% of the estimates are in the south-east quadrant (50 of the 10,000 iterations), showing that, in those iterations, DBT-A led to lower costs and higher benefits compared with enhanced TAU. Overall, results suggest that DBT-A is not cost effective compared to enhanced TAU: using a cost per QALY threshold of £20,000, DBT-A had a 3% (2.5% + 0.5%) chance of being cost-effective.

Figure 8. Cost effectiveness plane of DBT-A compared with enhanced TAU over a time horizon of 5 years (PDF, 122K)

A cost effectiveness acceptability curve of the DBT-A intervention compared with enhanced TAU is presented in Figure 9 . At a threshold of £20,000, DBT-A had a 3% chance of being cost effective, and this percentage increased to 6% when the threshold was £30,000. There is a positive relationship between the cost effectiveness threshold and the chance of DBT-A being cost effective, and this is because the DBT-A intervention was, on average, slightly more effective (in terms of QALY gains) than enhanced TAU, while being heavily more costly.

Figure 9. Cost effectiveness acceptability curves for DBT-A compared with enhanced TAU over a 5 years’ time horizon (PDF, 350K)

To account for uncertainty in the incremental costs and QALYs estimation, a number of probabilistic univariate sensitivity analyses were conducted ( Table 31 ). The first sensitivity analyses included making different assumptions about the delivery of the DBT-A intervention: 1) varying the average number of individual psychotherapy and group skills training sessions delivered, as defined earlier in the methods (section ‘ Handling uncertainty and presentation of the results ’); 2) varying the average length of each DBT-A session, either individual or group; 3) assuming different healthcare professional’s salary bands. By exploring these model’s assumptions, the delivery of DBT-A remained unlikely to be cost effective in children and young people who RHS at 5 years time horizon in all cases ( Table 31 ). The second probabilistic univariate sensitivity analyses included making different assumptions about the healthcare costs associated with no RSH or incurred by CYP following an episode of RSH. Also by exploring these assumptions, the delivery of DBT-A remained unlikely to be cost-effective compared to enhanced TAU. As for the base-case analyses, these results suggest that DBT-A is slightly more effective and heavily more costly than enhanced TAU, and so, as the value placed on a QALY increases, the likelihood that the intervention is cost effective rises marginally.

Table 31. Probabilistic cost effectiveness estimates for DBT-A compared with enhanced TAU – Univariate sensitivity analysis (PDF, 494K)

Besides univariate sensitivity analyses, two probabilistic multivariate sensitivity analyses were conducted to study the combined effect of some input parameters on the results of the economic model ( Table 32 ). The first analysis included reducing simultaneously the average length of each individual and group session of DBT-A and assuming a lower professional’s salary. Under such a scenario of low delivery costs, DBT-A remained not cost-effective ( Table 32 ) compared with enhanced TAU, but its probability of being a cost-effective intervention increased to some extent. By means of the second multivariate sensitivity analysis, the usage of alternative QALY valuation has been explored (using utility weights to attach to the RHS and no RSH health states of 0.76 and 0.80, respectively – Cottrell 2018 ); over this scenario, DBT-A remained not cost effective compared to enhanced TAU, with a lower probability of being cost-effective compared to the base-case analysis ( Table 32 ).

Table 32. Probabilistic cost effectiveness estimates for DBT-A compared with enhanced TAU – Multivariate sensitivity analysis (PDF, 251K)

Finally, as suggested by the findings of the threshold sensitivity analysis ( Table 33 ), compared to enhanced TAU the DBT-A intervention will be cost effective if: 1) the risk of RSH after RSH in the model population would be at least 69% (in the base-case analysis this value was 14% under enhanced TAU, in the decision tree component, and 26% in the Markov model component); or the delivery cost of DBT-A would be at maximum £1,135 (instead of £2,801 with the base-case scenario); or the healthcare costs incurred by children and young people following an episode of RSH would be at least £55,000 (in base-case analysis this value was £1,859)

Table 33. Cost effectiveness estimates for DBT-A compared with enhanced TAU – Threshold sensitivity analysis (PDF, 229K)

The primary purpose of this economic model was to assess the relative cost-effectiveness of DBT-A versus enhanced TAU for children and young people following an episode of RHS. Our results suggest that the ICER for DBT-A is well above the NICE threshold of £20,000 per QALY over 5 years; therefore, DBT-A is not a cost-effective psychological therapy compared to the enhanced TAU. Secondly, starting with our base-case economic scenario, we aimed to simulate costs and effectiveness data exploring a number of scenarios; such as a different delivery mode of DBT-A, or varying the most relevant model’s assumptions (for example, NHS cost parameters, clinical input parameters, and QALY valuation). By exploring all these model’s assumptions, the delivery of DBT-A remained unlikely to be cost effective in children and young people who RHS, suggesting confidence around models’ results when model assumptions varied. According to the committee’s advice, the only plausible change in input parameters that would make DBT-A cost-effective is when the baseline risk of self-harm repetition combined with the risk of RSH following RSH in the model population would be at least 69%, which would be reflecting the healthcare circumstances and needs of a particular sub-group of CYP who RSH, such as those CYP at very high risk of self-harmrecurrence. Summing up, the present economic model shows that DBT-A is a very costly intervention with relatively low benefits for the overall population of CYP who RSH. On the other hand, the present analysis suggests that DBT-A might be a cost-effective treatment in the specific subgroup of CYP who RSH and have a very high risk of repeating self-harm over time, incurring high management costs, such as CYP with significant emotional dysregulations who have frequent episodes of self-harm, as noted by the committee. When discussing the evidence and drafting the recommendations for this area of the guideline, the committee pointed out all the above considerations.

None of the analyses identified in the economic evidence review were focused on DBT for people who RSH, except for Haga (2018) and Priebe (2012) ; both studies were cost-effectiveness analyses conducted alongside RCTs; with the one study from Norway and ( Haga 2018 ) and the other one from the UK ( Priebe 2012 ). Haga (2018) compared the cost-effectiveness of DBT-A to enhanced TAU in adolescents who self-harmed, mostly individuals with borderline personality disorder, with its results suggesting that DBT-A had a high probability of being a cost-effective psychological treatment. Priebe (2012) compared the cost-effectiveness of DBT with TAU in adults with borderline personality disorder who have self-harmed in the UK. The results were inconclusive mostly because DBT was found to be more effective in reducing self-harm and more costly than TAU, but no QALYs were estimated. The committee found both economic analysis partially applicable to the decision-making context as they included mostly people who self-harmed with borderline personality disorder and they did not use the QALY as the measure of outcome. Therefore, the present analysis makes an important contribution to the existing evidence on the cost effectiveness of DBT-A in children and young people who RSH using incremental costs per QALY gained as the primary outcome measure, adopting a longer-term analytical time horizon; and obtaining effectiveness data from the Cochrane review and meta-analysis of clinical evidence ( Witt 2021b ), which informed the guideline.

The findings of the present model may be restricted by the paucity of self-harm related utility data. In the economic model, 2 different sets of utility data were used to reflect the health-related quality of life associated with RSH and no RSH. The first set of utility data (No RSH: 0.94 and RSH: 0.68; Kind 1999 and Tubeuf 2019 respectively) were considered by the committee to reflect the difference in utility between the two health states, although each value appeared to be an overestimate of the HRQoL in the respective health state. The difference between the two health states of the second set of utility data were considered by the committee too narrow (RSH: 0.76 and no RSH: 0.80 – Cottrell 2018 ). Nevertheless, no alternative utility data were available, and therefore, after considering the available data, it was suggested to use the first set of utility values in the base-case analysis, and investigate the second set of utility data ( Cottrell 2018 ) in sensitivity analysis.

The results of the guideline economic analysis suggest that DBT-A for CYP who have self-harmed is not cost-effective from a NHS and personal social services perspective, compared to enhanced TAU. Based on the findings of the economic model and supplemented by the results of the clinical review, the committee pointed out the important role played by DBT-A only in the management of self-harm recurrence in CYP who self-harmed and are at very high risk of self-harm repetition over time, such as CYP with significant motional dysregulations who have frequent episodes of self-harm.

Cooney 2010

Hawton 2012

Hawton 2020

McCauley 2018

Mehlum 2014

NHS England and Health Education England 2016

Santamarina-Pérez 2020

Development and validation of the economic models

People present to an emergency department at a general hospital with self-harm repetition

After having received health care support and treatment, people will either: a) repeat an episode of self-harm; b) not repeat an episode of self-harm

In case of repetition of self-harm, people would re-present to an emergency department at a general hospital; In case people do not repeat self-harm after having received health care assistance and support, there is in place a follow-up programme

After having re-presented, they are managed across different care settings

In the short/medium-term period (for example, 1 to 5 years), people who have self-harmed can die because: a) of suicide -after a repeated episode of self-harm; b) of any other cause of death but suicide -after a repeated episode of self-harm; c) of any other cause of death but self-harm

Figure 10. Illustrative self-harm process model (PDF, 513K)

Patients with a recent episode of RSH (within 6 months) re-present to hospital for self-harm as a result of any type of non-fatal self-poisoning or self-injury;

They receive either CBT-based psychotherapy in addition to TAU or TAU alone after having received a care intervention they are followed-up for an overall period of 5 years.

At the end or during this follow-up period, these patients can either repeat or not an episode of self-harm

In the case of self-harm repetition, they will present to an acute general hospital or primary care, in either way they will receive a comprehensive biopsychosocial assessment

In the case of self-harm repetition, and after having received biopsychosocial assessment: a) patients can require hospital/inpatient care; b) patients who no longer require acute/physical care are discharged from the hospital to other care settings (including primary care, inpatient psychiatric care, social care, and outpatient psychiatric care).

Figure 11. Illustrative self-harm service pathways model (PDF, 758K)

The committee confirmed that both conceptual frameworks ( Figure 10 , Figure 11 ) included explicit reference to all clinically meaningful events and did described the disease process in terms of healthcare resource use comprehensively by not discriminating between different age subgroups of patients (adults and CYP).

Finally, as part of the model validation, the identification of evidence sources and selection of relevant input parameters to inform both economic models was performed by the guideline health economist, checked for accuracy by another health economist and agreed with a health-economics sub-group formed by members of the committee for this purpose ( Kaltenthaler 2011 ). Finally, all inputs and models’ formulae were systematically checked; the models were tested for logical consistency by setting input parameters to null and extreme values and examining whether results changed in the expected direction. The base-case results and results of sensitivity analyses were discussed with the committee to confirm their plausibility.

Kaltenthaler 2011

Tappenden 2016

Appendix J. Excluded studies

Excluded studies for review question: what psychological and psychosocial interventions (including safety plans and electronic health-based interventions) are effective for people who have self-harmed, excluded effectiveness studies.

See the Characteristics of excluded studies table from the Cochrane review of Psychosocial interventions for self-harm in adults and the Characteristics of excluded studies table from the Cochrane review of Interventions for self-harm in children and adolescents .

Excluded economic studies

Table 34. Excluded studies from the guideline economic review.

Excluded studies from the guideline economic review.

Appendix K. Research recommendations

Research recommendations for review question: what psychological and psychosocial interventions (including safety plans and electronic health-based interventions) are effective for people who have self-harmed, research question.

What is the effectiveness of specific psychological interventions including digital vs face-to face (technology use) in different populations and settings?

Why this is important

Although there has been increased research attention on determining the effectiveness of different psychological interventions for people who have self-harmed, it is not clear which interventions work for whom, what the active ingredients are, and the extent to which mode of delivery (digital vs face-to face) affects the effectiveness.

Download PDF (239K)

Final version

Evidence reviews underpinning recommendations 1.11.1 to 1.11.10 and research recommendation 4 in the NICE guideline

Disclaimer : The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.

Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.

NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government , Scottish Government , and Northern Ireland Executive . All NICE guidance is subject to regular review and may be updated or withdrawn.

  • Cite this Page Evidence reviews for psychological and psychosocial interventions: Self-harm: assessment, management and preventing recurrence: Evidence review J. London: National Institute for Health and Care Excellence (NICE); 2022 Sep. (NICE Guideline, No. 225.)
  • PDF version of this title (2.6M)

In this Page

Other titles in this collection.

  • NICE Evidence Reviews Collection

Related NICE guidance and evidence

  • NICE Guideline 225: Self-harm: assessment, management and preventing recurrence

Supplemental NICE documents

  • NICE guideline: methods (PDF)
  • Glossary (PDF)

Related information

  • PMC PubMed Central citations
  • PubMed Links to PubMed

Similar articles in PubMed

  • Review Psychosocial interventions for self-harm in adults. [Cochrane Database Syst Rev. 2016] Review Psychosocial interventions for self-harm in adults. Hawton K, Witt KG, Taylor Salisbury TL, Arensman E, Gunnell D, Hazell P, Townsend E, van Heeringen K. Cochrane Database Syst Rev. 2016 May 12; 2016(5):CD012189. Epub 2016 May 12.
  • Self-harm and psychosocial characteristics of looked after and looked after and accommodated young people. [Psychol Health Med. 2013] Self-harm and psychosocial characteristics of looked after and looked after and accommodated young people. Harkess-Murphy E, Macdonald J, Ramsay J. Psychol Health Med. 2013; 18(3):289-99. Epub 2012 Aug 6.
  • A pragmatic randomised controlled trial and economic evaluation of family therapy versus treatment as usual for young people seen after second or subsequent episodes of self-harm: the Self-Harm Intervention - Family Therapy (SHIFT) trial. [Health Technol Assess. 2018] A pragmatic randomised controlled trial and economic evaluation of family therapy versus treatment as usual for young people seen after second or subsequent episodes of self-harm: the Self-Harm Intervention - Family Therapy (SHIFT) trial. Cottrell DJ, Wright-Hughes A, Collinson M, Boston P, Eisler I, Fortune S, Graham EH, Green J, House AO, Kerfoot M, et al. Health Technol Assess. 2018 Mar; 22(12):1-222.
  • Short-term and long-term effects of psychosocial therapy for people after deliberate self-harm: a register-based, nationwide multicentre study using propensity score matching. [Lancet Psychiatry. 2015] Short-term and long-term effects of psychosocial therapy for people after deliberate self-harm: a register-based, nationwide multicentre study using propensity score matching. Erlangsen A, Lind BD, Stuart EA, Qin P, Stenager E, Larsen KJ, Wang AG, Hvid M, Nielsen AC, Pedersen CM, et al. Lancet Psychiatry. 2015 Jan; 2(1):49-58. Epub 2015 Jan 8.
  • Review The effectiveness, acceptability and cost-effectiveness of psychosocial interventions for maltreated children and adolescents: an evidence synthesis. [Health Technol Assess. 2016] Review The effectiveness, acceptability and cost-effectiveness of psychosocial interventions for maltreated children and adolescents: an evidence synthesis. Macdonald G, Livingstone N, Hanratty J, McCartan C, Cotmore R, Cary M, Glaser D, Byford S, Welton NJ, Bosqui T, et al. Health Technol Assess. 2016 Sep; 20(69):1-508.

Recent Activity

  • Evidence reviews for psychological and psychosocial interventions Evidence reviews for psychological and psychosocial interventions

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

Connect with NLM

National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894

Web Policies FOIA HHS Vulnerability Disclosure

Help Accessibility Careers

statistics

IMAGES

  1. Problem-Solving Therapy: Definition, Techniques, and Efficacy

    intervention and problem solving in counseling brainly

  2. problem solving steps and tips brainly

    intervention and problem solving in counseling brainly

  3. Problem-Solving Therapy: How It Works & What to Expect

    intervention and problem solving in counseling brainly

  4. Problem-Solving Therapy: How It Works & What to Expect

    intervention and problem solving in counseling brainly

  5. What Conditions Does Problem Solving Therapy Treat?

    intervention and problem solving in counseling brainly

  6. What Conditions Does Problem Solving Therapy Treat?

    intervention and problem solving in counseling brainly

VIDEO

  1. Problem Solving

  2. The angels envy humans?

  3. Dar। Best Motivational Story। How To Get Rid Of Mental Fear and Anxiety । Inspirational speech।

  4. Problem Solving Thinking Psychology

  5. PROBLEM SOLVING IN COGNITIVE PSYCHOLOGY

  6. What Is The Purpose of a Family Intervention?

COMMENTS

  1. 22 Best Counseling Interventions & Strategies for Therapists

    Clients can be helped to dispute such thinking using "reason, logic, and facts to support, negate or amend their rules" (Nelson-Jones, 2014, p. 265). Such interventions include: Functional disputing. Pointing out to clients that their thinking may stand in the way of achieving their goals. Empirical disputing.

  2. Problem-Solving Therapy: Definition, Techniques, and Efficacy

    Problem-solving therapy is a brief intervention that provides people with the tools they need to identify and solve problems that arise from big and small life stressors. It aims to improve your overall quality of life and reduce the negative impact of psychological and physical illness. Problem-solving therapy can be used to treat depression ...

  3. Unit 2- The Counselling Process Flashcards

    Stage two: Assessment and diagnosis . Stage three: Formulation of counseling goals . Stage four: Intervention and problem solving . Stage five: Termination and follow-up . Stage six: Research and evaluation . Focus on counselling. The focus of counseling may shift as the counseling process progresses over time. .

  4. Problem-Solving Therapy: How It Works & What to Expect

    Problem-solving therapy (PST) is an intervention with cognitive and behavioral influences used to assist individuals in managing life problems. Therapists help clients learn effective skills to address their issues directly and make positive changes. PST is used in various settings to address mental health concerns such as depression, anxiety, and more.

  5. Defining the Counseling Process and Its Stages

    The counseling process is a planned and structured dialogue between client and counselor. The counselor is a trained and qualified professional who helps the client identify the source of their concerns or difficulties; then, together, they find counseling approaches to help deal with the problems faced (Krishnan, n.d.).

  6. Problem-Solving Therapy

    Problem-solving therapy aims to help individuals adopt a realistically optimistic view of coping, understand the role of emotions more effectively, and creatively develop an action plan geared to reduce psychological distress and enhance well-being. Interventions include psychoeducation, interactive problem-solving exercises, and motivational ...

  7. 10 Best Problem-Solving Therapy Worksheets & Activities

    We have included three of our favorite books on the subject of Problem-Solving Therapy below. 1. Problem-Solving Therapy: A Treatment Manual - Arthur Nezu, Christine Maguth Nezu, and Thomas D'Zurilla. This is an incredibly valuable book for anyone wishing to understand the principles and practice behind PST.

  8. Solving Problems the Cognitive-Behavioral Way

    Key points. Problem-solving is one technique used on the behavioral side of cognitive-behavioral therapy. The problem-solving technique is an iterative, five-step process that requires one to ...

  9. 20 Cognitive Behavioral Therapy (CBT) Techniques with Examples

    Relaxation and Stress Reduction Techniques: CBT incorporates relaxation techniques like deep breathing, muscle relaxation, and imagery to mitigate stress. These methods equip individuals with practical skills to manage phobias, social anxieties, and stressors effectively.

  10. Problem solving therapy Use and effectiveness in general practice

    Problem solving therapy has been described as pragmatic, effective and easy to learn. It is an approach that makes sense to patients and professionals, does not require years of training and is effective in primary care settings. 1 It has been described as well suited to general practice and may be undertaken during 15-30 minute consultations. 2 ...

  11. Intervention & Strategies in Counseling and Psychotherapy

    The book covers a wide range of topics including play therapy, parent education, couples therapy, and problem-solving counseling. This book is essential reading not only for Adlerian psychologists, but also counselors, psychologists, and psychotherapists of any theoretical stripe who wish to keep their practical skills up-to-date.

  12. 7. Developing an Intervention

    Developing an Intervention. 7. Developing an Intervention. This toolkit provides supports for developing core components of a community intervention and adapting them to fit the context. Identify the community problem/goal to be addressed and what needs to be done. Include: Assess the level of the problem or goal.

  13. Analyze each situation Identify the following process of ...

    3. Assessment and Diagnosis: c. After Mary tells about her problem, the counselor assesses the situations of Mary before they proceed counseling. 4. Intervention and Problem-solving: d. The counselor discusses with Mary the possible solution and the possible risk and benefits of each procedure. 5. Research and Evaluation: f.

  14. 3.1: Interventions and Problem Solving

    During the implementation phase, interventionists and collaborators will initiate and work on each strategy for change. The final phase in the process of intervention is evaluation. Sociologists use evaluation to find out if a program, service, or intervention works (Steele and Price 2008). There are two types of evaluation.

  15. Using the solving problems together psychoeducational group counseling

    Problem-focused interventions are considered to be one of the most effective group counseling strategies with adolescents. This article describes a problem-focused group counseling model, Solving Problems Together (SPT), that focuses on working with students who struggle with negative peer pressure. Adapted from the teaching philosophy of problem-based learning, SPT provides students with the ...

  16. Improved problem-solving abilities: Counseling involves ...

    Counseling uses techniques like talk therapy and CBT to improve problem-solving abilities through enhanced coping mechanisms, reduced anxiety, better decision-making, and increased self-awareness. Tailored approaches in psychotherapy address unique client anxieties, with cognitive appraisal training and various coping strategies further aiding ...

  17. Evidence reviews for psychological and psychosocial interventions

    Summary of the evidence. The Cochrane review of psychosocial interventions for self-harm in adults investigated 12 comparisons, with the following findings: Comparison 1: Cognitive behavioural therapy (CBT)-based psychotherapy (e.g. CBT, problem-solving therapy [PST]) versus TAU or another comparator.

  18. 1. What are your problems that need counseling? 2. How do you ...

    - Problem-solving: Identify the specific problem, break it down into manageable steps, and develop a plan of action to address it. - Seeking professional help: Consider seeking counseling or therapy from a qualified professional who can provide guidance and support tailored to your specific needs. 3. Yes, counseling is important for several ...

  19. An example of a type of counseling specialization based ...

    Final answer: Counseling specializations can be based on intervention techniques such as Cognitive-Behavioral Therapy, family therapy, group therapy, individual therapy, or couples therapy.. Explanation: An example of a type of counseling specialization based on an intervention or technique could be Cognitive-Behavioral Therapy.This therapeutic technique is oriented towards problem-solving and ...

  20. What interventions or techniques can enhance problem-solving skills and

    Interventions and techniques to enhance problem-solving skills and critical thinking abilities can take various forms. For instance, applying Bloom's taxonomy in the classroom helps in structuring the learning process through different levels of engagement from simple recall to complex analysis and creation, as suggested by Athanassiou, McNett ...