Mixed Results for Family Therapy for Self-Harming Adolescents

David Cottrell, MBBS, MA

Self-harm is a serious problem in the United States and around the world. The Centers for Disease Control and Prevention (CDC) reports that Americans made 383,000 emergency department (ED) visits for self-inflicted injuries in 2013. In 2015, the CDC reports that ED visits because of self-harm went up to 505,507.

Among youth, self-harm rates were relatively stable until 2008. From 2009-2015, rates for girls began trending upwards, with girls 10-14 years old experienced a 18.8% annual increase in ED visits due to self-inflicted injuries.

“Self-harm in adolescents is common and repetition occurs in a high proportion of these cases,” said David Cottrell, MBBS, MA, Professor of Child & Adolescent Psychiatry at the Leeds Institute of Health Sciences, University of Leeds, UK. “Scarce evidence exists for effectiveness of interventions to reduce self-harm.”

The Self-Harm Intervention: Family Therapy (SHIFT) trial tested a new form of family therapy for young people with a history of self-harm. Unfortunately, investigators did not find evidence that the family therapy intervention reduced subsequent hospital visits for self-harm when compared to treatment as usual.

"Future studies need to focus on sub-groups within the self-harm population as it is such a large and varied group," Cottrell told MD Magazine. "We are doing a longer term follow up of this sample which we hope to publish later this year."

“These disappointing results have notable implications for future research in the field of adolescent self-harm,” said Dennis Ougrin, MBBS, PhD, PGDip, and Joan Asarnow, PhD, who published comments on the SHIFT trial.

The phase 3, multicenter, randomized trial study was conducted at 40 Child and Adolescent Mental Health Services centers across the UK. Investigators compared youth aged 11-17 years who were assigned to family therapy (n=415) with a control of youth who received the usual treatment (n=417). Therapists trained in family therapy techniques and supervised for compliance conducted family therapy sessions about once per month for 6 months.

Caregivers and patients completed questionnaires for suicide ideation, quality of life, depression, mental health, family functioning, self-harm, emotional traits, health economics, and engagement with therapy were administered at baseline and throughout the study period.

The study collected primary outcome data for 96% of participants, however these results did not vary significantly between groups. There were 118 hospital visits (28%) for repeat self-harm events in the family therapy group, compared to 103 (25%) in the treatment as usual group.

“Research should focus on the definition of self-harm…and on understanding the basic science of the drivers of self-harm, which should inform our interventions,” said Ougrin and Asarnow. However, they acknowledged that such studies would take years to produce results and suggested that in the meantime “one approach is to target the treatable conditions that often accompany self-harm, such as anxiety and depression.”

The study authors did note that participants in the family therapy group reported better results for several secondary behavioral outcomes, “suggesting family therapy had a significant positive effect on general mental health, even if this did not translate into reduced repetition of self-harm.” However, severe attrition on most secondary outcomes limits the strength of this interpretation.

“Young people who self-harm form a varied and heterogeneous group, and self-harm is likely to be the final common pathway for a wide range of problems,” said Cottrell and colleagues. “Further research is needed to develop a more personalized approach and to identify which interventions are most helpful for which young people.”

The study, “Effectiveness of systemic family therapy versus treatment as usual for young people after self-harm: a pragmatic, phase 3, multicentre, randomised controlled trial,” was published in The Lancet Psychiatry in March.