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Family therapy not superior to treatment as usual for teen self-harm
Among teenagers who self-harm, a family therapy intervention had no more benefit than treatment as usual in reducing subsequent hospitalization for self-harm, study findings showed.
“Self-harm in adolescents has serious consequences, and those who self-harm have a four times greater risk of death from any cause and a ten times greater risk of suicide than the general population. A single effective intervention has not been identified,” David J. Cottrell, FRCpsych, Leeds Institute of Health Sciences, University of Leeds School of Medicine, and colleagues wrote. “Family factors (parent–child interaction, perceived support, expressed emotion, experience of abuse, parental conflict, and parental mental health) are important risk factors associated with self-harm in children and adolescents.”
In a phase 3, randomized controlled trial, researchers compared the effectiveness of family therapy and treatment as usual among youth aged 11 to 17 years who had self-harmed at least twice and had presented to a Child and Adolescent Mental Health Services (CAMHS) center in the U.K. after self-harm.
Family therapy consisted of six, 1.25-hour sessions that used a theoretical approach to “allow for flexibility and integration of a broad range of conceptualizations from within the field of family therapy and other therapeutic approaches,” Cottrell told Healio Psychiatry.
“[The approach] emphasized the relational context of problems that families bring to therapy, and that language, meaning, behavior and emotions are all part of the change process,” Cottrell said in an interview. “The manual permitted seeing the adolescent alone or in parallel sessions with a team member seeing the parents, and it encouraged the use of reflecting teams.”
Treatments as usual consisted of a wide range of different therapeutic approaches and took about the same amount of time, according to Cottrell. The investigators looked at hospital attendance for self-harm in the 18 months after initiation, then performed primary and safety analyses in the intention-to-treat population.
Overall, 415 participants received family therapy and 417 received treatment as usual. At the 18-month follow-up, Cottrell and colleagues observed no significant different between the number of hospital attendances for repeat self-harm events.
“The study is important, as we had large numbers (by far the biggest trial in the field to date) and were able to track subsequent self-harm (or not) in nearly all the 832 participants,” Cottrell told Healio Psychiatry. “The take-home message is that for young people who have self-harmed, having already self-harmed at least once, family therapy was no more effective than treatment as usual in reducing further self-harm.”
Repeated self-harm occurred less among male participants and those aged 15 years or older. In the family therapy group, 118 participants had hospital attendances, and in the treatment as usual group, 103 had hospital attendances (HR = 1.14; 95% CI 0.87–1.49; P = .33). In addition, assessment of questionnaire outcomes for depression, quality of life, hopelessness, family functioning, caregiver mental health and expressed emotion showed no significant differences between the two groups. Number of adverse events were similar in both groups as well (787 vs. 847). However, family therapy did show a positive effect on general emotional and behavioral problems among teenagers in this study, according to the authors.
“Family therapy did improve general mental health as reported by young people and their caregivers, but sadly did not reduce subsequent self-harm. However, there was evidence that where families reported difficulty in discussing emotions, or where young people reported ease in discussing emotions, family therapy was more effective in reducing later self-harm,” Cottrell said. “Conversely, when young people reported difficulty in expressing emotion, or families reported healthy emotional functioning, other interventions might be indicated. Given that those who self-harm do so for a wide range of reasons, this may point the way for clinicians to sub-groups where family therapy may, or may not, be indicated.”
Although family therapy for self-harm might not be the most effective intervention for teenagers, “it certainly has not had its final word yet,” according to a related editorial written by Dennis Ougrin, PhD, child and adolescent psychiatry, King's College London, and Joan R. Asarnow, PhD, department of psychiatry and biobehavioral sciences, David Geffen School of Medicine, UCLA.
“The scarce evidence for effective interventions for self-harm in adolescents should be analyzed in detail and combined with results from similar randomized trials in adults, with careful interpretation,” they wrote. “Effective treatment of self-harm in young people without family involvement seems just as unlikely as effective treatment of anxiety without exposure.” – by Savannah Demko
Disclosures: Cottrell reports grants from National Institute for Health Research, chairing the NIHR Clinician Scientist Fellowship Panel and co-authoring of the Self-Harm Intervention: Family Therapy manual. Please see the full study for other authors’ relevant financial disclosures. Ougrin reports royalties from Hodder Arnold. Asarnow reports funding from the National Institute of Mental Health, the American Foundation for Suicide Prevention, the Substance Abuse and Mental Health Services Administration, the American Psychological Association and the Society of Clinical Child and Adolescent Psychology.
Editor's note: This article was updated on Feb. 20 with comments from Cottrell.
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