Systemic family therapy is not superior to treatment as usual in reducing subsequent acts of self-harm in adolescents who have a history of the disorder, new research shows.
Investigators led by David J. Cottrell, PhD, foundation chair in child and adolescent psychiatry, Leeds Institute of Health Sciences, United Kingdom, compared a manual-based family therapy intervention to more generalized therapies in young people who had self-harmed at least twice.
The researchers found no significant difference between the groups with respect to rates of hospitalization for repetition of self-harm.
“Clinicians are therefore still unable to recommend a clear, evidence-based intervention to reduce repeated self-harm in adolescents,” the authors write.
Because adolescents who self-harm “form a varied and heterogeneous group and self-harm is likely to be the common pathway for a wide range of problems,” further research should focus on developing “a more personalized approach” and identifying “which interventions are most helpful for which young people,” they add.
The study was published online February 12 in Lancet Psychiatry.
Global Public Health Problem
“Self-harm in adolescents is a global public health problem,” the authors write, but a “single effective intervention has not been identified.”
They note that previous studies that included “strong family involvement and substantial treatment dose” showed “significant reductions in self-harm events.”
Because family factors, such as parent-child interaction, perceived support, expressed emotion, experience of abuse, parental conflict, and parental mental health, are “associated with self-harm in children and adolescents,” a therapeutic approach that draws on and mobilizes the existing strengths and resources of the child and family is “a logical potential intervention after self-harm.”
The Self-Harm Intervention: Family Therapy (SHIFT) trial was designed to investigate a “new form” of family therapy for self-harm. It was conducted in response to a call for action by the National Institute for Research Health Technology Assessment, a UK-based organization, to “investigate the clinical effectiveness and cost-effectiveness of family therapy for adolescents who self-harm.”
The family therapy intervention was based on a modified version of an existing approach described in a family therapy manual. Sessions were conducted over a 6-month period at approximately monthly intervals, although initially, they were held more frequently.
Treatment as usual was “diverse,” with the most common modality being supportive therapy or counseling. Other interventions included cognitive-behavioral therapy, family work (discussion meetings with families without formal family therapy), and formal systemic family therapy.
Participants (n = 832) included children and adolescents aged 11 to 17 years (mean age, 14.3 years; SD, 1.4 years) who had been referred to Child and Adolescent Mental Health Services (CAMHS) for self-harm following at least two prior episodes.
Participants were randomly allocated to receive either family therapy (n = 415) or treatment as usual (n = 417).
The researchers measured suicidal ideation, quality of life, depression, mental health, family functioning, self-harm, emotional traits, health economics, and engagement with therapy. Assessments were administered at baseline and at 3, 6, 12, and 18 months after random group assignments.
The primary outcome was repetition of self-harm leading to hospital attendance during the 18 months following group assignment.
Secondary outcomes included repetition of self-harm leading to hospital attendance during the 12 months following group assignment, cost per self-harm event averted by family therapy, characteristics of self-harm episodes, suicidal ideation, quality of life, depression, overall mental health and emotional and behavioral difficulties, hopelessness, and family functioning.
Of the participants, 89% were female, and 89% had self-harmed on at least three previous occasions. The most recent episode consisted of self-injury, self-poisoning, or both (71%, 22%, and 6% respectively).
As determined on the basis of the Suicide Attempt Self-Injury Interview, 62% of participants met criteria for nonsuicidal self-injury.
Positive Impact on Mental Health
At the 18-month follow-up, full primary outcome data were available for 96% of participants, and partial data were available for 4%.
However, “substantial loss” to follow-up occurred for participant-reported secondary outcomes; only 60% of participants in the family therapy group and 45% in the treatment-as-usual group were available at 12 months.
At the 18-month follow-up, 27% of all participants had been hospitalized after repeated self-harm: 28% of the family-therapy group, and
25% of the treatment-as-usual group (hazard ratio, 1.14, 95% confidence interval, 0.87 – 1.49; P = 0.33]).
Repeated self-harm was less common in males and in participants aged 15 years or younger.
The proportions of patients who repeated self-harm were higher in the subgroups who were referred to CAMHS via hospital, as compared to those referred via the community, and in participants with an index episode that combined self-injury with poisoning, in comparison to either method alone.
Participants often engaged in a different method of self-harm than the one they used in the index event. More than half of participants who had self-injured at their index episode subsequently engaging in self-poisoning.
The researchers found significant moderation of the primary outcome, as measured by the unemotional subscale of the young person–reported Inventory of Callous Unemotional Traits and the affective involvement subscale of the caregiver-reported family functioning Family Assessment Device.
In participants who reported difficulty talking about feelings, the risk for hospital attendance for repeat self-harm was increased in the family therapy group, compared to the treatment-as-usual group. In participants who reported being able to discuss feelings easily, the risk was decreased in the family therapy group, compared to the treatment-as-usual group (P = .010).
There were similar numbers of adverse events in the family therapy group and the treatment-as-usual group.
Participants and their caregivers in the family therapy group reported significantly better outcomes on several elements of general emotional and behavioral difficulties, as measured by the Strengths and Difficulties Questionnaire, “suggesting that family therapy had a significant positive effect on general mental health, even if this did not translate into reduced repetition of self-harm,” the authors note.
Monthly Therapy Not Enough
Commenting on the study for Medscape Medical News, Dennis Ougrin, PhD, clinical senior lecturer, Institute of Psychiatry, Psychology, and Neuroscience, King’s College London, United Kingdom, said that it “addressed a very important subject,” because suicide is a leading cause of death in young people, and self-harm is the “strongest predictor of suicide that we know of.”
He was not surprised by the findings.
“Those of us who work with young people with self-harm will know that it takes significantly more than several monthly sessions to reduce it, and some young people and their families require very intense work, even daily contact,” said Ougrin, who is the coauthor of an accompanying editorial.
“One conclusion to be drawn is that offering monthly systemic family therapy is unlikely to significantly reduce the risk of serious self-harm in young people,” he noted.
However, “it is important to emphasize that self-harm in young people is very unlikely to be tackled effectively without engaging family members, and clinicians should not confuse formal systemic family therapy with family engagement, which is essential, no matter what psychological therapy is offered to the young people.”
He added, “The most promising way forward would be to focus on cognitive-behavioral therapy and the related therapies, such as dialectical-behavior therapy, including the investigation of the optimal role of family members in delivering these therapies.”
The investigators note that longer follow-up studies are needed and that family therapy “might have had benefits beyond that of the participant.”
The research was funded by the National Institute for Health Research (NIHR) Health Technology Assessment Programme. Dr Cotrell has received grants from the NIHR. He is chair of the NIHR Clinician Scientist Fellowship Panel and is a coauthor of the SHIFT manual. The other authors’ relevant financial relationships are listed on the original article. Dr Ougrin has received royalties from Hodder Arnold for a book on self-harm. His coauthor’s relevant financial relationships are listed in their editorial.
Lancet Psychiatry. February 12, 2018. Full text, Editorial
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