Discussion
This study offers an independent evaluation of two brief interventions, a hybrid IP and Stabilisation, targeted at self-harm reduction within a third-sector organisation. Empirical research on interventions specifically focused on self-harm reduction outside of statutory clinical services remains limited. The focus on brief, remote and third sector-delivered interventions is relevant given the increasing demand for accessible and flexible mental health support. Expanding access to mental health support beyond traditional healthcare settings is a direction supported by the NHS Long Term Plan’s emphasis on community-based and digital mental health services.22
Key findings
The study provides preliminary support for the effectiveness of IP and Stabilisation in reducing self-harm frequency among help-seeking adults over the short term and suggests that both practice-based interventions offer a viable, low-intensity self-harm treatment that can be delivered remotely, which are not associated with adverse events. Participants in both intervention groups reported significantly fewer episodes of self-harm compared with those on the waitlist, demonstrating medium-to-large effect sizes. While defining a clinically meaningful reduction in self-harm frequency remains a subject of ongoing debate, the observed reduction of over 50% in both intervention groups suggests a promising short-term impact and is comparable to effect sizes achieved following longer in-person DBT interventions for individuals with borderline personality disorder.23
In addition, both interventions demonstrated significant reductions in suicidal ideation compared with the waitlist control group, aligning these lower intensity treatment options with the broader literature on psychosocial interventions for suicide prevention.12 17 The impact on depressive symptomatology was mixed. While reductions in depression symptoms were found for both interventions, these were only statistically significant for Stabilisation. It is possible that a skill-based intervention like Stabilisation can address depressive symptoms without the need for more intensive therapeutic approaches. Similar skill-based interventions targeting distress reduction and emotional regulation have shown effectiveness in reducing Post-traumatic stress disorder (PTSD) symptoms.24 25 Potentially, the skill-based approach of Stabilisation, even in its brief format, may have broader applications to mental health challenges. Conceivably, an insight-focused therapy (psychodynamic, emotional-focused approaches, IP) could have less immediate impact on improving mood, or even an initial worsening of symptoms, through the active process of getting in touch with pain/trauma compared with symptom-focused work (CBT, DBT, stabilisation), where practical changes could result in more immediate positive differences.
A necessary component of future examination would be to identify the active ingredients of these interventions in relation to outcome change. This is particularly important given that both interventions incorporate a blend of approaches and evidence-based principles. Of note, despite differing theoretical underpinnings, and consistent with functional accounts of self-harm,26 27 the focus of both Stabilisation and Integrative Therapy is on the emotional distress that often underlies self-harming behaviours. This supports targeting distress reduction as a key driver of self-harm in brief intervention development.
A study design which enables a dismantling of the various mechanisms which may underlie behaviour change, including component specifications for the current interventions, skill acquisition, cognitive restructuring, as well as the role of the therapeutic alliance, and wider contribution of the implementation context, is a useful next step. Such mechanistic research would help to tailor and optimise these approaches. It would also support potential successful translation and replication beyond this specific service setting.
The wider evidence base in relation to brief interventions for self-harm and suicide ideation is associated with mixed findings. Overall, current evidence suggests circumspection and a more nuanced dismantling of how choices relating to intervention, study population and implementation strategy are likely to impact on outcomes.
Limitations
The study has strong ecological validity, embedded within routine clinical practice and developed in response to service identified needs. Methodological rigour is provided through a quasi-randomised, waitlist-controlled design. The pragmatic, continuous short recruitment design is advantageous when evaluating existing services, as interventions are offered promptly on referral, minimising delays. Nonetheless, the pragmatic nature of the trial raises important methodological issues. Randomisation was applied when allocating between waitlist and intervention, but thereafter a clinical decision determined intervention allocation and participants may have had a greater likelihood of benefitting from the intervention judged to be of greatest potential support, introducing bias. The service did not seek to ascertain the superiority of either intervention against each other, but against the receipt of no treatment. Nonetheless, interpretations are therefore caveated on the incorporation of clinical judgement into treatment decision-making. A fully randomised trial would be necessary to definitively establish the effectiveness of these interventions. However, the focus on the evaluation of a third-sector delivered intervention offers a timely, real-world applicability given that a large proportion of those seeking help for self-harm and suicide will not engage with statutory provision, may face long waits between referral and treatment for NHS mental health services4 10 and may have a treatment preference for third-sector support. Nonetheless, the generalisability of these approaches for help seekers outside of this specific service context cannot be assumed. The pragmatic nature of the study resulted in a largely female study sample that also spanned a broad range of ages (18–59 years). It is recognised that the presentation of self-harm will differ across age groups and that therapeutic treatments for self-harm differ in terms of associated cost-effectiveness for adults versus children and young people.28 29
The Harmless Measure, a service-based self-reported measurement tool for assessing self-harm and suicidality, has not undergone formal academic testing for reliability and validity and therefore lacks broader peer-reviewed scrutiny. The tool is not consistent with measurement approaches in comparison studies, which, for example, measure frequency in terms of discrete events. It was also not possible to assess the internal consistency of the PHQ-9 due to limited access to individual item data.
Clinical implications
Despite these important methodological limitations, this study’s findings, while preliminary, contribute to a shifting landscape of approaches to self-harm and suicide management and prevention. If we are to challenge the traditional reliance on resource-intensive, long-term therapies and respond to calls for an expanded community-based and preventative service offer,4 22 then the present early scrutiny of brief remotely delivered, community-based interventions in reducing self-harm frequency and suicidal ideation is to be welcomed. Alternative and accessible approaches are needed that cater to diverse needs and circumstances, including populations who may face additional barriers to accessing traditional in-person therapies, such as those with neurodivergent conditions, limited mobility or residing in rural areas. While findings here are subjected to replication and long-term follow-up, from a clinical perspective, the significant reduction in self-harm frequency suggests that these brief interventions may be viable, first-line treatment options for individuals presenting with self-harm and could contribute to multilevel and flexible treatment options.
With demand for third-sector services increasing, and this being a preferred treatment setting for some,10 support offered in these settings will play an invaluable role as part of wider treatment provision, or within stepped care approaches. Providing scrutiny and evaluation of service-based treatments (as an alternative to standard therapeutic offers) and outcomes is an important first step in explicating the contribution such settings make. The present findings provide promising evidence (through a small-scale pragmatic trial) that treatment approaches within the third sector demonstrate positive effects on core therapeutic targets (self-harm frequency and suicidal ideation), are not associated with adverse outcomes, and warrant further examination.
Future directions
A potential benefit of a briefer-form intervention for self-harm is an increased likelihood of continued engagement and session attendance and therefore receipt of a full, intended intervention dosage.16 Here, 92% of those receiving an intervention completed six therapeutic sessions. In the context of limited healthcare resources and an increasing demand for mental health services, the economic viability and cost-effectiveness of implementing a low-intensity intervention compared with traditional treatment approaches would need exploration. Where interventions can demonstrate comparable efficacy to more expensive, longer and intensive treatments, brief and scalable treatments should be prioritised.30
Summary
This study provides early support for two brief, remotely delivered service-developed interventions, Stabilisation and IP, in reducing self-harm frequency and suicidal ideation in help-seeking adults over a 6-week period. Additionally, the Stabilisation group exhibited a notable reduction in depressive symptoms, suggesting a broader impact on mental health. Within the context of the current setting, the findings indicate clinically meaningful effects. The focus on brief and remotely deliverable interventions aligns with the priorities outlined in suicide prevention strategies and contributes to a broader discussion around the delivery of a more comprehensive and effective system of care for individuals at risk and particularly in a landscape where access to traditional therapies may be limited. Findings must be interpreted cautiously due to methodological limitations, particularly the quasi-randomisation procedure, which may have introduced bias. Overall, current evidence indicates further work to definitively establish effectiveness, maintenance and mechanisms of effect and to support the broader applicability of these interventions outside of the current service.