This programme is a treatment manual written for mental health professionals. It assumes clinical training, experience of working with adolescents, and a supervision framework. It replaces neither your clinical judgement nor your professional responsibility. Diagnostic criteria are reformulated in our own words and never reproduced: refer to the original manuals for the wording itself. It is not addressed to the people concerned: if you find yourself thinking about ending your life, call your country's emergency services or a suicide prevention line, today.
1. The programme at a glance
Indication. Repeated self-harm without suicidal intent, suicidal ideation, or a suicide attempt, in adolescents aged roughly twelve to eighteen, as outpatients, with people around them able to provide supervision and to make the home safe.
Reference model. A cognitive behavioural therapy centred on the function of the act, borrowing from dialectical behaviour therapy adapted for adolescents what has been best evaluated in this indication: chain analysis, distress tolerance and emotion regulation skills, and parallel work with the parents. It incorporates the safety planning intervention and restriction of access to means.
Format. Fourteen 50-minute sessions. Two sessions in the first week, then one a week up to the twelfth, then every fortnight. Three of them are not sessions with the young person alone: two parent sessions and a final joint session, and one session is devoted to the school and the wider network. Two follow-ups, at one month and at three months.
Target mechanism. Not obtaining a promise to stop, but making the crisis survivable in another way: making the environment safe while the young person does not yet have another solution, identifying the exact point in the chain where the act becomes inevitable, and putting something else there — a skill, a person, a delay.
| Session |
Subject |
Session output |
| 1 |
Assess and make safe |
Risk explored, means restricted, next date set |
| 2 |
The safety plan |
Plan in the young person's hand, two copies |
| 3 |
Parent session: making the home safe |
Inventory done, measures carried out and checked |
| 4 |
Chain analysis |
One complete chain, one link chosen |
| 5 |
Emotions: naming and measuring |
Vocabulary and scale established |
| 6 |
Getting through a crisis without self-harm |
Four skills tried, a box assembled |
| 7 |
Regulating before the crisis |
Five upstream levers, two chosen |
| 8 |
Thoughts, and the mid-point review |
One thought tested, review with numbers |
| 9 |
Relationships and conflict |
One request prepared, one refusal prepared |
| 10 |
Parent session: validating without giving in |
Two reactions changed |
| 11 |
The body, the scars and the shame |
One social exposure prepared |
| 12 |
Reasons for living |
Written list, one dated project |
| 13 |
School and network session |
A named adult, an alerting plan |
| 14 |
Review, relapse, joint session |
Written plan, parent version, follow-up dates |
What the young person and the parents take away. Seven printable worksheets, listed in section 43 and downloadable from this page: my weeks, my safety plan, my chain, my emotions, my toolbox, the parents' corner, my plan for what comes next.
What sets this programme apart from the others on this site. Three things. Safety comes first, before any formulation and before any work on thoughts: sessions 1 to 3 contain almost nothing else. Chain analysis replaces the search for causes, because the useful question is not why he did it but at what precise moment it became inevitable. And the parents are not optional allies: means restriction depends entirely on them.
2. Before you start
Who this programme is for
This text is written for psychologists, child and adolescent psychiatrists, psychotherapists and doctors trained in cognitive behavioural therapy with adolescents, working in a setting that allows an emergency to be handled: a known procedure, access to a specialist opinion, and supervision.
It is not written for young people or for parents. It contains procedures, thresholds, criteria for hospitalisation, and it names methods — which, said to someone directly concerned, would be useless at best and harmful at worst.
The preliminary question: can this be treated as an outpatient?
Four decisions come before any procedure, and the first three are taken in the first session.
Is there an emergency right now? Active intent with a plan and accessible means, a recent attempt, an overdose in progress. Section 15 gives the criteria and what is organised within the session.
Can the environment be made safe? This is the question that decides outpatient care, more than the severity of the act. A young person whose parents refuse to remove the medicines from the house is not in the same case as one whose parents did it that same evening.
Which behaviour are we talking about? This is the sorting of section 3, and it changes what follows. Repeated self-harm without suicidal intent, suicidal ideation without any act, a suicide attempt: three situations, three different urgencies, one common foundation.
What is going on underneath? Depression, anxiety disorder, post-traumatic stress disorder, substance use, eating disorders, borderline features, autism spectrum disorder. Sections 8 and 9 give the differential and the comorbidities.
What this programme does not treat
It does not treat a crisis in progress. A young person with active intent and a plan needs an immediate referral, not a first appointment in a fortnight. The protocol starts once immediate safety is established.
It does not treat, on its own, a psychotic disorder, an eating disorder that is front and centre, or severe dependence. These are situations where the specialist opinion comes first and where the self-inflicted act is one symptom among others.
It does not treat a situation of ongoing abuse. Protection comes first, and it belongs to a procedure, not to a therapy. An adolescent who hurts himself in a house where he is being hurt does not need to learn to tolerate his distress.
It does not replace institutional care when that is indicated: day hospital, crisis unit, admission. Section 41 says when to consider it.
What this programme is not
It is not a complete dialectical behaviour therapy. Dialectical behaviour therapy adapted for adolescents is a substantial set-up — a skills group, phone coaching, a consultation team — and it is the best-evaluated approach in this indication. This manual borrows its most transferable tools for ordinary individual work; it does not claim to match it, and section 41 says when you have to move to the full programme.
It is not a drug treatment. The place of medication is set out in section 17, in full, including what is uncertain.
It is not a family therapy, even though two sessions belong to the parents and what happens at home is dealt with.
How to use it
Read the whole text before the first session, in particular sections 3, 12, 13, 14 and 15: the sorting, what risk assessment can and cannot do, means restriction, confidentiality with a minor, and the criteria for hospitalisation. These are the five places where people go wrong, and four of them can have immediate consequences.
Each session is described with the same structure: the aim, the steps, what you say, common mistakes, and the criterion for moving on.
Three warnings specific to this reason for referral.
You will be frightened. That is normal, and it is not a training deficiency. What matters is that the fear does not take the decisions for you: not the reflex admission, not the avoided subject, not the promise extracted.
You will be alone with the decision, and you should not be. No section of this manual replaces a second opinion. Know, before the first session, who you call, and at what hour.
And you have to have allowed for the worst. A proportion of the young people seen for this reason will do it again during treatment, and a small proportion will die. This manual does not promise otherwise. What it offers is what reduces repetition and what makes the work bearable — including for you, and section 45 comes back to that.
3. Three behaviours not to be confused
This is the section that governs the rest, and it is the one where people go wrong in both directions. Three behaviours often present under the same words — "he is hurting himself" — and they call for neither the same urgency, nor the same explanation, nor the same response.
1. Self-harm without suicidal intent
What you observe. Self-inflicted acts — cutting, burning, hitting oneself, scratching, head-banging, picking at skin — carried out without the intention of ending one's life. They are most often repeated, discreet, located on areas that can be covered, and followed by rapid relief.
What goes with it. A rise in tension before, a settling afterwards, and very often shame. The young person may describe the act as effective, and you have to hear that: it works, and that is exactly the problem.
What this implies. This is the core of the programme described here. What is treated is the function of the act and the regulation that is missing, not the act itself.
And what should not be concluded from it. That it is not serious. A history of self-harm is one of the factors most consistently associated with later suicide. The two sentences go together and are said together.
2. Suicidal behaviour
What you observe. An act carried out with, at least in part, the intention of dying. The intent may be ambivalent, fluctuating, and reconstructed after the fact — that is the rule rather than the exception at this age.
What goes with it. Often marked impulsivity, a very short delay between the decision and the act, a relational or humiliating trigger, and sometimes alcohol.
What this implies. Safety comes before everything else, assessment is immediate, and means restriction is not negotiable. The programme applies afterwards, on the same foundation.
3. Suicidal ideation without any act
What you observe. Thoughts, of very variable form: from "I wish I wasn't here" to a precise plan. They are common at this age, and their frequency alone does not tell you how serious they are.
What matters. The move from passive thoughts to intent, the existence of a plan, access to means, preparatory acts, and above all the trajectory: what has worsened over a few weeks counts for more than what has been stable for two years.
What this implies. The safety plan, means restriction, and treatment of what is going on underneath — most often a depression, and section 9 comes back to that.
How you tell them apart, in practice
Four questions, asked of the young person, alone, without detours and without flinching.
"What were you hoping would happen?" This is the most useful question, and it is better than "did you want to die?", which invites a defensive answer. The answers are often clear: for it to stop in my head, for the tension to come down, to feel something, to disappear.
"When did you decide?" A decision taken ten seconds before is not the same thing as one that has been forming for three days, and that changes the measures as much as the understanding.
"What did you do straight afterwards?" Hide, clean up, go back to sleep, call someone, nothing at all. What follows tells you about the intent better than the account of the intent does.
"Was it the first time?" The repetition and how it has changed over recent months count for more than the severity of today's injury.
What the severity of the injury does not tell you
It does not tell you the intent. A superficial injury can go with an intention to die, and an overdose that looks alarming may correspond to a mistaken belief about how toxic something is.
It does not tell you the prognosis. The factor that counts is repetition, not depth.
It does not tell you the suffering. That is the most wounding mistake, and adolescents meet it regularly in emergency departments.
Mixed situations, which are the rule
The same adolescent can cut himself to bring down tension on Tuesday and take tablets with the intention of dying on Saturday. The two behaviours coexist in a substantial proportion of the young people concerned, and the presence of one increases the probability of the other.
The practical rule: you ask about intent for each episode, not for the person. "You cut yourself" and "you are suicidal" are not categories you file someone under; they are descriptions of episodes, and they are asked about each time.
What does not belong in this section
Self-inflicted acts with a cultural or aesthetic purpose — piercings, tattoos, ritual scarification — are not self-harm in the clinical sense.
Self-injurious stereotypies in a young person with an autism spectrum disorder or an intellectual disability call for a different analysis and a different response. See section 8.
Risk-taking behaviour — dangerous driving, heavy substance use, repeated unprotected sex — is not self-harm, even when it shows indifference to danger. It is identified and treated, and section 9 comes back to it.
4. The clinical picture by age
What does not change
Three elements are found at every age. A rapid, poorly identified emotional escalation before the act. Relief in the minutes that follow, which is precisely what installs the repetition. And a considerable gap between what the young person shows and what they live: most of the adolescents concerned have been hurting themselves for months before anyone knows.
Before thirteen
It is rarer, and it is taken seriously. Self-harm before adolescence is less frequent, and its presence goes with a heavier context: maltreatment, neurodevelopmental disorders, early depression.
What you observe. Less codified acts: hitting, biting, banging, scratching. Cutting tends to appear later.
What misleads. Trivialising — "he is having a tantrum" — and its opposite, panic. A child who hits his head when he is furious is not doing the same thing as an eleven-year-old who cuts himself in secret in the evening.
What this changes. The work is done more with the parents, the materials are concrete, and assessment of the family context is the priority.
From thirteen to fifteen
This is the peak. Self-harm most often begins between twelve and fourteen, and this is the period when it is most frequent.
What you observe. Cutting on the forearms and thighs, an onset often linked to a discovery — a peer, a video, a forum —, a very clear regulatory function, and considerable shame.
What misleads. Two opposite things. The idea that it is "for attention", when concealment is the rule. And the idea that it is a passing fashion, when a proportion of those concerned carry on for years.
What is added at this age. The social dimension: the act can become a language within a group, and exposure to online content matters. See section 39.
From sixteen to eighteen
What you observe. The picture diverges. In some, self-harm fades of its own accord. In others, it becomes chronic and joins up with substance use, relational instability and suicidal behaviour.
What gets worse. Access to means increases — alcohol, medicines, mobility, vehicles — and the delay between the thought and the act shortens when intoxication is added.
What misleads. An adolescent who says "I've stopped" when the acts have moved elsewhere — to alcohol, to food restriction, to something else. Ask what has replaced it.
What differs by sex, and what to do with that
Self-harm is reported more often in girls in clinical and community samples, with a less marked difference in more recent samples.
Deaths by suicide are more frequent in boys, which is explained in part by the means used.
What this changes in practice. You do not look less hard in a boy. The forms you need to be able to spot in him are more often blows, burns, fights sought out, and rising consumption — and they are less often named as self-harm, by him or by those around him.
The forms that go unnoticed
Acts that do not involve cutting. Hitting oneself, biting, banging, preventing wounds from healing, pulling out hair or skin. They are less visible and often not mentioned unless you ask differently.
Putting oneself in danger without direct injury: walking in the road, not treating an illness, stopping a necessary medication, seeking out violent situations.
Self-harm hidden behind another complaint: repeated "accidental" burns, repeated falls, wounds that never heal.
What self-harm is not
It is not manipulation. This is the most widespread and most false idea, and it is still put about by clinicians. The great majority of acts are concealed.
It is not a personality trait. You do not "become a borderline" at fifteen because you cut yourself. See section 8.
It is not a harmless phase. It often stops, and it nevertheless predicts later risk.
5. What the act is for: the functions
Functional analysis is the most useful tool in this manual, because it gives you the target directly. The question is not "why does he hurt himself" but "what does the act give him, within the minute".
Four main answers, which combine, and a fifth that has to be talked about.
Function 1: bringing down an unbearable tension
By far the most common. An emotion rises — anger, anxiety, self-disgust —, it becomes physically intolerable, and the act makes it drop within minutes.
What this changes. The target is distress tolerance: you have to supply something that produces a comparable effect within the same time frame, not advice that requires patience. That is what session 6 is for.
Function 2: getting out of emptiness or disconnection
The young person describes a state of absence, floating, unreality — often among those who have lived through violence. The act brings back a sensation, and therefore a presence.
What this changes. Grounding skills replace soothing skills: cold, contact, movement, orienting in the room. And the question of trauma is raised explicitly. See section 8.
Function 3: punishing oneself
The young person is not trying to feel better: he considers that he deserves the pain. This is common, often unspoken, and it changes the tone of the work.
What this changes. Offering soothing skills to someone who believes they deserve to be punished does not work, and can be experienced as one more failure to understand. Self-criticism and shame are treated in their own right — sessions 8 and 11 — before you expect the skills to take.
Function 4: acting on the people around
Making something known without having to say it, getting a reaction, interrupting a conflict, preventing someone from leaving. This function exists, it is a minority, and it is very badly named by the word "manipulation".
What this changes. You do not treat it by removing the reaction of those around — which produces escalation — but by building another channel: a direct, prepared request that obtains the same thing. That is what session 9 is for.
The fifth, which has to be named: because it works
Part of the repetition is no longer explained by the original function but by the fact that the act has become the automatic, learned, reliable solution. Some young people describe a form of need, relief sought for its own sake, escalation in frequency or intensity.
What this changes. You say it plainly, without dramatising: it looks like what any heavily reinforced behaviour does, and treatment consists of making the alternative just as accessible and almost as fast.
How you identify the function
By what happens in the five minutes afterwards. This is the best source. Relief? Coming back to himself? A sense of having got what he deserved? Did someone come?
By what immediately precedes it. A conflict, a thought, a sense of absence, a memory.
By the place and the time. Alone in the bathroom in the evening does not have the same function as after an argument, with the door open.
By what has already been tried and has not worked. A young person who tried to sleep, to listen to music and to call someone before cutting himself is telling you the level of intensity you have to reach.