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What Is Problem-Solving Therapy?

Arlin Cuncic, MA, is the author of The Anxiety Workbook and founder of the website About Social Anxiety. She has a Master's degree in clinical psychology.

Daniel B. Block, MD, is an award-winning, board-certified psychiatrist who operates a private practice in Pennsylvania.

Verywell / Madelyn Goodnight

Problem-Solving Therapy Techniques

How effective is problem-solving therapy, things to consider, how to get started.

Problem-solving therapy is a brief intervention that provides people with the tools they need to identify and solve problems that arise from big and small life stressors. It aims to improve your overall quality of life and reduce the negative impact of psychological and physical illness.

Problem-solving therapy can be used to treat depression , among other conditions. It can be administered by a doctor or mental health professional and may be combined with other treatment approaches.

At a Glance

Problem-solving therapy is a short-term treatment used to help people who are experiencing depression, stress, PTSD, self-harm, suicidal ideation, and other mental health problems develop the tools they need to deal with challenges. This approach teaches people to identify problems, generate solutions, and implement those solutions. Let's take a closer look at how problem-solving therapy can help people be more resilient and adaptive in the face of stress.

Problem-solving therapy is based on a model that takes into account the importance of real-life problem-solving. In other words, the key to managing the impact of stressful life events is to know how to address issues as they arise. Problem-solving therapy is very practical in its approach and is only concerned with the present, rather than delving into your past.

This form of therapy can take place one-on-one or in a group format and may be offered in person or online via telehealth . Sessions can be anywhere from 30 minutes to two hours long.

Key Components

There are two major components that make up the problem-solving therapy framework:

Applying a positive problem-solving orientation to your life
Using problem-solving skills

A positive problem-solving orientation means viewing things in an optimistic light, embracing self-efficacy , and accepting the idea that problems are a normal part of life. Problem-solving skills are behaviors that you can rely on to help you navigate conflict, even during times of stress. This includes skills like:

Knowing how to identify a problem
Defining the problem in a helpful way
Trying to understand the problem more deeply
Setting goals related to the problem
Generating alternative, creative solutions to the problem
Choosing the best course of action
Implementing the choice you have made
Evaluating the outcome to determine next steps

Problem-solving therapy is all about training you to become adaptive in your life so that you will start to see problems as challenges to be solved instead of insurmountable obstacles. It also means that you will recognize the action that is required to engage in effective problem-solving techniques.

Planful Problem-Solving

One problem-solving technique, called planful problem-solving, involves following a series of steps to fix issues in a healthy, constructive way:

Problem definition and formulation : This step involves identifying the real-life problem that needs to be solved and formulating it in a way that allows you to generate potential solutions.
Generation of alternative solutions : This stage involves coming up with various potential solutions to the problem at hand. The goal in this step is to brainstorm options to creatively address the life stressor in ways that you may not have previously considered.
Decision-making strategies : This stage involves discussing different strategies for making decisions as well as identifying obstacles that may get in the way of solving the problem at hand.
Solution implementation and verification : This stage involves implementing a chosen solution and then verifying whether it was effective in addressing the problem.

Other Techniques

Other techniques your therapist may go over include:

Problem-solving multitasking , which helps you learn to think clearly and solve problems effectively even during times of stress
Stop, slow down, think, and act (SSTA) , which is meant to encourage you to become more emotionally mindful when faced with conflict
Healthy thinking and imagery , which teaches you how to embrace more positive self-talk while problem-solving

What Problem-Solving Therapy Can Help With

Problem-solving therapy addresses life stress issues and focuses on helping you find solutions to concrete issues. This approach can be applied to problems associated with various psychological and physiological symptoms.

Mental Health Issues

Problem-solving therapy may help address mental health issues, like:

Chronic stress due to accumulating minor issues
Complications associated with traumatic brain injury (TBI)
Emotional distress
Post-traumatic stress disorder (PTSD)
Problems associated with a chronic disease like cancer, heart disease, or diabetes
Self-harm and feelings of hopelessness
Substance use
Suicidal ideation

Specific Life Challenges

This form of therapy is also helpful for dealing with specific life problems, such as:

Death of a loved one
Dissatisfaction at work
Everyday life stressors
Family problems
Financial difficulties
Relationship conflicts

Your doctor or mental healthcare professional will be able to advise whether problem-solving therapy could be helpful for your particular issue. In general, if you are struggling with specific, concrete problems that you are having trouble finding solutions for, problem-solving therapy could be helpful for you.

Benefits of Problem-Solving Therapy

The skills learned in problem-solving therapy can be helpful for managing all areas of your life. These can include:

Being able to identify which stressors trigger your negative emotions (e.g., sadness, anger)
Confidence that you can handle problems that you face
Having a systematic approach on how to deal with life's problems
Having a toolbox of strategies to solve the issues you face
Increased confidence to find creative solutions
Knowing how to identify which barriers will impede your progress
Knowing how to manage emotions when they arise
Reduced avoidance and increased action-taking
The ability to accept life problems that can't be solved
The ability to make effective decisions
The development of patience (realizing that not all problems have a "quick fix")

Problem-solving therapy can help people feel more empowered to deal with the problems they face in their lives. Rather than feeling overwhelmed when stressors begin to take a toll, this therapy introduces new coping skills that can boost self-efficacy and resilience .

Other Types of Therapy

Other similar types of therapy include cognitive-behavioral therapy (CBT) and solution-focused brief therapy (SFBT) . While these therapies work to change thinking and behaviors, they work a bit differently. Both CBT and SFBT are less structured than problem-solving therapy and may focus on broader issues. CBT focuses on identifying and changing maladaptive thoughts, and SFBT works to help people look for solutions and build self-efficacy based on strengths.

This form of therapy was initially developed to help people combat stress through effective problem-solving, and it was later adapted to address clinical depression specifically. Today, much of the research on problem-solving therapy deals with its effectiveness in treating depression.

Problem-solving therapy has been shown to help depression in:

Older adults
People coping with serious illnesses like cancer

Problem-solving therapy also appears to be effective as a brief treatment for depression, offering benefits in as little as six to eight sessions with a therapist or another healthcare professional. This may make it a good option for someone unable to commit to a lengthier treatment for depression.

Problem-solving therapy is not a good fit for everyone. It may not be effective at addressing issues that don't have clear solutions, like seeking meaning or purpose in life. Problem-solving therapy is also intended to treat specific problems, not general habits or thought patterns .

In general, it's also important to remember that problem-solving therapy is not a primary treatment for mental disorders. If you are living with the symptoms of a serious mental illness such as bipolar disorder or schizophrenia , you may need additional treatment with evidence-based approaches for your particular concern.

Problem-solving therapy is best aimed at someone who has a mental or physical issue that is being treated separately, but who also has life issues that go along with that problem that has yet to be addressed.

For example, it could help if you can't clean your house or pay your bills because of your depression, or if a cancer diagnosis is interfering with your quality of life.

Your doctor may be able to recommend therapists in your area who utilize this approach, or they may offer it themselves as part of their practice. You can also search for a problem-solving therapist with help from the American Psychological Association’s (APA) Society of Clinical Psychology .

If receiving problem-solving therapy from a doctor or mental healthcare professional is not an option for you, you could also consider implementing it as a self-help strategy using a workbook designed to help you learn problem-solving skills on your own.

During your first session, your therapist may spend some time explaining their process and approach. They may ask you to identify the problem you’re currently facing, and they’ll likely discuss your goals for therapy .

Keep In Mind

Problem-solving therapy may be a short-term intervention that's focused on solving a specific issue in your life. If you need further help with something more pervasive, it can also become a longer-term treatment option.

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We've tried, tested, and written unbiased reviews of the best online therapy programs including Talkspace, BetterHelp, and ReGain. Find out which option is the best for you.

Shang P, Cao X, You S, Feng X, Li N, Jia Y. Problem-solving therapy for major depressive disorders in older adults: an updated systematic review and meta-analysis of randomized controlled trials . Aging Clin Exp Res . 2021;33(6):1465-1475. doi:10.1007/s40520-020-01672-3

Cuijpers P, Wit L de, Kleiboer A, Karyotaki E, Ebert DD. Problem-solving therapy for adult depression: An updated meta-analysis . Eur Psychiatry . 2018;48(1):27-37. doi:10.1016/j.eurpsy.2017.11.006

Nezu AM, Nezu CM, D'Zurilla TJ. Problem-Solving Therapy: A Treatment Manual . New York; 2013. doi:10.1891/9780826109415.0001

Owens D, Wright-Hughes A, Graham L, et al. Problem-solving therapy rather than treatment as usual for adults after self-harm: a pragmatic, feasibility, randomised controlled trial (the MIDSHIPS trial) . Pilot Feasibility Stud . 2020;6:119. doi:10.1186/s40814-020-00668-0

Sorsdahl K, Stein DJ, Corrigall J, et al. The efficacy of a blended motivational interviewing and problem solving therapy intervention to reduce substance use among patients presenting for emergency services in South Africa: A randomized controlled trial . Subst Abuse Treat Prev Policy . 2015;10(1):46. doi:doi.org/10.1186/s13011-015-0042-1

Margolis SA, Osborne P, Gonzalez JS. Problem solving . In: Gellman MD, ed. Encyclopedia of Behavioral Medicine . Springer International Publishing; 2020:1745-1747. doi:10.1007/978-3-030-39903-0_208

Kirkham JG, Choi N, Seitz DP. Meta-analysis of problem solving therapy for the treatment of major depressive disorder in older adults . Int J Geriatr Psychiatry . 2016;31(5):526-535. doi:10.1002/gps.4358

Garand L, Rinaldo DE, Alberth MM, et al. Effects of problem solving therapy on mental health outcomes in family caregivers of persons with a new diagnosis of mild cognitive impairment or early dementia: A randomized controlled trial . Am J Geriatr Psychiatry . 2014;22(8):771-781. doi:10.1016/j.jagp.2013.07.007

Noyes K, Zapf AL, Depner RM, et al. Problem-solving skills training in adult cancer survivors: Bright IDEAS-AC pilot study . Cancer Treat Res Commun . 2022;31:100552. doi:10.1016/j.ctarc.2022.100552

Albert SM, King J, Anderson S, et al. Depression agency-based collaborative: effect of problem-solving therapy on risk of common mental disorders in older adults with home care needs . The American Journal of Geriatric Psychiatry . 2019;27(6):619-624. doi:10.1016/j.jagp.2019.01.002

By Arlin Cuncic, MA Arlin Cuncic, MA, is the author of The Anxiety Workbook and founder of the website About Social Anxiety. She has a Master's degree in clinical psychology.

Cognitive Behavioral Therapy

Solving problems the cognitive-behavioral way, problem solving is another part of behavioral therapy..

Posted February 2, 2022 | Reviewed by Ekua Hagan

What Is Cognitive Behavioral Therapy?
Find a therapist who practices CBT
Problem-solving is one technique used on the behavioral side of cognitive-behavioral therapy.
The problem-solving technique is an iterative, five-step process that requires one to identify the problem and test different solutions.
The technique differs from ad-hoc problem-solving in its suspension of judgment and evaluation of each solution.

As I have mentioned in previous posts, cognitive behavioral therapy is more than challenging negative, automatic thoughts. There is a whole behavioral piece of this therapy that focuses on what people do and how to change their actions to support their mental health. In this post, I’ll talk about the problem-solving technique from cognitive behavioral therapy and what makes it unique.

The problem-solving technique

While there are many different variations of this technique, I am going to describe the version I typically use, and which includes the main components of the technique:

The first step is to clearly define the problem. Sometimes, this includes answering a series of questions to make sure the problem is described in detail. Sometimes, the client is able to define the problem pretty clearly on their own. Sometimes, a discussion is needed to clearly outline the problem.

The next step is generating solutions without judgment. The "without judgment" part is crucial: Often when people are solving problems on their own, they will reject each potential solution as soon as they or someone else suggests it. This can lead to feeling helpless and also discarding solutions that would work.

The third step is evaluating the advantages and disadvantages of each solution. This is the step where judgment comes back.

Fourth, the client picks the most feasible solution that is most likely to work and they try it out.

The fifth step is evaluating whether the chosen solution worked, and if not, going back to step two or three to find another option. For step five, enough time has to pass for the solution to have made a difference.

This process is iterative, meaning the client and therapist always go back to the beginning to make sure the problem is resolved and if not, identify what needs to change.

Advantages of the problem-solving technique

The problem-solving technique might differ from ad hoc problem-solving in several ways. The most obvious is the suspension of judgment when coming up with solutions. We sometimes need to withhold judgment and see the solution (or problem) from a different perspective. Deliberately deciding not to judge solutions until later can help trigger that mindset change.

Another difference is the explicit evaluation of whether the solution worked. When people usually try to solve problems, they don’t go back and check whether the solution worked. It’s only if something goes very wrong that they try again. The problem-solving technique specifically includes evaluating the solution.

Lastly, the problem-solving technique starts with a specific definition of the problem instead of just jumping to solutions. To figure out where you are going, you have to know where you are.

One benefit of the cognitive behavioral therapy approach is the behavioral side. The behavioral part of therapy is a wide umbrella that includes problem-solving techniques among other techniques. Accessing multiple techniques means one is more likely to address the client’s main concern.

Salene M. W. Jones, Ph.D., is a clinical psychologist in Washington State.

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Effective problem-identification and problem-solving in counselling – in 4 steps

By Author Elly Prior

Posted on Published: 24-09-2010 - Last updated: 10-07-2022

Categories Counselling and therapy

Discover how to identify and address your (or your client’s ) problems effectively

You’re searching out information about problem-solving in counselling as a beginning therapist or as a client. I’ve got you either way.

What qualifies me to write about problem-solving skills in the counselling process?

Well, I’ve 24 years experiences in counselling – you can find out about my counselling/therapy journey on my About page .

It’s my aim to walk you through my strategy for problem-identification and solving problems in the counselling process.

If you’re here as a client, please note, that the steps below are only a small and specific part of how a therapist might help you in counselling. There’s much more to being an effective counsellor!

Nevertheless, problem-solving is an essential part of the counselling process.

As a therapist, you’ll want to know how to deal with challenges in the client-counsellor relationship as well as helping a client to deal with their particular issues.

Let’s start with taking a look at why effective problem-identification is so important…

Focus on remedies not faults. -Jack Nicklaus

Identifying the problem

Uncovering essential information as part of your problem-solving strategy in counselling will prevent you from:

solving only part of the problem and the real problem rearing it’s ugly head again in the future
solving a problem that’s really only a diversion – a red herring.
solving a problem that’s only a symptom of an underlying issue
misusing your resources (usually your imagination!) or leaving vital resources unused
becoming too absorbed and emotional reducing your ability to consider the problem in a wider context.

Abstract and over-generalised thinking causes minor issues to appear much bigger than they really are. And, significant problems are more likely to appear unmanageable.

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Self-hypnosis is not only effective in reducing stress.

You can amplify your critical thinking with the Improve Your Critical Thinking hypnosis download.

Get all your questions about hypnosis answered – see my article Hypnotherapy online FAQ page .

Problem-solving skills in counselling

As a therapist or counsellor you need to be adept at problem-solving skills before you can teach and empower a client to solve their own problems.

Whether or not you are a (beginning) therapist, here’s what I would do…

As human beings, the more emotional we are, the more limited our thinking becomes. We get stuck through black and white thinking. Not very helpful if we need to identify and analyse a problem!

My first strategy, therefore, is to calm yourself with a breathing exercise. You’ll find one in my article Uncommon stress relief tips .

(As a therapist, I would, of course, have already established rapport with my client.)

Abstract and over-generalised thinking causes minor issues to appear much bigger than they really are.

Familiarise yourself with your essential emotional needs and your innate resources – the human givens (article includes a free worksheet). In other words, get back to the basics – know what you were born with.

When you can meet your essential needs in balance, making good use of your inborn resources, you and your loved ones are much more likely to thrive.

These two steps should ideally form the basis of your problem-solving strategy in counselling.

Case study of the application of my problem-solving strategy

The case study below is an example of how a sense of calmness and careful examination of the problem simply made it disappear.

My client here was a young person in college but the problem-solving strategy could be applied to any situation.

Limited thinking – a case study

Jenny was unhappy, hated college, and decided she was going to change colleges after her exams. She didn’t want to do the all-important final two years where she was currently studying. Jenny was the victim of emotional, black and white thinking.

First, I spent some time calming her right down with some breathing exercising while having her imagine being in beautiful surroundings (our imagination is an inborn resource!).

Next, when she was in a much calmer state of mind, we examined all the factors that had created the problem.

I helped her to think clearly by asking pertinent questions (see steps below). We explored what precisely she thought was so awful and how often she was troubled by that.

I also asked her who and what she liked and valued.

What was the exact problem that had lead her to want to move college?

Well, there were three separate problems.

She disliked two teachers, one of whom she only saw for one hour a week. She found one subject really hard but hadn’t asked for help. She had fallen out with a friend but had already made new friends.

The real problem was her perception of the situation and the high level of emotions.

In a calm state, she was able to see things in a different light and the problem was solved.

Much to her surprise, she found that in reality things were not so bad after all and she was happy to stay. The situation hadn’t changed, but her perception of it had.

Photo: Albert Einstein. Quote: 'The only way to solve a problem is to change the thinking that created it.' - Albert Einstein

Problem-identification in the counselling process

Step 1: identify the problem by gathering essential information.

The real problem may actually be very different from the one you think you have! Take your time with my problem-solving techniques – there’s no need to rush the steps.

Don’t even worry if it takes you several days to answer the questions – think of this as a project and a new start. So why not pour yourself a drink, kick off your shoes and get started…

Take a big sheet of paper, draw a circle for each of the contributing factors and write in the details to start off your problem-solving steps:

Identify the timing

When exactly does the problem occur?
When exactly is it at its worst?
When does it not occur?
Can you identify a pattern from this information?

Identify the place

Where exactly does the problem mostly occur?
Where does it not occur?
Can you identify a pattern?

Identify the sequence in the process

What exactly happens before the problem occurs?
How exactly does the problem start?
What happens that causes the problem to continue?
What exactly was your train of thought?
What are you doing/feeling/seeing/hearing?

Gather information about other people

Friend or foe – how are they detracting from or contributing to your problem?

What significant people are present or absent when the problem occurs?
What do others/your partner/friend/colleague/family think about the problem?
Who doesn’t know about the problem and should know?
What do you anticipate they might think when they find out?
Can one of them play devil’s advocate to give you a completely different perspective?
Can you identify a pattern from the information you’ve gathered?

Become clear about your (client’s) role

What part of the problem is for you to sort out and no-one else?
What do you think are your personal weaknesses?
What evidence of those do you have?
What actions can you take to turn those weaknesses into strengths?
Are you able to separate yourself from the problem by giving it a colour, name or shape?
What part of the problem do you actually have (some) control over?
What assumptions did you make when you previously tried to sort out this problem?
Do you need help with the problem?

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Problem-solving in the counselling process

A hugely important part of my counselling process was to identify my client’s resources.

Identify your (client’s) resources and strengths

The most important aspect of any problem-solving strategy is to take stock of your personal resources for solving the problem(s).

What parts of your role as a partner/colleague/employee/friend are working well?
What evidence do you have for that?
What exactly are you doing that makes it work well?
What skills and resources do you use in your spare time and at work?
What are your achievements? (These could be large one-offs or simple everyday ones, e.g. passing your driving test, getting your PhD or cooking a meal)
Who has solved a similar problem? How did they do it?
Who can help and/or advise you whilst remaining objective?
Who can support and encourage you whilst remaining objective?
Who do you admire? And how do you imagine they might have solved the problem?
What would you consider to be life’s little treats? (e.g. a hot bath, first flowers in spring, looking at art, reading an inspiring book, etc.) It’s vital to be aware of what would make you feel good, what you consider to be a reward when you want to recharge your energy.

Beyond the problem

What would you be doing/concentrating on if you didn’t have this particular problem right now?
How exactly would you and/or the situation be different?
What would your friends/family/colleagues notice about you/the situation?
What would happen if you just ignored the problem?
Could you view the present situation as an alternative solution, even though it’s clearly not ideal?
Are there any possible benefits of the situation?
Can you make any other changes, without having to solve the problem first?
How would you ideally like it to end?
What small steps can you take towards an eventual solution or part-solution?
What can you do today that will make a difference tomorrow?
Are there any other opportunities to turn a negative in a positive?
What will you settle for if all else fails?

Background photo: couple and counsellor. Text: Effective problem-solving in counselling in 4 steps.

Solving problems in counselling

Step 2: analyse and identify the exact problem.

You’ll have already gathered specific details about the problem(s).

So, take a deep breath, have a break and make yourself another drink. Then we can continue problem-identification in the counselling process …

Decide on your headings: either for every aspect of that one problem or for all of the different problems. Break things up into smaller parts if necessary
Draw a mind map or flow-chart, or draw the problem in whatever way makes sense to you
Include your resources (i.e. your strengths and capabilities) under each heading
Think about whose problem it really is – it might not be yours… but do be honest with yourself
Write a short statement about how you feel about the problem and what exactly it is (this will help you to communicate more effectively with others)

How to solve problems in the counselling process

Step 3: solving the problem(s).

The tree which moves some to tears of you, is in the eyes of others merely a green thing that stands in the way.” William Blake

The next strategy is to devise a solution – finally!

10-point problem-solving plan

Decide what the ideal solution for you would be.
Decide what you can live with.
Decide on an alternative solution.
Decide on the steps you can take right now to bring about some change. This will help you to feel more positive and in control.
Decide who you need to ask for help.
Decide what you think other people might need from you and check with them.
Decide who you need to have a conversation with, what you would say and when that might be possible.
Make a list with exact timings of your planned actions. This is one of the most important techniques.
Set a review date to hold yourself (and maybe others) to account.
Sleep on it, but have a notepad by the side of your bed. Just as you drift off you may come up with a brilliant idea. If you don’t write it down there and then, you’ll probably have forgotten by the morning!

You’ve now identified exactly what the problems and potential solutions are. Perhaps you’ve even broken them up into smaller parts.

The next step is to deal with the smallest (or easiest) one first, to help build your confidence.

Alternatively, you can decide to go for the big one the moment you get out of bed and … get it done!

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Step 4 – Review your problem-solving strategies

There’s no point in having a plan with problem-solving strategies if you don’t take the time to review it.

As a counsellor, I would use the following counselling sessions to keep track of my client’s progress, of course.

If you’re working by yourself, you’ll need to also check your progress against your action points and their respective dates.

The following questions will help you to mark the progress you’ve made…

What precise steps have you taken to solve the problem (or even just part of it)?
Which strategies were successful and which were less so?
What should you continue to do? (i.e. what works!)
What parts of the plan could do with an update?
Are other people keeping to their side of the bargain?
What can you do to encourage or remind them?
Set another review date.

There is no failure, only feedback!

The above problem-solving strategies in counselling can stop you from getting stuck and becoming overwhelmed.

Once you’ve got a robust process in place, you’ll be able to work through any problem you encounter now and in the future.

All you have to remember is to stay calm, ask the right questions, and draw on your innate resources to make your solutions a reality.

You’ve got this!

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5 Problem-Solving Therapy: Theory and Practice

Published: May 2017
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Problem-solving therapy (PST) is a psychosocial intervention that teaches clients to cope with the stress of “here-and-now” problems in order to reduce negative health and mental health outcomes. In this chapter, the six stages of PST—problem orientation, problem definition, solution generation, decision-making, solution implementation, and outcome evaluation—are explained and exemplified via vignettes. Areas for which problem-solving therapy has been found useful are summarized, including depression, anxiety, relationship difficulties, and distress related to medical problems such as cancer and diabetes. The chapter describes contexts for practice, including primary care and home care, as well as adaptations for the use of PST with older adults. Finally, a case example of a problem-solving intervention with an unemployed depressed older man is presented to illustrate this approach.

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Counsellor Competencies pp 59–109 Cite as

Egan’s Model of Problem-Management

Bernd-Joachim Ertelt 4 ,
William E. Schulz 5 &
Andreas Frey 4
First Online: 24 April 2022

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The practical approach to problem-solving and the opening up of possibilities is responsible for the unbroken popularity of G. Egan’s book “The skilled helper”.

He recognised from the outset that there was a tension between behavioural science psychology, on the one hand, and humanistic psychology, on the other.

In all editions of his book, Egan tried to combine the two psychological directions, recognising that the behaviourist counselling always needed humanising.

It was important for him not only to present a model of helping but also to provide counsellors with a set of techniques and skills to make his approach actually work.

Updated translation of chapter 3 from: Handbuch Beratungskompetenz, 4th ed. by Bernd-Joachim Ertelt & William E. Schulz, 2019, Springer Verlag.

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H. RUSSELL SEARIGHT, PhD, MPH

Am Fam Physician. 2009;79(4):277-284

A more recent article on counseling patients in primary care is available.

Author disclosure: Nothing to disclose.

Although it is often unrecognized, family physicians provide a significant amount of mental health care in the United States. Time is one of the major obstacles to providing counseling in primary care. Counseling approaches developed specifically for ambulatory patients and traditional psychotherapies modified for primary care are efficient first-line treatments. For some clinical conditions, providing individualized feedback alone leads to improvement. The five A’s (ask, advise, assess, assist, arrange) and FRAMES (feedback about personal risk, responsibility of patient, advice to change, menu of strategies, empathetic style, promote self-efficacy) techniques are stepwise protocols that are effective for smoking cessation and reducing excessive alcohol consumption. These models can be adapted to address other problems, such as treatment nonadherence. Although both approaches are helpful to patients who are ready to change, they are less likely to be successful in patients who are ambivalent or who have broader psychosocial problems. For patients who are less committed to changing health risk behavior or increasing healthy behavior, the stages-of-change approach and motivational interviewing address barriers. Patients with psychiatric conditions and acute psychosocial stressors will likely respond to problem-solving therapy or the BATHE (background, affect, troubles, handling, empathy) technique. Although brief primary care counseling has been effective, patients who do not fully respond to the initial intervention should receive multimodal therapy or be referred to a mental health professional.

The primary care sector provides at least one half of all U.S. mental health services. 1 , 2 In the United States, 50 percent of patients treated for major depressive disorder are treated solely by primary care physicians, 3 and about 20 percent of psychotherapy sessions are provided in primary care. 4 However, family physicians often report time pressures and lack of knowledge as barriers to providing systematic counseling. Several models for brief counseling have been developed specifically for the outpatient primary care setting, and other problem-focused psychotherapies may be adapted for this setting.

Family physician counseling is an efficient and cost-effective initial intervention in a stepped-care approach. 5 – 7 As a first-line therapy, brief counseling is effective for many problems; is acceptable to most patients; and reduces the need for more time-intensive, costly treatment and referral for specialty care. 6 , 7 Evidence indicates that assessment and treatment overlap with many psychiatric conditions and health risk behaviors. Providing individualized feedback and recommendations about a patient’s alcohol consumption, 8 , 9 diet, 10 and mood disorders 11 often leads to at least short-term improvement without other therapies.

Patient responsiveness to physician education and direct advice is variable. Table 1 summarizes counseling approaches that address health risk behaviors or adherence problems, ambivalence to change, and broader psychosocial issues.

The Five A’s

The five A’s (ask, advise, assess, assist, arrange) 12 technique ( Table 2 13 , 14 ) is an efficient strategy for addressing health risk behaviors, such as smoking and alcohol use, and may be adapted to promoting healthy behaviors, including regular exercise. Asking questions presumptively (“How much do you smoke?”) may elicit more reliable information.

When advising patients, communication theory suggests that a defensive reaction is less likely if the physician begins with an “I” statement (“I recommend that you…”) rather than a “You” statement (“You need to...”). 15 , 16 Although educational handouts may augment the physician’s advice, printed material should not replace direct verbal recommendations.

Before developing a plan, it is necessary to assess the patient’s motivation for imminent change. After assisting the patient in developing concrete strategies for change, close follow-up should be arranged. For example, because nicotine withdrawal during smoking cessation includes unpleasant physical and emotional reactions, arranging supportive contact increases the likelihood of success. 13 Research including pregnant smokers found that the five A’s technique led to greater cessation rates than physician recommendations alone. 12 , 13

FRAMES Protocol

The FRAMES (feedback about personal risk, responsibility of patient, advice to change, menu of strategies, empathetic style, promote self-efficacy) protocol ( Table 3 14 , 17 ) also targets health risk behaviors. It begins with concrete, individualized patient feedback related to the behavior, 17 such as a CAGE questionnaire score for alcohol use, blood pressure, glucose levels, or A1C levels. The physician may also link a presenting complaint, such as sleep disturbance in a heavy drinker 18 or frequent respiratory infections in a long-term cannabis user, 19 to the under-lying substance abuse.

The physician directly or indirectly communicates the importance of the patient taking responsibility for change. Patient ambivalence should be briefly explored—if the patient appears ambivalent or is currently uninterested in addressing the issue, the physician should provide direct, succinct advice and indicate that it is an important future topic. Whenever feasible, the patient should receive a range of options to consider rather than a specific directive. By providing a menu of strategies, the physician communicates a willingness to collaborate while emphasizing that implementation is the patient’s responsibility. Communicating with empathy has been shown to increase patient satisfaction 20 and adherence. 21 The final step is promoting the patient’s sense of self-efficacy with an encouraging statement about the plan he or she has developed.

Stages of Change (Transtheoretical Model)

The transtheoretical model ( Table 4 14 , 22 , 23 ) assumes that health behavior changes in stages that reflect various levels of patient motivation and perceived self-efficacy (i.e., precontemplation, contemplation, preparation, action, and maintenance). 22 The physician asks targeted questions designed to increase patient motivation for change until motivation increases to the point of initiating action. The transtheoretical model, originally developed for smoking cessation, is supported by considerable research and appears to be effective for reducing other health risk behaviors 22 and for improving chronic disease self-management. 24 , 25 The model, using individualized patient feedback, is associated with improved adherence to a hypertensive regimen at 12 and 18 months. 24 With self-management of chronic diseases, such as type 2 diabetes, patients are likely to be at different stages for specific aspects of management (e.g., diet, activity level, blood glucose self-monitoring, taking medications). 25

During precontemplation and contemplation, patients are more likely to respond to a cognitive approach, such as discussing the benefits of habit change, possibly supported by written information. In the precontemplation stage, the patient perceives that the disadvantages of changing outweigh the benefits, whereas this pattern is reversed in the action stage. 23 Therefore, during precontemplation and contemplation, physicians should highlight the advantages of change. 23 , 26

In the preparation stage, the patient chooses a starting date and strategy for change. The action stage should target the behavioral skills and day-to-day challenges the patient encounters during his or her efforts to change. 23

During action and maintenance, brief lapses or more enduring relapses are common. 23 , 26 Physicians should praise and support the patient’s efforts to change and use statistical evidence to stress that episodes of relapse are normal. For example, only about 7 percent of persons initiating a smoking cessation attempt are abstinent after one year, 13 and multiple attempts are usually needed before achieving lifetime cessation.

Motivational Interviewing

Motivational interviewing ( Table 5 27 , 28 ) recognizes that patients may be ambivalent about change 27 and emphasizes patient autonomy, values, and collaboration with the physician. 28 The technique includes agenda setting, exploration, providing information, listening and summarizing, and generating options and contracting.

Beginning with agenda setting, the physician asks permission before discussing psychosocial conflicts, adherence, or health risk behavior. After eliciting permission, the physician then explores the topic with change-oriented queries focusing on the patient’s investment, urgency, perceived need, and reasons for considering change. 28 With an understanding of the patient’s motivation and values, factual information about the importance of change and treatment availability is presented in an emotionally neutral manner. This interpersonal style, which facilitates a partnership between patient and physician, 29 is in contrast to the “righting reflex” (in which the physician unilaterally presents the correct course of action). 28

Proponents of motivational interviewing believe that physician directiveness activates patient resistance. 27 , 28 However, using this technique, information is immediately followed by eliciting the patient’s reaction, which the physician then summarizes. In concluding the encounter, the patient is encouraged to consider treatment options and tentatively agrees to a specific plan with the physician (contracting). Evidence indicates that in primary care clinics, brief physician motivational interviewing has a positive effect on weight loss attempts, 30 exercise efforts, 31 decreased substance use, 32 and blood pressure control. 33

Problem-Solving Therapy

Problem-solving therapy ( Table 6 34 ) is a four-step approach (problem definition, generating alternative solutions, decision making, solution verification and implementation), which was developed from research comparing the problem-solving skills of clinical versus nonclinical populations. 34 , 35 Problem-solving therapy’s systematic framework begins with the physician asking questions to specifically define the problem using factual, concrete information. This method is particularly useful for patients exhibiting catastrophization, a cognitive and emotional escalation process in which life difficulties are exaggerated. 36 Diffusing concerns and targeting a specific, potentially modifiable feature is particularly important when addressing psychosocial crises.

While brainstorming for alternative solutions, the patient may indicate that the problem would be readily solved if someone else would change. When this occurs, physicians should redirect the patient to solutions that the patient can control to facilitate decision making and evaluation of possible consequences for each possible solution.

After the patient makes a decision, the physician verifies the solution by restating the plan and addressing any obstacles that might interfere with its execution. Lastly, the physician addresses the practical implementation of the plan. Research in health care settings supports the effectiveness of problem-solving therapy for a range of clinical problems, including major depressive disorder and nonadherence to a diabetes regimen. 37 – 39

The BATHE (background, affect, troubles, handling, empathy) technique, developed specifically for family physicians, is helpful for patients exhibiting psychiatric syndromes or a broad range of psychosocial problems. 40 The questions are almost always asked in the specific order listed in Table 7 . 14 , 40 , 41 The initial open-ended background question is a reminder to listen to the patient’s presenting narrative. Physicians are often concerned that initial open-ended questions will lead to overly long descriptions. However, most patients complete their answers in less than one minute, with 90 percent completing their answer in less than two minutes. 42 If the patient takes longer than a few minutes, keep the interview moving by politely interrupting and asking how the patient feels about his or her concerns. 41

Although the physician may briefly summarize the patient’s answer to the background question, the physician should quickly proceed to the “affect” question. Some patients have difficulty articulating feelings and continue to describe the problem, or they are simply unaware of their emotions. In response, the physician may repeat the question or suggest descriptors.

The “troubles” question provides a useful focus, particularly when the problem seems overwhelming. 40 , 41 Although the physician may believe that he or she knows what is most upsetting, the assumption may be incorrect. It may be tempting to recommend solutions, but handling the problem is the patient’s responsibility. However, the patient’s attempted solutions often cause more upheaval than the problem itself 43 —a point that the physician may reflect back to the patient. By focusing and labeling key dimensions, the physician’s questions facilitate the patient’s ability to generate realistic coping strategies.

Communicating empathy creates a physician-patient partnership and indicates that the physician is actively listening to the patient. If the visit is a follow-up, the opening question should target events in the time interval from the last visit. 41 Most BATHE interviews can be conducted in less than five minutes. 41

Approach to the Patient

In mental health settings, most evidence-based psychotherapies require a minimum of 10 to 15 sessions, 44 and approximately 50 percent of patients do not complete the treatment course. 3 Evidence-based reviews of primary care counseling indicate that brief approaches may lead to short-term reductions in psychosocial distress 45 , 46 and longer-term reductions in alcohol use 47 , 48 and depressive symptoms. 49 The models presented in this article may be implemented in approximately five to 10 minutes and can be integrated into most office visits. These strategies make up the first stage of a stepped-care approach 5 , 50 in which brief interventions, including providing patients with screening information, are the initial treatments. There are typically two options for patients who fail or incompletely respond to the initial intervention. For highly symptomatic patients or those with multiple high-risk behaviors, referral to a mental health specialist may be the next step. Alternatively, in less severe situations, the physician may add a second intervention, such as pharmacotherapy, more intensive education, or an additional counseling strategy. If problems persist, referral to a mental health or substance abuse specialist is recommended.

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Defining the Counseling Process and Its Stages

The process begins with exploring the challenges a client faces before assisting them in resolving developmental and situational difficulties (Sajjad, 2017).

The counselor supports clients with physical, emotional, and mental health issues, helping them resolve crises, reduce feelings of distress, and improve their sense of wellbeing (American Psychological Association, 2008).

When successful, treatment can change how a client thinks, feels, and behaves regarding an upsetting experience or situation (Krishnan, n.d.).

This article explores what counseling is and is not, and the stages and steps involved in a successful outcome.

Before you continue, we thought you might like to download our three Positive Psychology Exercises for free . These science-based exercises will explore fundamental aspects of positive psychology including strengths, values, and self-compassion, and will give you the tools to enhance the wellbeing of your clients, students, or employees.

This Article Contains

Defining the counseling process, the stages of the counseling process, 7 steps in the counseling process, real-life examples of the counseling phases, 12 valuable skills for each phase, a look at the process in group counseling, a take-home message, frequently asked questions.

All of us will, occasionally, take on the role of counselor. We informally offer family, friends, and colleagues advice regarding their relationships, finances, career, and education.

On the other hand, “a professional counselor is a highly trained individual who is able to use a different range of counseling approaches with their clients” (Krishnan, n.d., p. 5).

Counseling as a profession involves (Krishnan, n.d.):

Dedicated time set aside to explore difficulties, stressful situations, or emotional upset faced by a client
Helping that client see their situation and feelings from a different viewpoint, potentially to facilitate change
Building a relationship based on trust and confidentiality

The counseling process should not include:

Providing advice
Being judgmental
Pushing the counselor’s values
Encouraging the client to behave as the counselor would in their own life
Emotional attachment between the counselor and client

According to the American Psychological Association (2008), counseling psychologists “help people with physical, emotional and mental health issues improve their sense of wellbeing, alleviate feelings of distress and resolve crises.”

Counseling works with clients from childhood through to old age, focusing on “developmental (lifespan), environmental and cultural perspectives,” including (American Psychological Association, 2008):

Issues and concerns in education and career
Decisions regarding school, work, and retirement transitions
Marital and family relationship difficulties
Managing stressful life events
Coping with ill health and physical disability
Mental disorders
Ongoing difficulties with getting along with people in general

While we often see counseling and psychotherapy as interchangeable, there are subtle distinctions. Counseling is typically short term, dealing with present issues and involving a helping approach that “highlights the emotional and intellectual experience of a client,” including how they feel and think about a problem or concern (Krishnan, n.d., p. 6).

Psychotherapy is often a longer term intensive treatment, helping the client overcome profound difficulties resulting from their psychological history and requiring them to return to earlier experiences (Krishnan, n.d.; Australia Counselling, n.d.).

The counseling process has been described as both an art and a science, helping to bring about changes in thought, emotion, and behavior in the client (Sajjad, 2017).

Counselors and clients must both be aware that the counseling process requires patience. There is rarely a quick fix, and things may need to get worse before they get better. In addition, the counseling process is collaborative. The counselor does not fix the client; the work requires interaction and commitment from both parties (Krishnan, n.d.).

The counseling process is a planned and structured dialogue between client and counselor. The counselor is a trained and qualified professional who helps the client identify the source of their concerns or difficulties; then, together, they find counseling approaches to help deal with the problems faced (Krishnan, n.d.).

Hackney and Cormier (2005) propose a five-stage model for defining the counseling process through which both counselor and client move (Krishnan, n.d.).

Stage one: (Initial disclosure) Relationship building

The counseling process begins with relationship building . This stage focuses on the counselor engaging with the client to explore the issues that directly affect them.

The vital first interview can set the scene for what is to come, with the client reading the counselor’s verbal and nonverbal signals to draw inferences about the counselor and the process. The counselor focuses on using good listening skills and building a positive relationship.

When successful, it ensures a strong foundation for future dialogue and the continuing counseling process.

Stage two: (In-depth exploration) Problem assessment

While the counselor and client continue to build a beneficial, collaborative relationship, another process is underway: problem assessment .

The counselor carefully listens and draws out information regarding the client’s situation (life, work, home, education, etc.) and the reason they have engaged in counseling.

Information crucial to subsequent stages of counseling includes identifying triggers, timing, environmental factors, stress levels, and other contributing factors.

Stage three: (Commitment to action) Goal setting

Effective counseling relies on setting appropriate and realistic goals, building on the previous stages. The goals must be identified and developed collaboratively, with the client committing to a set of steps leading to a particular outcome.

Stage four: Counseling intervention

This stage varies depending on the counselor and the theories they are familiar with, as well as the situation the client faces.

For example, a behavioral approach may suggest engaging in activities designed to help the client alter their behavior. In comparison, a person-centered approach seeks to engage the client’s self-actualizing tendency.

Stage five: Evaluation, termination, or referral

Termination may not seem like a stage, but the art of ending the counseling is critical.

Drawing counseling to a close must be planned well in advance to ensure a positive conclusion is reached while avoiding anger, sadness, or anxiety (Fragkiadaki & Strauss, 2012).

Part of the process is to reach an early agreement on how the therapy will end and what success looks like. This may lead to a referral if required.

While there are clear stages to the typical counseling process, other than termination, each may be ongoing. For example, while setting goals, new information or understanding may surface that requires additional assessment of the problem.

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Many crucial steps go together to form the five stages of the counseling process. How well they are performed can affect the success of each stage and overall outcome of counseling (Krishnan, n.d.).

Key steps for the client

The client must take the following four steps for counseling to be successful (Krishnan, n.d.):

Willingness Being willing to seek and attend counseling is a crucial step for any individual. It involves the recognition that they need to make changes and require help to do so. Taking the next action often involves overcoming the anxiety of moving out of the comfort zone and engaging in new thinking patterns and behaviors.
Motivation Being willing to make changes and engage in them involves maintaining and sustaining motivation. Without it, the counseling process will falter when the real work begins.
Commitment The client may be willing and motivated, but change will not happen without continued patience and commitment. Commitment may be a series of repeating decisions to persist and move forward.
Faith Counseling is unlikely to succeed unless the client has faith in themselves, the counselor, and the process. Taking the step to begin and continue with counseling requires the belief that it can be successful.

Key steps for the counselor

Each step in the counseling process is vital to forming and maintaining an effective counselor–client relationship. Together they support what Carl Rogers (1957) describes as the core conditions for successful therapy:

Unconditional positive regard Through acceptance and nonjudgmental behavior, the therapist makes space for the needs of the client and treats them with dignity. For more on developing this, we have these Unconditional Positive Regard worksheets , which may prove helpful.
Empathy The counselor shows genuine understanding, even if they disagree with the client.
Congruence The words, feelings, and actions of the counselor embody consistency.

Counselors often help clients make important and emotional decisions in their lives. To form empathy, they must intimately take part in the client’s inner realm or inscape .

Several well-performed steps can help the counselor engage with the client and ensure they listen openly, without judgment or expectation. The counselor must work on the following measures to build and maintain the relationship with the client (Krishnan, n.d.):

Introduce themselves clearly and with warmth.
Invite the client to take a seat.
Address the client by the name they are most comfortable with.
Engage in relaxed social conversation to reduce anxiety.
Pay attention to nonverbal communication to identify the client’s emotional state.
Invite the client using open questions to explain their reason for coming to counseling.
Allow the client time to answer fully, without pressure.
Show that they are interested in the client as a person.

Each of the above steps is important. Taken together, they can facilitate the formation of a valuable counseling relationship.

Ultimately, counseling is collaborative and requires a series of ongoing steps – some taken by the client, others by the counselor, and several jointly. For a successful outcome, appropriate resources, time, and focus must be given to each one, and every win must be recognized and used to support the next.

While there are guiding theories and principles, the counselor must make the counseling process specific to the individual.

The following two real-life examples provide a brief insight into the counseling process and richness of the scenarios counselors face.

Lost direction

‘Jenny’ arrived in counseling with little income, no sense of direction, and lacking a sense of control over her life (Fielding, 2014).

The counselor began by forming a picture of her situation and what had led her to that point.

Sessions then moved on to explore Jenny’s beliefs about herself: where they came from, how they affected her, and their appropriateness for current and future circumstances.

A series of brainstorming sessions were used to understand Jenny’s needs, family relationships, and past, and identify her irrational beliefs. Once Jenny uncovered her core beliefs, the counselor worked with her to replace them with more rational ones.

Jenny ended counseling overjoyed with her new preferred beliefs, along with a renewed sense of confidence and control over her life.

Saving a marriage

It is not just individuals who need help, but relationships too. When ‘John’ and ‘Sue-Anne’ attended counseling early on in their marriage, it was because, having lost their group of friends, they found themselves on their own with only each other’s company (Starak, 2010).

Early on in counseling, it became clear that they both needed time to ponder some serious questions, including:

Who am I? What values do I bring to this relationship?

The exercises helped John and Sue-Anne better understand their values, strengths, and what motivated their daily actions. By focusing on what each of them wanted their relationship to look like, they could clarify how much time they wanted to spend together and their roles within the marriage.

The counseling process enabled them to form a shared picture of how their marriage and life would look from now on.

Good communication is vital to all stages of counseling. Skills should ideally include (Krishnan, n.d.; Lesley University, n.d.; American Psychological Association, 2008):

Active listening techniques
Clarification
Effective questioning

Beyond that, to build rapport with the client, counselors must also:

Be able to experience and show empathy (rather than sympathy)
See things from the client’s perspective
Have a genuine interest in others’ wellbeing
Use self-reflection to observe themselves and empathize with others
Show accessibility and authenticity during counseling sessions
Be flexible in their views and thinking regarding differing values and multicultural issues
Be able to maintain a sense of humor
Be resilient and able to bounce back from difficult situations

A mental health practitioner delivering positive outcomes in increasingly diverse populations benefits from developing theory, knowledge, and skills.

Partly due to its high degree of success, low cost, and wide availability, group therapy can be a good option for many clients.

It is essential to remember that group therapy is not the same as individual therapy performed within a group setting; it has specific and dedicated techniques and an additional skillset. Unfortunately, however, training has not always kept up with the specialist needs of group therapy (Novotney, 2019).

There are other, unique considerations and processes involved when offering and running group therapy, including being able to (Novotney, 2019):

Get the right fit Not all clients are suitable for group therapy. They may be better placed in a one-to-one setting. High-quality screening is required to ensure the fit of the individual to the group and vice versa.

The Group Readiness Questionnaire has been designed to identify risk factors and the potential for dropout.

Explain expectations upfront Individuals’ expectations of group therapy must be realistic. Change takes time, whether in a group or an individual setting. Also, the counselor must educate clients that group therapy is not about shouting and heated exchanges. Sessions can be fun and rewarding.
Build cohesion quickly The issues being addressed can set the tone of the group and the speed at which it bonds. Grief groups, for example, often form cohesion quickly, while others can take more work and require splitting into smaller groups or pairs.
Seek feedback Early and regular feedback can help assess how individuals and the group are functioning and whether dropout is likely.
Identify and address ruptures Group work can lead to disagreements. Concerns and ruptures should be worked through early on, either bringing up issues directly with the members involved or more generally as a group.

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Counseling helps clients by bringing much-needed change to their lives (Sajjad, 2017).

While personal and theoretical approaches may vary, a professional counselor will typically begin by building a relationship with the client before understanding their situation and their reason for seeking help. They can then explore how to move forward and assist the client in changing their thinking, emotional responses, and behavior.

Whether performed individually or as a group, empathy and a collaborative approach are crucial to therapeutic success. The stronger the relationship and the more committed and motivated the client, the more likely a robust and appropriate outcome is reached.

When successful, counseling offers the client the opportunity to change by establishing specific goals, improving their coping skills, promoting decision making, and improving relationships across life domains (Sajjad, 2017).

Time spent gaining knowledge, training, and practicing is vital to gaining the required skills for this challenging yet rewarding profession. In return, mental health professionals have the potential to help people in a wide variety of situations live more productive and satisfying lives.

We hope you enjoyed reading this article. Don’t forget to download our three Positive Psychology Exercises for free .

The 10 principles of counseling are:

Respect for client autonomy
Empathy and understanding
Non-judgmental attitude
Confidentiality
Cultural sensitivity and competence
Trust and rapport
Collaborative approach
Professional boundaries
Self-awareness and self-reflection
Ethical and legal standards

The 5 C’s of counseling refer to the essential qualities that a counselor should possess:

Competence: possessing the necessary knowledge and skills to effectively help clients
Compassion: showing empathy and caring for clients
Confidence: having confidence in oneself and one’s abilities as a counselor
Connection: building a strong therapeutic relationship with clients
Character: demonstrating ethical and professional behavior

The golden rule in counseling is to treat others how you would like to be treated. This means being respectful, empathetic, and non-judgmental with clients, and creating a safe and supportive environment for them to explore their issues and concerns. It also means adhering to ethical and professional standards and always acting in the best interest of the client.

American Psychological Association. (2008). Counseling psychology. Retrieved June 17, 2021, from https://www.apa.org/ed/graduate/specialize/counseling
Australia Counselling. (n.d.). What’s the difference between counselling and psychotherapy? Retrieved June 17, 2021, from https://www.australiacounselling.com.au/whats-difference-between-counselling-and-psychotherapy/
Fielding, L. (2014, November 25). A case of lost direction. Australian Institute of Professional Counsellors. Retrieved June 17, 2021, from https://www.aipc.net.au/articles/a-case-of-lost-direction/
Fragkiadaki, E., & Strauss, S. M. (2012). Termination of psychotherapy: The journey of 10 psychoanalytic and psychodynamic therapists. Psychology and Psychotherapy: Theory, Research and Practice , 85 (3), 335–350.
Hackney, H., & Cormier, L. S. (2005). The professional counselor: A process guide to helping . Pearson.
Krishnan, S. (n.d.). The counselling process . Retrieved June 15, 2021, from http://www.dspmuranchi.ac.in/pdf/Blog/stages%20of%20counselling.pdf
Lesley University. (n.d.). 6 critical skills every counselor should cultivate. Retrieved June 17, 2021, from https://lesley.edu/article/6-critical-skills-every-counselor-should-cultivate
Novotney, A. (2019). Keys to great group therapy. Monitor on Psychology. Retrieved June 17, 2021, from https://www.apa.org/monitor/2019/04/group-therapy
Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology , 21 , 95–103.
Sajjad, K. S. M. (2017). Essentials of counseling . Abosar Prokashana Sangstha.
Starak, Z. (2010, October 6). How to save your marriage by creating a relationship. Australian Institute of Professional Counsellors. Retrieved June 17, 2021, from https://www.aipc.net.au/articles/how-to-save-your-marriage-by-creating-a-relationship/

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Wow u have been helpful with these notes am grateful

I wish to thank you very much for this useful article, which throws more light on both the concept and process of counselling. I am a Guidance – Counsellor in a secondary school where students have a lot of behavioural issues. I believe this article has thrown more light that will help me figure out how best to journey with them.

I loved this article. So precise and to the point and so easy to understand. I am an undergraduate psychology student and needed to study this topic for my exam. From the examination point of view this is perfect.

The theme of Counseling explained in practical and easily understandable language.Respect to the client and unconstitutional positive regard, confidentiality and maintaining professional etiquette must be of prime concern. I am highly benefited.

I love the simplicity, directness and comprehensiveness of this well written article on Counselling. It contains all that’s needed to impart the knowledge and skills of this important and useful process that counselling is.

Well written article and simplest in all forms of understanding. Very useful in imparting knowledge to others

The articles here are very informative and relevant to my work. I am a counseling psychologist from Kenya. I would love to learn more.

This peice is carefully researched and clearly presented in a simple and clear term. I hope this is collectively applied in all areas to solve psychological problems.

Refugee needs counseling to reduce mental tension. I wish I could have such a book. Domestic conflict and violence are rampant in the community.Thanks.(Koboko Uganda)

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Evidence reviews for psychological and psychosocial interventions

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NICE Guideline, No. 225

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Psychological and psychosocial interventions

Review question

What psychological and psychosocial interventions (including safety plans and electronic health-based interventions) are effective for people who have self-harmed?

Introduction

People who self-harm or engage in suicidal behaviour are often in distress and may benefit from effective psychological or psychosocial support to help reduce distress and repeat self-harm or suicide in the future. There is often limited availability of psychological and psychosocial interventions targeted for this group of people and they may be excluded from generic psychological therapy services. Determining which interventions are effective for children and young people and for adults is therefore important so that evidence-based psychological and psychosocial interventions can be commissioned and offered. The aim of this review is to find out what psychological and psychosocial interventions are effective for people who have self-harmed.

Summary of the protocol

See Table 1 for a summary of the Population, Intervention, Comparison and Outcome (PICO) characteristics of this review.

Summary of the protocol (PICO table).

For further details see the review protocol in appendix A .

Methods and process

During the development of this guideline, two registered Cochrane protocols were identified which matched the committee’s intended PICOs. The Cochrane protocols differed from the committee’s intended population in that the Cochrane protocols excluded studies that included people who had self-harmed who had a neurodevelopmental disorder or learning difficulty, however no studies were identified that were excluded from the reviews on these grounds alone.

The Cochrane review team completed two reviews investigating the effectiveness of psychosocial interventions in adults ( Witt 2021a ) and psychosocial and pharmacological interventions in children and young people (CYP) ( Witt 2021b ) during guideline development and presented their results to the guideline committee, which used them to make recommendations. Cochrane’s methods are closely aligned to standard NICE methods, minor deviations (the use of GRADE only on main outcomes with no overall quality rating for those with zero events in either arm, summary of findings tables instead of full GRADE tables, defining primary and secondary outcomes as opposed to critical and important and including countries from a broader range of income categories than the majority of the other reviews in the guideline) relevant to the topic area were highlighted to the committee and taken into account in discussions of the evidence.

Declarations of interest were recorded according to NICE’s conflicts of interest policy .

Effectiveness evidence

Included studies.

Two Cochrane reviews ( Witt 2021a , Witt 2021b ) including 83 randomised controlled trials were considered in this report. Of the studies included in these reviews, 76 were from the review investigating psychosocial interventions for adults (Allard 1992, Amadéo 2015, Andreoli 2015, Armitage 2016, Bateman 2009, Beautrais 2010, Bennewith 2002, Brown 2005, Carter 2005, Cedereke 2002, Clarke 2002, Crawford 2010, Davidson 2014, Dubois 1999, Evans 1999a, Evans 1999b, Fleischmann 2008, Gibbons 1978, Gratz 2006, Gratz 2014, Grimholt 2015, Guthrie 2001, Gysin-Maillart 2016, Hassanian-Moghaddam 2011, Hatcher 2011, Hatcher 2015, Hatcher 2016, Hawton 1981, Hawton 1987, Harned 2014, Husain 2014, Hvid 2011, Kapur 2013, Kawanishi 2014, Liberman 1981, Lin 2020, Linehan 1991, Linehan 2006, Linehan 2015, Marasinghe 2012, McAuliffe 2014, McMain 2009, McMain 2017, McLeavey 1994, Morgan 1993, Morthorst 2012, Mouaffak 2015, Mousavi 2015, Mousavi 2017, Naidoo 2014, O’Connor 2015, O’Connor 2017 , O’Connor 2020, Owens 2020 , Patsiokas 1985, Priebe 2012 , Sahin 2018, Salkovskis 1990, Slee 2008, Sreedaran 2020, Stewart 2009, Tapolaa 2010, Torhorst 1987, Torhorst 1988, Turner 2000, Tyrer 2003 , Vaiva 2006, Vaiva 2018, Van der Sande 1997, Van Heeringen 1995, Walton 2020, Wang 2016, Waterhouse 1990, Wei 2013, Weinberg 2006, Welu 1977), and 17 studies were from the review investigating pharmacological and psychosocial interventions for children (Asarnow 2017, Cooney 2010, Cotgrove 1995, Cottrell 2018 , Donaldson 2005, Green 2011 , Griffiths 2019, Harrington 1998 , Hazell 2009, McCauley 2018, Mehlum 2014, Ougrin 2011, Rossouw 2012, Santamarina-Pérez 2020, Sinyor 2020, Spirito 2002, Wood 2001a). These reviews were used for recommendation making by the committee, as they were considered sufficiently relevant, high quality and up to date.

The Cochrane reviews are summarised in Table 2 , however full details of the Cochrane reviews including methods are available in the review of Psychosocial interventions for self-harm in adults and the review of Interventions for self-harm in children and adolescents .

See the Cochrane reviews for the literature search strategies for the adults review and the CYP review , study selection flow charts for the adults review and the CYP review , forest plots in the adults review and the CYP review and summary of findings tables for the adults review and the CYP review .

Excluded studies

See the lists of excluded studies in the Cochrane adults review and the CYP review with reasons for their exclusions.

Summary of included studies

Summaries of the studies that were included in this review are presented in Table 2 .

Summary of included studies.

See the Cochrane adults review and CYP review for characteristics of studies tables.

Summary of the evidence

Comparison 1.1: Individual-based CBT-based psychotherapy versus TAU or another comparator. This intervention was more effective for ‘repetition of self-harm’ at post-intervention (low certainty of the evidence according to GRADE criteria), as well as at 6, 12, and 24-month follow-up, and for ‘frequency of self-harm repetition’ by the 6 and 12-month assessments. CBT-based psychotherapy had no effect on ‘frequency of self-harm repetition’ by the post-intervention assessment, nor on ‘time to self-harm repetition’.
Comparison 1.2: Group-based CBT-based psychotherapy versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ at post-intervention (moderate certainty of the evidence according to GRADE criteria), nor by the 6 or 12-month assessment, and no evidence of effect on ‘frequency of self-harm repetition’ by the 12-month assessment.
Comparison 2.1: Standard DBT versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ at post-intervention (very low certainty of the evidence according to GRADE criteria), nor by the 12-month assessment. DBT was more effective for ‘frequency of self-harm repetition’ by the post-intervention assessment, but there was no evidence of effect by the 6-month assessment,
Comparison 2.2: DBT group-based skills training versus TAU or another comparator. There was no evidence of effect for this intervention only compared to standard DBT for ‘suicide reattempts’ or ‘NSSI’ at post-intervention (moderate certainty of the evidence according to GRADE criteria), nor by the 12-month assessment, and no evidence of effect on ‘frequency of suicide reattempts’ or ‘frequency of episodes of NSSI’ at the post-intervention or 12-month assessments, nor on ‘time to first suicide attempt’.
Comparison 2.3: DBT individual therapy versus TAU or another comparator. There was no evidence of effect for this intervention only compared to standard DBT for ‘suicide reattempts’ or ‘NSSI’ at post-intervention (moderate certainty of the evidence according to GRADE criteria), nor by the 12-month assessment, and no evidence of effect on ‘frequency of suicide reattempts’ or ‘frequency of episodes of NSSI’ at the post-intervention or 12-month assessments, nor on ‘time to first suicide attempt’.
Comparison 2.4: DBT prolonged exposure protocol versus TAU or another comparator. There was no evidence of effect for this intervention compared to standard DBT for ‘repetition of self-harm’ at post-intervention (moderate certainty of the evidence according to GRADE criteria), nor by the 6-month assessment, and no evidence of effect on ‘frequency of self-harm repetition’ at the post-intervention or 6-month assessments.
Comparison 3: MBT versus TAU or another comparator. This intervention was more effective for ‘repetition of self-harm’ by the conclusion of the 18-month treatment period (high certainty of the evidence according to GRADE criteria), and for ‘frequency of self-harm repetition’ by the post-intervention assessment.
Comparison 4: Emotion-regulation psychotherapy versus TAU or another comparator. This intervention was more effective for ‘repetition of self-harm’ by the post-intervention assessment (moderate certainty of the evidence according to GRADE criteria), but there was no evidence of effect on ‘frequency of self-harm repetition’ by the post-intervention assessment.
Comparison 5: Psychodynamic psychotherapy versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the post-intervention assessment (moderate certainty of the evidence according to GRADE criteria). Psychodynamic psychotherapy was more effective for ‘time to repetition of self-harm’.
Comparison 6: Case management versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the post-intervention assessment (low certainty of the evidence according to GRADE criteria), nor by the 12-month assessment. There were conflicting data about the effectiveness of case management for ‘time to self-harm repetition’.
Comparison 7: Structured GP follow-up versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the post-intervention assessment, either according to hospital records or emergency medical records (low certainty of the evidence according to GRADE criteria).Structured GP follow-up was less effective for ‘episodes of self-poisoning’ by the post-intervention assessment, but there was no evidence of effect on ‘episodes of self-cutting’ or ‘other methods of self-harm’ by the post-intervention assessment.
Comparison 8.1: Brief Collaborative Assessment and Management of Suicidality (CAMS)-based intervention versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the 12-month assessment, nor for ‘frequency of self-harm repetition’ by the 12-month assessment.
Comparison 8.2: Brief guided Integrated Motivational-Volitional-focused intervention versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the 6-month assessment, nor for ‘frequency of self-harm repetition’ by the 6-month assessment or ‘time to self-harm repetition’.
Comparison 8.3: Brief self-guided Integrated Motivational-Volitional-focused intervention versus TAU or another comparator. Data on frequency of self-harm could not be disaggregated from data on frequency of suicidal ideation and therefore could not be included in the review.
Comparison 8.4: Brief alcohol-focused intervention versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the 6-month assessment.
Comparison 9.1: Emergency cards versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the post-intervention assessment (low certainty of the evidence according to GRADE criteria), nor by the 12-month assessment, and no evidence of effect on ‘frequency of self-harm repetition’ by the 12-month assessment, nor on ‘time to self-harm repetition’.
Comparison 9.2: Coping cards versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the post-intervention assessment (moderate certainty of the evidence according to GRADE criteria). Coping cards were more effective for ‘time to self-harm repetition’.
Comparison 9.3: GP letters versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the 12-month assessment, nor for ‘time to self-harm repetition’.
Comparison 9.4: Postcards versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the post-intervention assessment (very low certainty of the evidence according to GRADE criteria), nor by the 12-month assessment, and no evidence of effect for ‘frequency of self-harm repetition’ by the post-intervention or 12-month assessments.
Comparison 9.5: Telephone contact versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the post-intervention assessment (low certainty of the evidence according to GRADE criteria), nor by the 12 or 24-month assessment, and no evidence of effect for ‘frequency of self-harm repetition’ by the post-intervention assessment.
Comparison 9.6: Telephone contact combined with emergency cards and letters versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the post-intervention assessment (moderate certainty of the evidence according to GRADE criteria), and no evidence of effect for ‘frequency of self-harm repetition’ by the post-intervention assessment, nor for ‘time to self-harm repetition’.
Comparison 9.7: Telephone-based psychotherapy versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the post-intervention assessment (low certainty of the evidence according to GRADE criteria), nor by the 6 and 12-month assessments.
Comparison 10: Provision of information and support versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the 12-month post-intervention assessment (very low certainty of the evidence according to GRADE criteria). Provision of information and support was less effective for ‘frequency of self-harm repetition’ by the 6-month assessment.
Comparison 11: Other multimodal interventions versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the post-intervention assessment (very low certainty of the evidence according to GRADE criteria), nor for ‘time to self-harm repetition’. Provision of information and support was more effective for ‘frequency of self-harm repetition’ at the post-intervention assessment.
Comparison 12.1: Continuity of care by the same therapist versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the 12-month assessment.
Comparison 12.2: Interpersonal problem-solving therapy versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the 12-month assessment.
Comparison 12.3: Behaviour therapy versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the 24-month assessment.
Comparison 12.4: Intensive in- and outpatient treatment versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the 12-month assessment, nor on ‘frequency of self-harm repetition’ or ‘time to self-harm repetition’.
Comparison 12.5: General hospital management versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the post-intervention assessment (moderate certainty of the evidence according to GRADE criteria), nor by the 4-month assessment,
Comparison 12.6: Intensive outpatient treatment versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the 4 or 24-month assessment, nor on ‘frequency of self-harm repetition’.
Comparison 12.7: Home-based psychotherapy and telephone contact versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the 12-month assessment.
Comparison 12.8: Long-term therapy versus TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the post-intervention assessment (low certainty of the evidence according to GRADE criteria).
Comparison 1: Individual CBT-based psychotherapy (for example CBT, PST) compared to TAU or other comparator. There was no evidence of effect for this intervention compared to alternative psychotherapy for ‘repetition of self-harm’ at post-intervention (low certainty of the evidence according to GRADE criteria).
Comparison 2: DBT-A compared to TAU or another comparator. This intervention was more effective for ‘repetition of self-harm’ at post-intervention (high certainty of the evidence according to GRADE criteria), but there was no evidence of effect by the 12-month assessment when compared to alternative psychotherapy, nor for ‘frequency of self-harm repetition’ by the post-intervention or 12-month assessments.
Comparison 3: MBT-A compared to TAU or another comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ at post-intervention (very low certainty of the evidence according to GRADE criteria), nor by the 6-month assessment.
Comparison 4: Group-based psychotherapy versus TAU or other comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the 12 or 24-month assessments.
Comparison 5: Enhanced assessment approaches versus TAU or other comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the 6 or 12-month assessments.
Comparison 6: Compliance enhancement approaches versus TAU or other comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ by the 6-month assessment.
Comparison 7: Family interventions compared to TAU or other comparator. There was no evidence of effect for this intervention for ‘repetition of self-harm’ at post-intervention (moderate certainty of the evidence according to GRADE criteria), nor by the 18-month assessment, and no evidence of effect for ‘time to self-harm repetition’ by the post-intervention or 18-month assessments.
Comparison 8: Remote contact interventions versus TAU or other comparator. There was no evidence of effect for emergency cards for ‘repetition of self-harm’ by the 12-month assessment.

See the Cochrane adults review and the CYP review for summary of findings tables and full results, including all primary and secondary outcomes and sub-group analyses.

Economic evidence

A single economic search was undertaken for all topics included in the scope of this guideline. Nine economic studies were identified which were relevant to this question. Of the studies, 4 evaluated psychosocial interventions for adults ( Byford 2003 , O’Connor 2017 , Owens 2020 , and Priebe 2012 ), and 5 studies evaluated psychosocial interventions for CYP ( Byford 1999 , Cottrell 2018 , Green 2011 , Haga 2018 , Wijana 2021 ).

See the literature search strategy in appendix B and economic study selection flow chart in appendix G .

Economic studies not included in the guideline economic literature review are listed, and reasons for their exclusion are provided in appendix J .

Summary of included economic evidence

One UK study ( Byford 2003 ) on the cost-effectiveness and cost-utility of manual-assisted cognitive behaviour therapy (CBT-MACT) versus TAU alone.
One UK study ( O’Connor 2017 ) on the cost-effectiveness of a brief psychological intervention (volitional help-sheet) combined with TAU versus TAU alone.
One UK study ( Owens 2020 ) on the cost-utility of problem solving therapy combined with TAU versus TAU alone.
One UK study ( Priebe 2012 ) on the cost-effectiveness of dialectical behaviour therapy (DBT) versus TAU.

See the economic evidence tables in appendix H . See Table 3 to Table 6 for the economic evidence profiles of the included studies.

One UK study ( Byford 1999 ) on the cost-effectiveness of a social work intervention combined with TAU versus TAU alone.
One UK study ( Cottrell 2018 ) on the cost-utility of family therapy (FT) versus TAU.
One UK study ( Green 2011 ) on the cost-effectiveness of a manual-based developmental group psychotherapy programme combined with TAU versus TAU alone.
One study from Norway ( Haga 2018 ) on the cost-effectiveness of DBT for adolescents versus enhanced usual care.

One further study was identified as eligible for the review ( Wijana 2021 ). However, this study was characterised by very serious limitations and it has not been considered in decision making.

See the economic evidence tables in appendix H . See Table 7 to Table 10 for the economic evidence profiles of the included studies.

Economic evidence profiles for adults who have self-harmed

Economic evidence profiles for cognitive behaviour therapy in adults who have self-harmed.

Economic evidence profile for volitional help-sheet in adults who have self-harmed.

Economic evidence profile for problem solving therapy in adults who have self-harmed.

Economic evidence profile for dialectical behaviour therapy for adults who have self-harmed.

Economic evidence profiles for children and young people who have self-harmed

Economic evidence profile for social work intervention in children and young people who have self-harmed.

Economic evidence profile for family therapy in children and young people who have self-harmed.

Economic evidence profile for manual-based developmental group psychotherapy programmes in children and young people who have self-harmed.

Economic evidence profiles for dialectical behaviour therapy in children and young people who have self-harmed.

Economic model

Two cost-utility analyses were developed to assist the committee decision making in this area of the guideline, as the available economic evidence assessed a limited number of interventions, was often inconclusive or not applicable to the NICE decision-making context. Moreover, existing economic evidence was based on single studies, whereas the guideline was informed by systematic reviews and meta-analyses of RCTs of psychological and psychosocial therapies for children and adults who have self-harmed. One economic analysis aimed to evaluate the relative cost-effectiveness of CBT-informed psychological intervention in addition to TAU versus TAU alone for adults who self-harm; the other economic analysis aimed to evaluate the cost-effectiveness of DBT-A relative to enhanced TAU for children who self-harm. Both interventions were shown to be effective following meta-analyses of RCTs ( Witt 2021a , Witt 2021b ). This section provides a summary of the methods employed and the results of the economic analyses. See appendix I for full details.

Each economic analysis utilised a hybrid model, comprising a 6-month decision-tree, followed by a 3-state Markov model (repeat self-harm - RSH, noRSH and death) that lasted 4.5 years. The time horizon of each model was 5 years. This period was considered to be long enough to capture longer-term costs and effects of treatment, without significant extrapolation over the course of RSH. Both analyses adopted the perspective of the NHS and personal social services (PSS), and used the QALY as the measure of outcome. For both analyses, costs consisted of intervention costs and costs of health and social care services incurred by adults or children who have self-harmed, as relevant. The cost year was 2020.

Efficacy data were obtained from the two Cochrane reviews and meta-analyses that informed this area of the guideline ( Witt 2021a , Witt 2021b ). Other clinical data were obtained from cohort studies or RCTs conducted in the UK. Utility data were based on published evidence. Resource use data relating to the delivery of the interventions were based on the trials included in the meta-analyses that informed the guideline economic models, supplemented by the committee’s expert advice, so that resource use reflects optimal routine practice in the UK. Other health and social care costs incurred by people who have self-harmed were taken from cohort studies or RCTs conducted in the UK. National unit costs were used. Model input parameters were synthesised in a probabilistic analysis. This approach allowed more comprehensive consideration of the uncertainty characterising the input parameters and captured the non-linearity characterising the economic model structure. A number of deterministic sensitivity analyses were also carried out. Results were expressed in the form of incremental cost-effectiveness ratios (ICERs).

According to the base-case results of the cost-utility analysis concerning CBT-informed psychological intervention for adults who self-harm, the ICER of CBT-based psychotherapy added to TAU versus TAU was £9,088/QALY, which is below the lower NICE threshold of £20,000 per QALY. Alternative scenarios tested included increased intensity in the delivery of the CBT-based psychotherapy, different unit costs of health professionals delivering the intervention, alternative utility data, changes in the health and social care costs incurred by adults who self-harm, and changes in the baseline risk of RSH. Delivery of the CBT-informed psychological intervention remained likely to be cost effective in adults who self-harm in most scenarios tested, suggesting confidence in the model’s results.

According to the base-case results of the economic model on the cost-effectiveness of DBT-A versus enhanced TAU for children and young people at risk of RSH, the ICER for DBT-A versus enhanced TAU was £268,601/QALY, which is well above the lower NICE threshold of £20,000 per QALY; therefore, DBT-A is not a cost-effective psychological therapy compared to the enhanced TAU. A number of alternative scenarios were explored, such as a different delivery mode of DBT-A, different unit costs of health professionals delivering the intervention, changes in utility data, as well as changes in the baseline risks of RSH or 26 intervention cost of DBT-A or health and social care costs incurred by children and young people at risk of RSH that would be required in order for the intervention to become cost-effective. Delivery of DBT-A remained unlikely to be cost effective in children and young people who are at risk of RHS under most plausible scenarios, suggesting confidence around models’ results when model assumptions varied. The only plausible (although highly unlikely in the general population of children and young people at risk of RSH) change in input parameters that would make DBT-A cost-effective was when the baseline risk of self-harm repetition was at least 69%, which would be reflecting the healthcare circumstances and needs of a particular sub-group of CYP who RSH, such as those CYP at very high risk of self-harm recurrence over time, such as CYP with significant emotional dysregulations who have frequent episodes of self-harm.

Evidence statements

Psychological and psychosocial interventions for adults who have self-harmed.

Evidence from the guideline cost-utility analysis suggests that CBT-informed psychological intervention for adults who have self-harmed is likely to be cost-effective when added to TAU versus TAU alone from a UK NHS and personal social services perspective. The economic analysis is directly applicable to the NICE decision-making context and is characterised by minor limitations.
Evidence from a cost-utility analysis conducted alongside a RCT ( Byford 2003 , N=397) suggests that a manual-assisted cognitive behaviour therapy (MACT) is likely to be cost-effective compared with TAU in adults who have self-harmed in the UK. The study is directly applicable to the UK but has potentially serious limitations.
Evidence from a cost-effectiveness analysis conducted alongside a RCT ( O’Connor 2017 , N=518) suggests that brief psychological intervention (a volitional help-sheet) combined with TAU is likely to be cost-effective compared with TAU alone in adults who have self-harmed in the UK, as it was found to be more effective and less costly than TAU alone at 6 months follow-up. The study is directly applicable to the UK and has minor limitations.
Evidence from a cost-utility analysis conducted alongside a RCT ( Owens 2020 , N=62) suggests that cognitive behaviour based-psychotherapy (problem-solving therapy) added onto TAU is likely to be cost-effective compared with TAU alone in adults who have self-harmed in the UK, as it was found to be more effective and less costly than TAU alone. The study is directly applicable to the UK but has potentially serious limitations.
Evidence from a cost-effectiveness analysis conducted alongside a RCT ( Priebe 2012 , N=80) was inconclusive regarding the cost-effectiveness of dialectical behaviour therapy (DBT) compared with TAU in adults with borderline personality disorder who have self-harmed in the UK. This is because DBT was found to be more effective and more costly than TAU, but no QALYs were estimated and therefore a judgement needs to be made on whether the extra benefit is worth the extra cost. The study is partially applicable to the NICE decision-making context and is characterised by potentially serious limitations.

Psychological and psychosocial interventions for CYP who have self-harmed

Evidence from a cost-effectiveness analysis conducted alongside a RCT ( Byford 1999 , N=162) suggests that a home-based social work intervention may be potentially cost-effective compared with TAU in CYP who have self-harmed in the UK, as no statistically significant differences in costs or outcomes were found between the two interventions, however, costs were slightly lower for the intervention compared with TAU. The study is directly applicable to the NICE decision-making context but is characterised by potentially serious limitations.
Evidence from a cost-utility analysis conducted alongside a RCT ( Cottrell 2018 , N=832) suggests that family therapy is unlikely to be cost-effective compared with enhanced TAU in CYP referred to CAMHS (children and adolescent mental health services) after self-harm in the UK over 18 months, but may become cost-effective over 5 years. The study is directly applicable to the UK and is characterised by minor limitations.
Evidence from a cost-effectiveness analysis conducted alongside a RCT ( Green 2011 , N=364) is inconclusive regarding the cost-effectiveness of a manual-based developmental group psychotherapy programme combined with TAU versus TAU alone in CYP referred to CAMHS (children and adolescent mental health services) after self-harm in the UK. This is because the intervention was found to be more effective and more costly than TAU, but no QALYs were estimated and therefore a judgement needs to be made on whether the extra benefit is worth the extra cost. The study is partially applicable to the NICE decision-making context because, although it was conducted in the UK, no QALYs were estimated, and is characterised by minor limitations.
Evidence from the guideline cost-utility analysis suggests that dialectical behavioural therapy (DBT-A) for CYP who have self-harmed is not cost-effective from a NHS and personal social services perspective, compared to enhanced TAU. The economic analysis is directly applicable to the UK and is characterised by minor limitations.
Evidence from a cost-effectiveness analysis carried out alongside a RCT ( Haga 2018 , N=77) from Norway suggests that dialectical behaviour therapy for adolescents (DBT-A) is cost-effective compared with enhanced TAU in CYP who self-harmed, mostly people with borderline personality disorder, in Norway, as it is more effective and less costly than enhanced TAU. The study is partially applicable to the UK and is characterised by potentially serious limitations.

The committee’s discussion and interpretation of the evidence

The outcomes that matter most.

The Cochrane protocols’ primary outcome was occurrence of repeated self-harm within a maximum follow-up period of 2 years, which the committee agreed is critical as it is a direct measure of any differential effectiveness associated with the psychosocial intervention. All other outcomes listed in the Cochrane protocol (treatment adherence; depression; hopelessness; general functioning; social functioning; suicidal ideation; suicide) were agreed to be important outcomes by the committee. The committee agreed that treatment adherence would indicate the patient’s satisfaction with the intervention and ultimately determine its success. Depression, hopelessness, and suicidal ideation were agreed to be important outcomes as they are measures of well-being which may capture long-term health-related outcomes associated with the effectiveness of interventions. The committee agreed that general functioning and social functioning were also important as measures of how successful the intervention is at reducing the impact of self-harm on the person’s day-to-day life and ability to build and maintain relationships. Suicide was also agreed by the committee to be a direct measure of any differential effectiveness associated with the pharmacological intervention.

The quality of the evidence

When Cochrane assessed the evidence using GRADE methodology it was found to range from high to very low quality, with most of the evidence being moderate or low quality. Where evidence was downgraded it was mainly due to imprecision of the effect size (where the 95% confidence intervals for the pooled effect included the null value), risk of bias as per Cochrane RoB 2.0 (due to bias in the randomisation process, deviations from the intended interventions, missing outcome data, measurement of the outcome, and/ or selection of the reported results), and in some cases, significant heterogeneity between studies as indicated by the I2 value. In 1 case, evidence was downgraded due to suspicion of publication bias.

The committee discussed the evidence presented by Cochrane which showed that although the evidence base remained somewhat uncertain regarding the effectiveness of most psychological and psychosocial interventions with regards to self-harm repetition in both adults and CYP, there was limited emerging evidence of low and high quality respectively which showed individual cognitive behavioural therapy (CBT) and dialectic behavioural therapy for adolescents (DBT-A) had positive effects on repetition of self-harm in their respective cohorts.

There was evidence about the effectiveness of a number of longer term and brief psychological interventions but it was unclear whether they were effective for key populations (such as men or people who repeatedly self-harm). The committee made a research recommendation on the effectiveness of psychological interventions in these populations.

Benefits and harms

The committee agreed, based on their knowledge and experience, that all treatment should be planned according to the psychosocial assessment, as assessment can indicate the suitability of potential treatments. The committee also discussed the fact that self-harm is often associated with coexisting conditions such as depression or anxiety, and agreed that planning treatment for self-harm in isolation of these other factors could lead to an inappropriate care pathway, or a lowered chance of recovery. The committee discussed the various coexisting conditions that are frequently associated with self-harm, and agreed there were a number of NICE guidelines that clinicians should be aware of, so they can understand when a patient may have coexisting conditions and how these might interact with self-harm. This would allow clinicians to appropriately plan treatment for patients according to their overall needs and not any one factor in isolation, prioritising any coexisting conditions to ensure the most appropriate intervention is provided for the individual and to promote person-centred care.

The committee agreed that overall, the evidence showed a beneficial effect of psychological and psychosocial therapies on various outcomes and therefore psychological or psychosocial therapy generally should be recommended for children and adults who have self-harmed. In particular, for adults there was evidence from 20 trials that showed psychological interventions informed by CBT had positive effects on repetition of self-harm at longer follow-up assessments, as well as small beneficial effects on depression, hopelessness, and suicidal ideation over time. However, the committee acknowledged that the evidence from the Cochrane review was flawed due to the wide interpretation of ‘CBT-based psychotherapies’ which included therapeutic elements not necessarily typical to CBT, such as problem-solving therapy. The categorisation of all interventions throughout the evidence review was indistinct with some of the comparisons including therapies which overlapped across different interventions. However, the evidence did show a potential benefit of psychological interventions which were structured, person-centred, time-limited, and informed by cognitive behavioural therapy. The recommendation that a CBT-informed psychological intervention should be offered to people who self-harm was therefore based on the evidence that this had a positive effect on reducing repeat self-harm at long-term follow-up. The committee agreed other treatment modalities might be effective in adults who have self-harmed as long as they meet these principles. The committee discussed the evidence from the qualitative review on involving families and carers in management of self-harm (Evidence Report D) which showed that long waiting times for treatment was often a barrier to help-seeking, and agreed based on this evidence as well as their own experience that treatment should be offered as soon as possible to people who had self-harmed. The committee discussed whether the specific period of within 72 hours of assessment should be recommended, but ultimately agreed that without specific evidence, and based on their knowledge that it can be unfeasible to start longer term treatment within that timeframe, the timeframe should be nonspecific. However, the committee still wanted to acknowledge the potential negative effects of delaying treatment on repeat self-harm and suicide based on their knowledge and experience, and therefore agreed on the recommendation that treatment should start without delay. The recommendation regarding the number of sessions was based on the committee’s discussion of the cost-effectiveness evidence, as outlined below, however the committee agreed it was important to highlight the fact that some people may need more than 10 sessions, to ensure people receive the person-centred care they need and to enhance their experience of services. Additionally, any psychological or psychosocial interventions should be tailored to the individual’s needs and preferences, based on the committee’s knowledge and experience that enabling service users to make informed decisions about and have input on their own care has a beneficial effect on the person’s satisfaction and likelihood to engage with services.

There were limited data from 1 trial which showed mentalisation-based therapy (MBT) had positive effects on absolute repetition of self-harm and frequency of self-harm at post-intervention, while data from 2 trials showed emotion-regulation psychotherapy in a group setting also had positive effects on absolute repetition of self-harm at post-intervention specifically for women diagnosed with borderline personality disorder. The evidence of effects for standard dialectical behaviour therapy (DBT) on frequency of self-harm repetition in adults was uncertain. Finally, there was no evidence of an effect of self-harm repetition for remote contact interventions, case management, information and support, and other multimodal interventions. The committee agreed that the evidence allowed them to make recommendations for CBT-informed psychological interventions, however on the basis of such an uncertain evidence base for MBT, emotion-regulation psychotherapy and DBT, the committee could not make specific recommendations for these interventions for adults.

For children and young people, there was high-certainty evidence from 4 trials that DBT-A had a positive effect on repetition of self-harm in adolescents at post-intervention but an uncertain evidence base for other therapies: Cochrane reported low-certainty evidence regarding whether CBT had a positive effect on repetition of self-harm at post-intervention; very low-certainty evidence regarding whether MBT-A had a positive effect on repetition of self-harm at post-intervention; no evidence of effect on repetition of self-harm at post-intervention for family therapy; no evidence of effect on repetition of self-harm for compliance enhancement approaches, group-based psychotherapy, a remote contact intervention (emergency cards), or for therapeutic assessment. The committee agreed that the evidence for DBT-A allowed them to make recommendations for this therapy, however the committee could not make specific recommendations for any other therapies on the basis of such an uncertain evidence base. Therefore, the recommendation to consider offering DBT-A to children and young people was based on the evidence showing DBT-A has a positive effect on reduced repetition of self-harm in adolescents. However, the committee agreed they could not make a strong recommendation because the evidence was limited by the fact that participants in studies which showed this effect had all self-harmed more than once, were all between the ages of 12 and 18 years and were mostly female, and there was no evidence of effect of DBT-A on repeat self-harm by 12-month follow-up. The committee discussed whether the evidence could be extrapolated to children under the age of 12 and agreed, based on their knowledge and expertise, that DBT-A was likely to be similarly effective in children due to the fact that DBT-A would be carried out by very specialised staff members for children under the age of 12. The committee agreed that the lack of evidence of for children under 12 years was likely to be more reflective of the small trial sizes and nature of the sample rather than representative of the effect of DBT-A on this age group. Additionally, there was no evidence showing potential harms of DBT-A for adolescents, and the committee agreed offering DBT-A to children under 12 carried similarly low risk of harm. On the other hand, the committee agreed that not providing a therapeutic intervention to children under the age of 12 could allow for self-harm to become a coping mechanism, or otherwise repeated behaviour in the patient. They therefore agreed that DBT-A should be recommended for both children and young people despite the lack of evidence for children, to reduce the rates of repeat self-harm and suicide in this age group. However, the committee agreed they could not be sure that DBT-A would be similarly effective for children and young people who did not frequently self-harm, so they could not extrapolate the evidence any further to other populations. The recommendation was also based on the committee’s discussion of the cost-effectiveness evidence, as outlined below, however there was insufficient evidence for the committee to define how frequent self-harm would have to be to determine whether the person should receive DBT-A. The committee also agreed they could not further define how DBT-A should be provided as per the recommendation for CBT, due to the lack of robustness in the evidence base.

The committee acknowledged the weak evidence base meant that interventions other than CBT-informed psychological interventions for adults or DBT-A for children and young people might be appropriate depending on the results of the person’s psychosocial assessment. They agreed the recommendation to plan treatment according to the person’s assessment and any coexisting comorbidities would ensure this was taken into consideration to ensure the person received the right intervention for them.

The committee agreed that any therapy offered should be delivered by staff with training in the relevant therapy and who are receiving appropriate supervision, to ensure the competence of the professional delivering the training allows for the needs of the person to be met and for the treatment to be tailored for people who self-harm. The committee agreed further limitations on which staff could deliver therapies were unnecessary and could result in implementation difficulties and delays in treatment provision.

The committee agreed that any intervention should be delivered in a collaborative way with the individual and should focus on the positive effects of therapies, based on their knowledge that a strength-based approach would have the effect of finding solutions rather than focusing on potential problems for the person.

Although safety planning was not analysed as a standalone intervention in the Cochrane psychological interventions review, the committee agreed that safety planning is an important aspect of care for people who have self-harmed that is already commonly used in current practice as an adjunct to another intervention such as CBT, based on their experience and expertise. The committee’s understanding of the importance of safety plans is supported by the qualitative evidence in the review for specialist staff skills (see Evidence Report P), in which specialist staff identified safety planning as a technique that can help people manage self-harm. The committee discussed the benefits of safety planning, which they agreed equipped people who had self-harmed with the ability to identify and use their strengths and sources of support to overcome crisis moments and prevent the thought, temptation, and accessibility of self-harm. The committee discussed whether to make a strong recommendation despite the low quality of the available evidence as assessed with GRADE CERQual, because safety planning is increasingly offered to people who have self-harmed as a part of existing practice. However, the committee agreed that a stronger recommendation for safety planning would overprivilege the evidence and imply the existence of strong data where they currently do not exist. Evidence about the benefits and harms of safety planning would be necessary to confidently make a strong recommendation. The committee agreed based on their knowledge and expertise that one of the most important aspects of safety planning was reducing lethal means access, because access to means is consistently recognised as a risk factor in suicide research. The committee thought that this should always be done in collaboration with the person to protect the individual’s autonomy and dignity in moments of crisis, which could increase service user satisfaction and lower distress. Three studies included in the Cochrane review explicitly used safety planning as a part of the intervention (Armitage 2016b; Gysin-Maillart 2016; Lin 2020); the committee considered the components of these safety-planning interventions and discussed their merits. The plans in these studies included identifying the following: long-term goals; potential crisis situations; individual warning signs; personal safety strategies (such as reinforcing positive thinking, rewarding not self-harming, seeking out social support, taking medication). The committee agreed it was important for people who had self-harmed to be able to recognise warning signs so they could proactively put their safety plan into action and prevent a potential crisis that could lead to self-harm. In order to prevent self-harm upon recognising warning signs, the committee agreed it was important for professionals to help people who have self-harmed develop coping strategies to minimise distress and lower the rates of self-harm, however the committee agreed these coping strategies should be individualised to ensure generic advice which might not be helpful for the individual is not given. The committee also agreed that consideration should be given to any potential barriers to enacting these strategies, as well as problem-solving to ensure the person is equipped to deal with these barriers as they come up. Qualitative evidence from both staff skills reviews showed that people who had self-harmed, as well as specialist and non-specialist staff, identified the ability to help patients develop coping strategies as an important skill for professionals to have. The quality of this evidence was low in the specialist review but moderate in the non-specialist review. The committee also discussed the benefits of helping people to identify social contacts and settings they could seek out in a crisis, because they agreed distraction was a useful technique that could lower the distress of the person and reduce the urge to self-harm in the moment, based on their experience. The qualitative review on support needs of people who had self-harmed (see Evidence Report A) found moderate quality evidence that people who had self-harmed identified family members and friends as important sources of emotional and/or practical support. The committee therefore recommended such contacts be identified as part of a safety plan because this support could be invaluable during a crisis to prevent self-harm. The committee discussed the fact that participants in the Gysin-Maillart study were given crisis cards with contact details for private and professional helpers who could be contacted in case of a crisis, and agreed that safety plans should include contact details for these services so the person can access spontaneous support and care in a crisis. In particular, the committee agreed that out-of-hours services were important based on their knowledge that often people need help in the evenings or at night when some services may not be accessible, rendering them useless to people who need them. Furthermore, the committee agreed that there were situations where a person might need to talk to services without it being an emergency, and added that these services should available to people regardless of their levels of distress/state of emergency. They agreed this would help prevent self-harm proactively rather than waiting until the person was in crisis.

The process of safety planning was seen as a therapeutic element in itself by the committee as their experience showed it had the benefits of allowing the person to feel listened to, understood, and validated. All three studies in the Cochrane review that explicitly used safety planning as a part of the intervention implemented collaborative decision-making with the person, which the committee agreed would improve the patient’s engagement with services based on their knowledge and expertise. The committee discussed how the safety plan should be provided to the person and agreed that the person should have a copy of the plan to hold, as this would emphasise the collaborative aspect of the safety plan and allow it to be more accessible to the person in a crisis. If the safety plan is not accessible, the committee agreed based on their knowledge and expertise that this would reduce its efficacy, especially if the person was too distressed to remember their plan. This could defeat the purpose of the safety plan and lead to repeat self-harm. The committee also discussed the importance of social connectedness as a protective factor against self-harm based on their expertise, and agreed that care plans should therefore be shared with family members/ carers and other professionals when appropriate.

The committee discussed their concern that the avoidance of offering appropriate psychological or psychosocial interventions based on availability or resource implication could have a significant harmful effect on the people who had self-harmed for whom these therapies should normally be offered. They also discussed the fact that some people do not receive appropriate interventions in current practice based on their demographic or certain comorbidities such as a diagnosis of borderline personality disorder. The committee agreed that such interventions should always be available to all people who have self-harmed, based on their expertise that this can reduce the likelihood of services not being offered to people who need them, in turn potentially reducing the rates of repeat self-harm or suicide.

Cost effectiveness and resource use

The committee noted that 9 relevant papers had been identified in the literature review of published economic evidence on this topic ( Byford 1999 , Byford 2003 , Cottrell 2018 , Green 2011 , Haga 2018 , O’Connor 2017 , Owens 2020 , Priebe 2012 , Wijana 2021 ); of these, Wijana 2021 was characterised by very serious limitations and was not considered further when formulating recommendations. Moreover, 2 bespoke economic analyses were undertaken for this area of the guideline.

One guideline economic analysis aimed to evaluate the relative cost-effectiveness of CBT-informed psychological intervention in addition to treatment as usual (TAU) versus TAU alone for adults who self-harm; the other guideline economic analysis aimed to evaluate the cost-effectiveness of DBT-A relative to enhanced TAU for children and young people (CYP) who self-harm. Both economic models were cost-utility analyses (CUA) that adopted the perspective of the NHS and personal social services (PSS). The committee agreed that both economic analyses are directly applicable to the NICE decision-making context and are characterised by minor limitations.

Of the 8 economic studies identified with the review of economic evidence and considered by the committee, 4 evaluated psychological and psychosocial interventions for adults ( Byford 2003 , O’Connor 2017 , Owens 2020 , and Priebe 2012 ), and 4 studies evaluated psychological and psychosocial interventions for CYP ( Byford 1999 , Cottrell 2018 , Green 2011 , and Haga 2018 ). The committee considered this economic evidence to be directly relevant to the guideline’s decision-making, with the exception of three studies ( Green 2011 , Haga 2018 , and Priebe 2012 ), because they either were conducted outside the UK, or they did not use the QALY as the measure of outcome and therefore assessment of the cost-effectiveness of interventions was not straightforward. Most studies included in the review were cost-effectiveness analyses ( Byford 1999 , Green 2011 , Haga 2018 , O’Connor 2017 , Priebe 2012 ), or CUAs ( Byford 2003 , Cottrell 2018 , and Owens 2020 ). All economic evaluations included were undertaken alongside clinical trials, however, most of the studies did adopt a relatively long-term time frame to reflect the long-term costs and benefits of psychological and psychosocial interventions for people who self-harmed; the time horizon in 5 studies was > 1 year ( Byford 2003 , Cottrell 2018 , Green 2011 , Haga 2018 , and Priebe 2012 ), whereas only three studies used a time horizon shorter than 1 year ( Byford 1999 , O’Connor 2017 , and Owens 2020 ). Some of the studies were characterised by potentially serious methodological limitations ( Byford 1999 , Byford 2003 , Haga 2018 , Priebe 2012 , Owens 2020 ).

Based on the findings of the Cochrane systematic reviews on interventions for adults and CYP who self-harmed, the committee considered CBT-informed psychological intervention for adults and DBT-A for CYP as potential candidates for recommendation, as these were the only interventions with adequate evidence suggesting these are effective. Hence, these interventions were prioritised for economic modelling.

The committee agreed that overall, according to the findings of the economic analysis, the CBT-informed psychological intervention is likely to be cost-effective in the treatment of adults who self-harm. The committee noted that the results of the economic analysis indicated that a CBT-informed psychological intervention was cost-effective if it was delivered in up to 10 sessions, after examining a number of alternative scenarios in sensitivity analysis. However, use of alternative utility data (that suggested narrower gains in utility following a reduction in self-harming behaviour) in combination with 8–10 sessions or with a lower excess NHS cost for people who repeat self-harm within 6 months relative to those who don’t resulted in the intervention becoming not cost-effective. Nevertheless, the committee expressed the view that these analyses reflected relatively extreme scenarios regarding the data used, where a narrow range of utility values was combined with either a large number of psychological therapy sessions or with a NHS excess cost that was likely lower that the usual cost incurred by people who self-harm.

Based on the findings of the economic model and supplemented by the results of the clinical review, the committee pointed out the potential vital role of CBT-informed psychological intervention in the management of self-harm recurrence in adults who self-harm, while ensuring NHS resources are used efficiently. Therefore, they agreed to make a strong (offer) recommendation, to ensure the widespread use of CBT-informed psychological intervention for care management of adults who had self-harmed across NHS services. Based on their expertise, the results of the clinical review and the base-case and sensitivity analysis of the respective guideline economic model, they recommended that CBT-informed psychological intervention be typically delivered over a range between 4 and 10 individual sessions. The committee noted that more than 10 individual sessions of CBT-informed psychological intervention are unlikely to be cost-effective at the NICE lower cost-effectiveness threshold, nevertheless, they expressed the view that, for a minority of people who self-harm, more than 10 sessions may be essential for their improvement, and therefore decided to include in the recommendation the option of more sessions for some adults, dependent on their individual needs, in order to cover the whole population of adults who self-harm.

The committee discussed the findings of the second guideline economic analysis performed on this topic. They noted that findings suggested that DBT-A for CYP who have self-harmed is not cost-effective from a NHS and personal social services perspective, compared to enhanced TAU. Therefore, based on their expertise, the results of the clinical review and the DBT-A economic model, they recognised that recommending a typical mode of delivery of the DBT-A intervention for the whole population of CYP who self-harm was not an efficient use of resources. However, they acknowledged the important role likely to be played by DBT-A in the management of self-harm recurrence in a number of subgroups of CYP who self-harm, such as those CYP with significant emotional dysregulations who have frequent episodes of self-harm. For this reason, they agreed to make a weaker (‘consider’) recommendation to ensure that DBT-A is used for care management of CYP with significant emotional dysregulations who have frequent episodes of self-harm.

The recommendations should increase the number of people receiving psychological interventions after an episode of self-harm, and reduce the number of people denied appropriate interventions because of limited or no availability. In turn, this should reduce repeat self-harm and suicide, and improve satisfaction and engagement with services.

The committee acknowledged that the recommendations for CBT-informed psychological intervention for adults and DBT-A for CYP are likely to increase overall costs related to the provision of psychological interventions to people who self-harm, if CBT-informed psychological interventions and DBT A are offered to more service users. There is also a likely resource impact depending on how many centres do not currently offer these therapies. The committee advised that for services that do not currently offer these therapies, training and additional staffing may be needed for these interventions to be available to all eligible service users.

Recommendations supported by this evidence review

This evidence review supports recommendations 1.11.1 to 1.11.9 and research recommendation 4: the effectiveness of specific psychological interventions, including digital vs face-to face. Other evidence supporting these recommendations can be found in the evidence reviews on involving families and carers (evidence report D).

References – included studies

Effectiveness.

Byford 1999

Byford 2003

Cottrell 2018

O’Connor 2017

Priebe 2012

Wijana 2021

Harrington 1998

Mehlum 2016

Appendix A. Review protocols

Review protocol for review question: what psychological and psychosocial interventions (including safety plans and electronic health-based interventions) are effective for people who have self-harmed.

See the Cochrane review protocols for Psychosocial interventions for self-harm in adults and Interventions for self-harm in children and adolescents .

Appendix B. Literature search strategies

Literature search strategies for review question: What psychological and psychosocial interventions (including safety plans and electronic health-based interventions) are effective for people who have self-harmed? (PDF, 364K)

Appendix C. Results of the search

Results of the search for review question: what psychological and psychosocial interventions (including safety plans and electronic health-based interventions) are effective for people who have self-harmed.

See Results of the search – figure 1 from the Cochrane review of Psychosocial interventions for self-harm in adults and Results of the search – figure 1 from the Cochrane review of Interventions for self-harm in children and adolescents .

Appendix D. Characteristics of studies tables

Characteristics of studies tables for review question: what psychological and psychosocial interventions (including safety plans and electronic health-based interventions) are effective for people who have self-harmed.

See the Characteristics of included studies tables from the Cochrane review of Psychosocial interventions for self-harm in adults and the Characteristics of included studies tables from the Cochrane review of Interventions for self-harm in children and adolescents .

Appendix E. Data and analyses

Data and analyses for review question: what psychological and psychosocial interventions (including safety plans and electronic health-based interventions) are effective for people who have self-harmed.

See the Data and analyses tables from the Cochrane review of Psychosocial interventions for self-harm in adults and the Data and analyses tables from the Cochrane review of Interventions for self-harm in children and adolescents .

Appendix F. Summary of findings tables

Summary of findings tables for review question: what psychological and psychosocial interventions (including safety plans and electronic health-based interventions) are effective for people who have self-harmed.

See the Summary of findings tables from the Cochrane review of Psychosocial interventions for self-harm in adults and the Summary of findings tables from the Cochrane review of Interventions for self-harm in children and adolescents .

Appendix G. Economic evidence study selection

Study selection for review question: What psychological and psychosocial interventions (including safety plans and electronic health-based interventions) are effective for people who have self-harmed? (PDF, 23K)

Appendix H. Economic evidence tables

Economic evidence tables for review question: What psychological and psychosocial interventions (including safety plans and electronic health-based interventions) are effective for people who have self-harmed? (PDF, 413K)

Appendix I. Economic model

Economic models for review question: what psychological and psychosocial interventions (including safety plans and electronic health-based interventions) are effective for people who have self-harmed.

The committee and the guideline health economist identified the choice of psychological interventions in people who have self-harmed as an area with potentially major resource implications. Many economic evaluations in this area have been identified in the review of economic evidence for this topic. Most of this evidence was considered to have potentially serious limitations ( Byford 1999 , Byford 2003 , Owens 2020 and Priebe 2012 ), though many studies were judged of higher methodological quality ( Cottrell 2018 , Green 2011 , Haga 2018 , and O’Connor 2017 ). When discussing this evidence, the committee noted that available economic evidence assessed a limited number of interventions and was often inconclusive or not applicable to the NICE decision-making context. Moreover, existing economic evidence was based on single studies, whereas the guideline was informed by two large systematic reviews and meta-analyses of RCTs of psychological and psychosocial therapies for children and adults who have self-harmed. Therefore, 2 bespoke economics models were developed, which were informed by Cochrane systematic reviews and meta-analyses, to increase the evidence base in order to assist the committee decision making for this area of the guideline. One economic analysis aimed to evaluate the relative cost-effectiveness of cognitive behavioural therapy (CBT)-informed psychological intervention in addition to TAU versus TAU alone for adults who repeated self-harm (RSH); the other economic analysis aimed to evaluate the cost-effectiveness of dialectical behavioural therapy adapted for adolescents (DBT-A) relatively to enhanced treatment as usual (TAU) for children and young people (CYP) who RSH; both analyses were placed in the UK. The models are described below (‘ CBT-informed psychological intervention for adults who have self-harmed ’, ‘ DBT-A for children and young people who have self-harmed ’).

CBT-informed psychological intervention for adults who have self-harmed

Objective of economic modelling.

The Cochrane systematic review of clinical evidence ( Witt 2021a ) demonstrated that CBT-informed psychological intervention in addition to treatment as usual (TAU) for adults who RSH is effective in reducing the repetition of self-harm episodes when compared with TAU alone; in addition, the existing clinical evidence was deemed adequate to inform exploratory bespoke economic modelling. Based on these considerations, an economic model was developed to assess the relative cost-effectiveness of CBT-informed psychological intervention in addition to TAU versus TAU alone for adults who RSH in the UK.

Economic modelling methods

The study population of the economic model comprised adults with a hospital presentation for self-harming in the prior six months; furthermore, people included in the economic model may have repeated single or multiple self-harm episodes in the past. The age of the population at the start of the model was 29 years, in accordance with a large UK-based prospective cohort study; 56% of the model’s population were women ( Cooper 2013 , Cooper 2015 ). The starting age of the cohort and its gender composition were needed in order to estimate mortality risks in the cohort over the time horizon of the economic analysis.

Intervention

The economic analysis considered CBT-informed psychological intervention as this was the only intervention that was shown to be effective in reducing the number of future RSH episodes according to the Cochrane systematic review and meta-analysis of the clinical evidence ( Witt 2021a ). The characteristics of CBT-informed psychological intervention in terms of effectiveness and resource use (healthcare professional time, and number of sessions delivered), were determined by the findings of the Cochrane systematic review and meta-analysis that informed the review question and economic analysis, supplemented by the committee’s expert opinion.

TAU was described as treatment provided by community mental health teams (CMHT) to adults who RSH after initial hospital management. As TAU was provided in both treatment arms, it was not costed.

Scope of the economic model

The economic analysis adopted the perspective of the NHS and personal social services (PSS), as recommended by NICE ( NICE 2020 ). The measure of outcome was the Quality Adjusted Life Year (QALY), which incorporated utilities associated with repetition of self-harm health-related quality of life (HRQoL). Costs to the NHS & PSS consisted of CBT-informed psychological intervention costs (healthcare professional time and number of sessions delivered as part of intervention) and use of health and social care services (including primary care, hospital medical care, emergency department presentations, inpatient psychiatric care, outpatient psychiatric care, psychotropic prescriptions, and social care) by adults who have self-harmed. The cost year was 2020.

Model structure

Figure 2 presents a schematic diagram of the hybrid decision-analytic model developed using Microsoft Office Excel 2013; it consisted of a simple decision tree lasting 6 months incorporating Markov nodes (represented by ‘M’ in Figure 2 – Part 1), and a Markov simulation model involving 3 health states (RSH, no RSH and death), which lasted 4.5 years with a 6-month cycle Figure 2 – Part 2). A 6-month cycle was used based on data availability and committee’s advice that this is an appropriate period over which to model RSH events. A half-cycle correction was applied.

The structure of the model, which aimed to simulate the natural history of the adult self-harming population, was driven by patterns of clinical practice in the UK and the availability of relevant data sources (see section ‘ Development and validation of the economic model ’ for further details). The model estimated the total costs and effects associated with the provision of CBT-informed psychological intervention to adults who RSH. According to the model structure, hypothetical cohorts of adults who RSH were either initiated on CBT-informed psychological intervention in addition to TAU or received TAU alone. Following care received, adults either RSH, did not RSH or died, with ‘death’ taken as the absorbing state ( Figure 2 ). Due to lack of long-term comparative clinical data, transitions between the ‘RSH’ and ‘no RSH’ health states in the Markov component of the model were assumed to be independent of the intervention received at the decision-tree part of the model. The transition probability to the death state depended on the RSH status of each person in the population.

The time horizon of the analysis was 5 years. This time frame was considered to be long enough to capture longer-term costs and effects of treatment, without significant extrapolation over the course of RSH.

Figure 2. Schematic structure of the economic model assessing the cost-effectiveness of CBT-informed psychological intervention for adults who RSH (PDF, 83K)

Cost input parameters

Intervention costs.

The intervention cost of CBT-informed psychological intervention was estimated by combining resource use associated with provision of CBT-informed psychological intervention with appropriate unit costs. It was assumed that the CBT-informed psychological intervention consisted of 6 sessions, which was the average intended number of sessions reported across studies informing the Cochrane systematic review and meta-analysis of clinical evidence ( Witt 2021a ). Based on this evidence and on the committee’s advice on patterns of attendance of adult patients to CBT-informed psychological intervention’s sessions in the UK, we estimated the proportions of people attending CBT-informed psychological intervention as reported in Table 13 . By weighing the intended number of sessions with their likely attendance rates we obtained the average number of attended CBT-informed psychological intervention sessions in the model, which is 4.725 (this is the mean number of sessions likely to be provided based on the attendance rates of service users). Each CBT session was assumed to last 55 minutes and to be provided by a health professional in NHS England Agenda for Change (AfC) Band 6, usually a mental health nurse. Each CBT-informed psychological intervention session was assumed to be delivered individually and face-to-face.

Table 13. People attending CBT-informed psychological intervention sessions 1 (PDF, 131K)

A Band 6 salary pay scale was used to estimate unit cost per hour worked by a professional delivering each session
All staff delivering CBT-informed psychological intervention were assumed to be mental health nurses, in order to estimate qualification costs
An additional training in CBT-informed psychological intervention was estimated to cost £2,000 according to the committee’s expert advice
The direct to indirect time of professionals delivering CBT-informed psychological intervention based on published estimates ( Curtis and Burns 2020 ) was considered when estimating unit costs of professionals involved in delivering CBT-informed psychological intervention.

Table 14. Unit cost of qualified mental health nurses, AfC band 6 (2020 prices) (PDF, 254K)

Details on the estimation of the cost of delivering CBT-informed psychological intervention (£396) are provided in Table 15 .

Table 15. Mean cost of delivery of the CBT-informed psychological intervention (PDF, 14K)

Healthcare costs associated with repeating self-harm

The estimation of costs incurred by an adult following an episode of RSH was based on a retrospective cost analysis by Sinclair (2011) , conducted in the UK. This study followed a cohort of self-harming patients presenting to a general hospital (n=150), mostly following an episode of deliberate self-poisoning (94% of the sample), and estimated their care cost from the perspective of the NHS and social care, which was divided into 6-month cost intervals. Among the 150 participants recruited in the study, 78 service users with available resource use in each period were analysed; the mean length of time in follow-up from their first ever episode of self-harm was 10.5 years (range 2–25 years). Resources measured in the study included primary care services, emergency department services, hospital (both medical and surgical) services such as inpatient bed days, outpatient consultations, laboratory investigations, inpatient and outpatient psychiatric care, psychotropic prescriptions, social service visits and social service residential placements. The cost estimate was based on a regression analysis that reported the cost coefficient incurred by people who had self-harmed between 6 months – 1 year ago compared with people who had self-harmed within the last 6 months. This 6-month cost difference between the two population subgroups, which was reported at £1,689 in 2004/05 prices, was applied as an additional cost incurred by people who self-harmed in the past 6 months in the model relative to those who did not self-harm in the past 6 months (thus the cost of people who did not self-harm in the past 6 months in the model was zero). This estimate was inflated to 2020 price year using Hospital and Community Health Services pay and price inflator up to 2016 and the NHS Cost Inflation Index after that and up to 2020 ( Curtis and Burns 2020 ); the 2020 price was £2,134.

Clinical input parameters

Clinical input parameters consisted of effectiveness data of repetition of self-harm associated with provision of CBT-based psychotherapy in addition to TAU compared with TAU alone; the 6-month risk of RSH in people who did RSH in the previous 6 months, which is the baseline risk of RSH in the model; and the 6-month risk of RSH in people who did not RSH in the previous 6 months.

Effectiveness data

Effectiveness data consisted of the risk ratio (RR) of RSH associated with provision of CBT-informed psychological intervention plus TAU to TAU alone. Data were derived from the Cochrane systematic review and meta-analysis of clinical evidence ( Witt 2021a ), which included 12 RCTs assessing the effectiveness of CBT-informed psychological intervention plus TAU relative to TAU alone in adults presenting to services following an episode of RSH, at 6 months follow-up.

By the six-month follow-up assessment, there was evidence of an effect for CBT-informed psychological intervention on repetition of self-harm (Odds Ratios [OR]: 0.52, 95% CI 0.38 to 0.70). Using the raw data, we estimated a RR of 0.66 (95% CI 0.53 to 0.82) ( Figure 3 ), which we subsequently combined with the absolute effect of TAU, in order to estimate the absolute effect of CBT-informed psychological intervention plus TAU.

Figure 3. Forest plot for CBT-informed psychological intervention plus TAU versus TAU for treatment of RSH in adults: risk ratio at 6 months follow-up. (PDF, 143K)

Other clinical data

The risk of self-harm repetition under TAU in people who had self-harmed within 6 months was estimated using data from Lilley 2008 . This UK-based prospective cohort study followed people who attended emergency departments following self-harm (n=7,344 aged 12 years or older) over 18-months and recorded episodes of repeat self-harm. Besides the overall rates of self-harm repetition, the study investigated the differences in repetition rate according to the method of self-harm used on the index episode, and the time from the index episode during the study.

During the study period, 10,498 visits to emergency department because of self-harm were reported. The study provided Kaplan–Meier curves, calculated using recurrent event analysis (where each repeat episode was treated as an index episode). The respective graph provided cumulative proportions of adults repeating self-harm at different time points over time. Using these data, it was possible to estimate the risk of RSH 6 months after the index episode, and also the risk of RSH between 6–12 months from the index episode. Data from the provided graph were extracted using appropriate software ( https://www.digitizeit.xyz/ ).

The risk of repeating self-harm after 6 months from a self-harm episode, as estimated from Lilley 2008 , was 0.288; this value was confirmed by the committee to be an accurate approximation of the 6-month risk of RSH in people who have self-harmed under TAU (baseline risk). This risk was used in the model twice: 1) as the baseline risk of RSH for people under TAU in the decision tree component; 2) as the 6-month transition probability in the Markov model component, for people who remain in the RSH state (that is, people who are already in the RSH state in the previous model cycle). The estimated risk of RSH between 6–12 months from the index episode in Lilley 2008 (that is, in people who did not RSH in the first 6 months after the index episode) was used to estimate the 6-month transition probability for people who move to the RSH state from the non-RSH state in the Markov model component; the estimated value was 0.074. This value was also validated by the committee. Based on Lilley 2008 , the estimated risk of RSH between 12–18 months from the indext episode was 0.058, suggesting a decrease in the risk over time. This difference in the risk for people who have not self-harmed for at least 6 months (0.074) versus the risk in those who have not self-harmed for at least 12 months (0.058) was considered to be too small to have any impact on the model findings and therefore, for simplicity, it was decided to use the higher figure of 0.074 for people who have not self-harmed in the last 6 months as a conservative higher estimate.

6-month transition probability of moving to the RSH state from the non-RSH state (that is, people who have not RSH in the last 6 months, in the previous model cycle): 0.074
6-month transition probability of remaining in the RSH state (that is, people who had RSH in the last 6 months, in the previous model cycle), including the risk of RSH in the first 6 months of the TAU arm: 0.288.

Mortality input parameters

People who have self-harmed have an increased mortality risk relative to the general population. A cohort study that followed individuals of all ages (n=30,950) presenting to emergency departments in the UK after deliberate self-poisoning or self-injury between 2000 and 2007 estimated the increased risk associated with self-harm; this study showed that all-cause mortality following hospital presentation for self-harm was more than twice that expected ( Bergen 2012 ). The increased likelihood of premature death after self-harm (standardised mortality ratio [SMR]) was 4.1 for males and 3.2 for females presented with self-harm relative to that of adults in the general population.

The SMRs of adults presented with RSH relative to adults in the general population was applied onto the most recent general mortality statistics for the population in England ( ONS 2020 ), to estimate the absolute mortality risk in people who self-harmed in the last 6 months (RSH state) relative to those who did not self-harm in the last 6 months (non-RSH state). Adults in the RSH state were assumed to be at increased mortality risk due to RSH only over the time during which they remained in the RSH state. Adults in the non-RSH state were assumed to carry the mortality risk of the general UK population. While in the decision-tree, all adults in the model were assumed to have an increased mortality risk, equal to that of the RSH state, regardless of their response to treatment, given that they were assumed to have self-harmed at model initiation.

Table 16 reports the 6-month mortality risks adopted at each 6-month period of the model.

Table 16. 6-month mortality probabilities for each 6-month model cycle in the study population (PDF, 57K)

Utility input parameters

In order to express outcomes in the form of QALYs, the health states of the economic model (RSH, non-RSH, death) needed to be linked to appropriate utility scores. Utility scores represent the HRQoL associated with specific health states on a scale usually from 0 (death) to 1 (perfect health); they are estimated using preference-based measures that capture people’s preferences on the HRQoL experienced in the health states under consideration.

To estimate QALYs for adults in the non-RSH state, the EQ-5D-derived utility value for adults aged 25–34 years in the general UK population was used (0.93 - Kind 1999 ). The utility value for adults who RSH was estimated using the EQ-5D-derived utility value reported in a UK study for 754 adolescents who self-harmed (0.68 - Tubeuf 2019 ). This study was a secondary analysis of a randomised controlled trial comparing family therapy with treatment as usual as an intervention for self-harming adolescents (Cottrel 2018). These EQ-5D-derived utility values were selected due to lack of more relevant data on adults and were presented to the committee when developing the economic model. The committee expressed the view that both values were overestimates of the utility relating to each of the two health states, as they noted that people who have previously self-harmed (even though they have not self-harmed over the previous 6 months) are unlikely to reach the utility value of the general population (0.93 - Kind 1999 ), and people who have recently self-harmed (in the last 6 months) are unlikely to have a utility as high as 0.68 ( Tubeuf 2019 )], but noted that the difference in utility values between the two health states of RSH and non-RSH (0.93–0.68=0.25) is probably reflective of changes in HRQoL between these two states, thus confirming the face validity of the differential utility data used in the model, both for adolescents and adults who have self-harmed. Alternative utility data reported in a recent UK economic evaluation were tested in a sensitivity analysis (utility values were 0.67 and 0.54 for non-RSH and RSH health states, respectively) ( Quinlivan 2019 ). The utility of 0.67 reflected the EQ-5D-based utility of ‘mental/behavioural problems’ or history of ‘mental/behavioural disorder’ in the UK, while the value of 0.54 reflected the utility of suicide attempt, according to 16 Dutch clinicians; the estimation of this second value does not meet NICE criteria for the estimation of utility values. When observing this evidence, the committee considered this difference in utility between the two health states to be very narrow and unlikely to be reflective of the true difference between the utility in the non-RSH and RSH health states; nevertheless, these data were still tested in sensitivity analysis to explore the impact of a potentially (even though unlikely) small change in HRQoL between the two health states on the results.

Discounting

Discounting at a rate of 3.5% was applied to costs and QALYs that accrued after the first year in the model, as per the NICE reference case ( NICE 2020 ).

Handling uncertainty and presentation of the results

Relative cost effectiveness between CBT-informed psychological intervention plus TAU vs TAU alone was estimated using the incremental cost-effectiveness ratio (ICER). The ICER was calculated using the following formula: ICER = ΔC / ΔE where ΔC is the difference in total costs between two treatment options and ΔE the difference in their effectiveness (QALYs). The ICER expresses the extra cost per extra unit of benefit (QALY) associated with one treatment option relative to its comparator. If an option has an ICER of up to £20,000–£30,000/QALY relative to its comparator (NICE lower and upper cost-effectiveness threshold, respectively) then the intervention is considered to be cost-effective ( NICE 2013 ). Estimation of such a ratio allowed consideration of whether the additional benefit was worth the additional cost when choosing one treatment option over another.

Model input parameters were synthesised in a probabilistic analysis. This means that the input parameters were assigned probability distributions (rather than being expressed as point estimates); this approach allowed more comprehensive consideration of the uncertainty characterising the input parameters. Subsequently, 10,000 iterations were performed, each drawing random values out of the distributions fitted onto the model input parameters. Results (mean costs and QALYs for each intervention) were averaged across the 10,000 iterations. This exercise provides more accurate estimates than those derived from a deterministic analysis (which utilises the mean value of each input parameter ignoring any uncertainty around the mean), by capturing the non-linearity characterising the economic model structure ( Briggs 2006 ).

In addition, alternative scenarios were tested in sensitivity analysis. Three categories of sensitivity analyses (SA) were performed: 1) Univariate SAs to assess the sensitivity of the results to variations in single input parameters; 2) Multivariate SAs to assess the sensitivity of the results to variations in combinations of input parameters; and 3) Threshold SAs to assess by how much specific parameter values would need to change, for the conclusions of the analysis to change. In each scenario, probabilistic analysis was conducted (and probability distributions were used for each altered parameter), in order to take uncertainty around mean values into account.

intensity and frequency of the CBT-informed psychological intervention: 1) extending the average number of intended sessions delivered as part of the CBT-informed psychological intervention; 2) varying the average length of each session; 3) assuming a different Band for health professionals delivering the intervention (AfC 7)
additional healthcare cost associated with self-harm repetition: change of ±50% in the value used in the base-case analysis, as this value reported in Sinclair (2011) had a wide standard deviation around the mean cost estimate
use of alternative utility weights for the RSH and no RSH health states (utility weights were 0.541 for RSH and 0.671 for no RSH - Quinlivan 2019 )
use of alternative utility data ( Quinlivan 2019 ) combined with 8 sessions of CBT-based psychological therapy. The ICER became £27,557/QALY.
use of alternative utility data ( Quinlivan 2019 ) combined with 10 sessions of CBT-based psychological therapy. The ICER became £46,203/QALY.
use of alternative utility data ( Quinlivan 2019 ) combined with a 50% reduction in the base-case extra cost associated with self-harm. The ICER became £32,498/QALY.
baseline risk of RSH
additional healthcare cost of RSH versus no RSH
difference in utility between RSH and no RSH health states

Table 17 provides information on the distributions assigned to input parameters in probabilistic sensitivity analyses.

Results of probabilistic analyses were presented in the form of cost effectiveness acceptability curves (CEACs), which demonstrated the probability of each of the 2 treatment options being the most cost effective at different levels of willingness-to-pay per QALY (that is, at different cost effectiveness thresholds the decision maker may set). Also, the cost effectiveness plane (CEP), which depicts the incremental costs and QALYs of CBT-informed psychological intervention plus TAU versus TAU alone (placed at the origin) was used to show the uncertainty around mean cost effectiveness outcomes of the model, represented as a cloud of points on the plane corresponding to the different 10,000 iterations of the economic model in the probabilistic analysis.

Table 17. Point estimates and probability distributions assigned to input parameters of the guideline economic model. (PDF, 386K)

Development and validation of the economic model

Please see for details about the methods followed to develop and validate the economic model ‘ Development and validation of the economic models ’.

Economic modelling results

Base-case analysis.

The average total costs from the 10,000 iterations were £2,283 and £2,424 per person for the TAU and CBT-informed psychological intervention plus TAU arms, respectively; the average incremental QALY was 0.02 for the CBT-informed psychological intervention + TAU compared to TAU alone ( Table 18 ). Accordingly, the average ICER was £9,088 per QALY gained, which is well below the lower NICE cost-effectiveness threshold of £20,000/QALY.

Table 18. Probabilistic cost effectiveness estimates for the CBT-based psychotherapy added to TAU compared with TAU at 5-years time horizon (PDF, 130K)

Figure 4 shows the cost effectiveness plane for the CBT-informed psychological intervention compared with TAU at 5-years based on 10,000 iterations. The diagonal line represents the willingness to pay per QALY threshold of £20,000. All the simulation estimates are on the right of the y-axis, showing that the CBT-informed psychological intervention is always more effective than TAU. Most of the ICERs are in the north-east quadrant (75% of the 10,000 iterations), where the CBT-informed psychological intervention results in higher costs compared with TAU. Of these, 51% are below the line showing the NICE threshold of £20,000 per QALY gained. In addition, the remaining estimates are in the south-east quadrant (25% of the 10,000 iterations), showing that, in those iterations, the CBT-informed psychological intervention + TAU led to lower costs compared with TAU alone; in these iterations the CBT-informed psychological intervention + TAU is dominant (this is, the intervention is both clinically superior and cost saving compared to the TAU). Overall, results suggest that the CBT-based psychotherapy added to TAU is likely to be cost effective compared to TAU alone, with a probability of 51% + 25% = 76%.

Figure 4. Cost effectiveness plane of CBT-informed psychological intervention added to TAU compared with TAU alone over a time horizon of 5 years (PDF, 444K)

A cost effectiveness acceptability curve of the CBT-informed psychological intervention compared with TAU alone is presented in Figure 5 . At a threshold of £20,000, the CBT-informed psychological intervention + TAU had a 76% chance of being cost effective, and this percentage increased to 92% when the threshold was £30,000. There is a positive relationship between the cost effectiveness threshold and the chance of CBT-informed psychological intervention being cost effective, and this is because the CBT-informed psychological intervention was, on average, more effective (in terms of QALY gains) than TAU, while either being cost saving or costing slightly more.

Figure 5. Cost effectiveness acceptability curves for the CBT-informed psychological intervention added to TAU compared with TAU alone over a 5 years’ time horizon (PDF, 472K)

Sensitivity analysis

To account for uncertainty in the incremental costs and QALYs estimation, a number of probabilistic univariate sensitivity analyses were conducted ( Table 19 ). The first sensitivity analyses included making different assumptions about the delivery of the CBT-informed psychological intervention: 1) varying the average number of sessions delivered, as defined earlier in the methods (section ‘ Handling uncertainty and presentation of the results ’); 2) Varying the average length of each CBT-informed psychological intervention from 50 to 65 minutes; 3) Assuming different healthcare professional’s salaries; 4) using alternative utility data from Quinlivan 2019 . By exploring these model’s assumptions, the delivery of the CBT-informed psychological intervention remained likely to be cost effective in adults who RSH at 5 years time horizon in all but one cases; it was unlikely to be cost effective when it was provided in more than 10 sessions ( Table 19 ). As for the base-case analyses, these results indicate the CBT-informed psychological intervention plus TAU is more effective than the TAU alone, and so, as the value placed on a QALY increases, the likelihood that the intervention is cost-effective rises.

Table 19. Probabilistic cost effectiveness estimates for the CBT-informed psychological intervention added to TAU compared with TAU alone – Univariate sensitivity analysis (PDF, 275K)

Besides univariate sensitivity analyses, multivariate sensitivity analyses were conducted to study the effect of using alternative utility weights combined 1) with an increase in the number of CBT-informed psychological intervention sessions and 2) with a 50% reduction in the excess NHS cost of RSH relative to RSH, on the results of the economic model ( Table 20 ). In none of these scenarios was CBT-informed psychological intervention found to be cost effective, using the NICE lower cost-effectiveness threshold of £20,000/QALY ( Table 20 ).

Table 20. Probabilistic cost effectiveness estimates for the CBT-informed psychological intervention added to TAU compared with TAU alone – Multivariate sensitivity analysis (PDF, 119K)

Finally, as suggested by the findings of the threshold sensitivity analysis ( Table 21 ), compared to TAU alone, CBT-informed psychological intervention plus TAU will remain cost effective if: 1) the baseline risk of RSH in the model population would be at least 21.5% (in the base-case analysis this value is 28.8 %); or the excess cost of RSH vs no RSH state would be at least £588 (instead of £2,133.53 with the base-case scenario); or the difference in utility between RSH and non-RSH state would be at least 0.10 (in base-case analysis this difference is 0.25)

Table 21. Cost effectiveness estimates for the CBT-informed psychological intervention added to TAU compared with TAU alone – Threshold sensitivity analysis (PDF, 230K)

The primary purpose of this economic model was to assess the relative cost-effectiveness of CBT-informed psychological intervention in addition to TAU versus TAU alone for adults who RSH. When considering a population of adults who RSH, our results suggest that the ICER for CBT-informed psychological intervention added to TAU was below the NICE threshold of £20,000 per QALY over 5 years. Secondly, starting with our base case economic scenario, we aimed to simulate costs and effectiveness data exploring a number of scenarios different from the base case; such as the intensive delivery of the CBT-informed psychological intervention, or considering the most relevant model’s assumptions (for example, NHS cost parameters, clinical input parameters, and QALY valuation). By exploring all these model’s assumptions, the delivery of the CBT-based psychotherapy remained likely to be cost effective in adults who RHS, suggesting confidence around both models’ results when model assumptions varied. The committee pointed all the above considerations out, when discussing the evidence and drafting the recommendations for this area of the guideline.

None of the analyses identified in the economic evidence review were focused on CBT-informed psychological intervention for people who RSH, except Byford (2003) . In this cost-utility analysis, which assessed the cost-effectiveness of manual-assisted cognitive behaviour therapy (MACT) relatively to TAU, MACT was found to be cheaper but slightly less effective than TAU, and, overall, more cost-effective than TAU. The results of this study are highly applicable to this guideline in terms of the population, healthcare system, interventions and outcomes considered ( Byford 2003 ). However, this study was considered to have potentially serious methodological limitations: the short-term time horizon, which was 12 months follow-up ( Tyrer 2003 ); in addition, the baseline and the relative intervention effects data were based on a single RCT ( Tyrer 2003 ).

Therefore, the present analysis makes an important contribution to the existing evidence on the cost effectiveness of CBT-informed psychological intervention(s) in people who RSH. It shows the cost-effectiveness CBT-informed psychological intervention added onto TAU compared to the TAU alone in the UK, using incremental costs per QALY gained as the primary outcome measure, adopting a longer-term analytical time horizon; and obtaining effectiveness data from the Cochrane review and meta-analysis of clinical evidence, which informed the guideline.

The model’s results should be interpreted in light of the information on the probabilities of repeating self-harm, since such data were based on a single, albeit large, study ( Lilley 2008 ). This was a prospective multicentre cohort analysis involving 10,498 consecutive episodes of self-harm at six English teaching hospitals, and its estimates of RSH are supported by alternative sources of evidence (such as Cooper 2015 ). The figures reported in Lilley 2008 were estimated from Kaplan–Meier curves which used recurrent event analysis (that is each repeat episode of self-harm treated as an index episode): the risk at 0–6 months was used to estimate the 6-month risk of remaining in the RSH state (that is, the 6-month risk of RSH in people who had self-harmed within the last 6 months); the risk at 6–12 months of the study was used to estimate the 6-month risk of moving to the RSH state from the non-RSH state (that is, the 6-month risk of RSH in people who had not self-harmed in the last 6 months). During the discussion of this evidence, the committee confirmed the face validity of these data, so, they agreed for these data to be used in the economic model.

The findings of the present model may be restricted by the paucity of self-harm related utility data. In the economic model, 2 different sets of utility data were used to reflect the health-related quality of life associated with RSH and no RSH. The first set of utility data (No RSH: 0.93 and RSH: 0.68; Kind 1999 and Tubeuf 2019 respectively) were considered by the committee to reflect the difference in utility between the two health states, although each value appeared to be an overestimate of the HRQoL in the respective health state. It is noted that this set of data has also been used in the base-case economic analysis described in McDaid 2022 , who estimated the cost-effectiveness of psychosocial assessment for individuals who present to hospital following self-harm in England. The second set of utility data does not meet NICE criteria for the estimation of utility values; in addition, the committee considered the difference in utility between the two health states too narrow (RSH: 0.54 and No RSH: 0.67 - Quinlivan 2019 ). Nevertheless, no alternative utility data were available, and therefore, after considering the available data, the committee advised that the first set of utility values be used in the base-case analysis, and the second set of utility data ( Quinlivan 2019 ) be investigated in sensitivity analysis.

Self-harm is strongly associated with mental health problems, and related utility values reflect the overall HRQoL of people experiencing/living with self-harm and other mental health problems, as it is not possible to isolate and represent separately HRQoL relating to self-harm and HRQoL relating to another mental-health problem. Similarly, people who have not self-harmed in the last 6 months (no RSH state), are expected to experience improvement in both their self-harming behaviour and associated mental health problems, and their HRQoL consequently reflects both improvements (as, again, it is not possible to isolate these from one another). Therefore, the utility values used in the model are assumed to reflect HRQoL related to self-harm that incorporates mental health problems or related improvements.

It is noted that the utility value of the no RSH state used in the base-case analysis is that of the general population in the UK, suggesting that the intervention has had a positive impact on other mental health problems. In sensitivity analysis, the utility value of the no RSH state reflects ‘mental/behavioural problem or history of mental disorder’. This is non-specific to the no RSH state and may also include improvement in other mental health problems (since it also incorporates the value of ‘history’ of a mental disorder). Therefore, the utility values of the no RSH state used both in base-case and sensitivity analysis reflect wider mental health improvements associated with this state, and not only improvements in self-harming behaviour.

Overall conclusions from the guideline economic analysis

The results of the guideline economic analysis suggest that individual CBT-informed psychological intervention is likely to be cost-effective in the treatment of adults who have RSH. When discussing the economic evidence, the committee acknowledged that these findings needed to be interpreted with some caution due to the limited evidence base characterising some of the models’ input parameters. Based on the findings of the economic model and supplemented by the results of the clinical review, the committee pointed out the vital role played by CBT-informed psychological intervention in the management of self-harm recurrence in adults, while ensuring NHS resources are used efficiently.

Bergen 2012

Briggs 2006

Cooper 2013

Cooper 2015

Curtis and Burns 2020

Davies 1998

Lilley 2008

McDaid 2022

Netten 1998

Norton 2018

Quinlivan 2019

Sinclair 2011

Tubeuf 2019

DBT-A for children and young people who have self-harmed

The Cochrane systematic review of clinical evidence ( Witt 2021b ) demonstrated that dialectical behavioural therapy adapted for adolescents (DBT-A) who repeated self-harm (RSH) is effective in reducing the repetition of self-harm episodes when compared with treatment as usual (TAU) or another comparator; in addition, the existing clinical evidence was deemed as adequate to inform exploratory bespoke economic modelling. Based on these considerations, an economic model was developed to assess the relative cost-effectiveness of DBT-A versus enhanced TAU for children and young people who have self-harmed in the UK.

The study population of the economic model comprised children and young people (CYP) with a hospital presentation for self-harming in the prior six months; furthermore, young people included in the economic model may have repeated single or multiple self-harm episodes in the past. The age of the population at the start of the model was 16 years, in accordance with a large UK-based prospective cohort study; 75% of the model’s population were women ( Hawton 2012 ). The starting age of the cohort and its gender composition were needed in order to estimate mortality risks in the cohort over the time horizon of the economic analysis.

The economic analysis considered DBT-A as this was the only intervention that was shown to be effective in reducing the number of future RSH episodes according to the Cochrane systematic review and meta-analysis of the clinical evidence ( Witt 2021b ). The characteristics of DBT-A in terms of effectiveness and resource use (healthcare professional time, and number of sessions delivered), were determined by the findings of the Cochrane systematic review and meta-analysis that informed the review question, supplemented by the committee’s expert opinion ( Witt 2021b ).

The comparator of the meta-analysis was ‘TAU or another comparator’. After reviewing the comparators in the studies included in the Cochrane meta-analysis that informed the guideline economic model, and following the committee’s expert advice, it was agreed that the comparator was equivalent, on average, to enhanced TAU. According to the committee’s expert opinion, enhanced TAU is expected to be diverse and delivered by a range of providers. In order to model the costs and outcomes of enhanced TAU, we considered enhanced TAU described in a clinical trial conducted in the UK ( Cottrell 2018 ) as treatment provided by children and adolescent mental health services (CAMHS) to children and young people who RSH after initial hospital management.

The economic analysis adopted the perspective of the NHS and personal social services (PSS), as recommended by NICE ( NICE 2020 ). The measure of outcome was the Quality Adjusted Life Year (QALY), which incorporated utilities associated with repetition of self-harm health-related quality of life (HRQoL). Costs to the NHS & PSS consisted of DBT-A and enhanced TAU-based intervention costs (healthcare professional time and number of sessions delivered as part of intervention) and use of health and social care services (including GP care, CAMHS, other primary care, hospital inpatient and outpatient care, emergency department presentations, physiotherapy, occupational therapy and social care) by children and young people who have self-harmed. The cost year was 2020.

Figure 6 presents a schematic diagram of the hybrid decision-analytic model developed using Microsoft Office Excel 2013; it consisted of a simple decision tree lasting 6 months incorporating Markov nodes (represented by ‘M’ in Figure 2 – Part 1), and a Markov simulation model involving 3 health states (RSH, no RSH and death due to suicide), which lasted 4.5 years with a 6-month cycle Figure 2 – Part 2). A 6-month cycle was used based on data availability and GC advice that this is an appropriate period over which to model RSH events. A half-cycle correction was applied.

The structure of the model, which aimed to simulate the natural history of the CYP self-harming population, was driven by patterns of clinical practice in the UK and the availability of relevant data sources (see section ‘ Development and validation of the economic model ’ for further details). The model estimated the total costs and effects associated with the provision of DBT-A and enhanced TAU for CYP who RSH. According to the model structure, hypothetical cohorts of CYP who RSH were either initiated on DBT-A or received enhanced TAU. Following care received, CYP either RSH, did not RSH or died by suicide, with ‘death’ taken as the absorbing state ( Figure 6 ). Due to lack of long-term comparative clinical data, transitions between the ‘RSH’ and ‘no RSH’ health states in the Markov component of the model were assumed to be independent of the intervention received at the decision-tree part of the model. The transition probability to the death by suicide state depended on the RSH status of each young person in the population.

Figure 6. Schematic structure of the economic model assessing the cost-effectiveness of DBT-A for children and young people who RSH (PDF, 195K)

Dialectical behaviour therapy costs

The intervention cost of DBT-A was estimated by combining resource use associated with provision of DBT-A with appropriate unit costs. It was assumed that DBT-A was a modular psychological treatment consisting of a combination of individual psychotherapy, group skills training, therapist consultation team, and telephone counselling. In our model, the DBT-A delivery mode consisted of 16 weekly sessions (60 minutes) of individual therapy, 16 weekly sessions (120 minutes) of skills training in a group format (2 therapists and 10 participants per group), 16 weekly sessions (120 minutes) of therapist consult team and out-of-hours counselling over the telephone as needed. Such assumptions on the DBT-A delivery mode were based on routine practice in the UK (according the advice of the committee) and the reported number and duration of sessions across studies informing the Cochrane review and meta-analysis of clinical evidence ( Witt 2021b ). Based on this evidence and on the committee’s advice on patterns of attendance of CYP to DBT-A’s individual psychotherapy sessions in the UK, we assumed the proportions of CYP attending DBT-A individual psychotherapy as reported in Table 22 . By weighing the intended number of individual psychotherapy sessions with their likely attendance rates we obtained the average number of attended DBT-A’s individual psychotherapy sessions in the model, which is 13.875 (this is the mean number of sessions likely to be provided based on the attendance rates of service users). This number was used in order to estimate the mean individual intervention cost. The number of therapist sessions per person attending group sessions was not altered from the intended number of 16 sessions, because the number of group sessions remains the same, whether a participant attends the full course of treatment or a lower number of sessions.

Table 22. People attending individual DBT-A sessions 1 (PDF, 243K)

A Band 7 salary pay scale was used to estimate unit cost per hour of the therapist delivering each session; unit costs of scientific and professional staff were used ( Table 23 )
The direct to indirect time of professionals delivering DBT-A based on published estimates ( Curtis and Burns 2020 ) was considered when estimating unit costs of professionals involved in delivering DBT-A ( Table 23 )
2/3 of staff delivering DBT-A were assumed to be mental health nurses and 1/3 clinical psychologists; this assumption was used in order to estimate qualification costs
An additional training in DBT-A was estimated to cost £ 9,463, equal to a post-graduate diploma in DBT, as agreed with the committee

Table 23. Unit cost of health professional staff delivering DBT-A, AfC band 7 (2020 price) (PDF, 260K)

Therapist consult team sessions and telephone counselling were not costed, as they were delivered by healthcare professionals already involved in delivering individual psychotherapy and group skills training sessions, with no additional use of their time (these components are included in the professionals’ direct-to indirect time ratio of contact with patients). After combining resource use with unit costs estimated as described above, the mean cost per CYP receiving the DBT-A intervention was estimated to be £2,801 ( Table 24 ).

Table 24. DBT-A delivery mode and total cost (PDF, 14K)

Enhanced treatment as usual costs

Based on the committee’s advice, enhanced TAU for CYP who have self-harmed in the UK was assumed to be in line with the treatment as usual reported in a multicentre RCT and economic analysis conducted in the UK ( Cottrell 2018 ). This study assessed the effectiveness and cost-effectiveness of family therapy (FT) compared with TAU across 3 English regions. Therefore, enhanced TAU consisted of the care offered to CYP referred to children and adolescent mental health services (CAMHS) following self-harm, and included CAMHS services, telephone contacts and therapist’s supervision. Cottrell (2018) reports a cost of TAU in the UK of £ 875 at 6 months follow-up, in 2014 prices ( Table 25 ) . This estimate was inflated to 2020 price year using the NHS Cost Inflation Index after that and up to 2020 ( Curtis and Burns 2020 ); the 2020 price was £ 961.

Table 25. Average enhanced TAU cost at 6 moths follow-up (Cottrell 2018; 2014 prices) (PDF, 135K)

Healthcare costs associated with self-harm

The estimation of healthcare costs associated with the RSH and non-RSH health states incurred by CYP who had self-harmed in the past was based on the economic analysis published by Cottrell (2018) . This study estimated health and social care costs following an episode of self-harm from the perspective of the NHS and PSS. This UK study comprised a cohort of adolescents aged 11 to 17 years who self-harmed prior to assessment by the CAMHS team (n=832). Resources measured in the study included health community and social care services, hospital services, and medication use. Besides baseline, resource use data were collected at 6, 12 and 18 months converted into costs using unit cost figures from the British National Formulary (BNF), Personal Social Services Research Unit (PSSRU) and the Department of Health’s National Schedule of Reference Costs ( Cottrell 2018 ). The costing results were reported 2014/2015 prices in terms of healthcare costs associated with RSH within the previous 6 months and healthcare costs associated with no RSH within the previous 6 months ( Table 26 ). These estimates were inflated to 2020 price year using the NHS Cost Inflation Index after that and up to 2020 ( Curtis and Burns 2020 ); the resulting costs associated with using healthcare services were £1,859 for CYP who RHS and £807 for CYP who did no-RHS within the last 6 months.

Table 26. Average 6-month healthcare cost associated with self-harm (Cottrell 2018) (PDF, 136K)

Effectiveness data consisted of the risk ratio (RR) of RSH associated with provision of DBT-A to TAU or other comparator. Data were derived from the Cochrane systematic review and meta-analysis of clinical evidence, which included 4 RCTs ( Cooney 2010 , McCauley 2018 , Mehlum 2014 , and Santamarina-Pérez 2020 ) assessing the effectiveness of DBT-A relative to TAU in CYP presenting to services following an episode of RSH, at 6 months follow-up ( Witt 2021b ). As reported in the Cochrane review of clinical evidence, the evidence was deemed to be of high certainty, and there was no evidence of a difference by comparator (TAU versus enhanced TAU versus alternative psychotherapy), even though there were some concerns with regards to the overall risk of bias for all four trials ( Witt 2021b ).

By the six-month follow-up assessment, there was evidence of an effect for DBT-A on repetition of self-harm (Odds Ratios [OR]: 0.46, 95% CI 0.26 to 0.82). Using the raw data, we estimated a RR of 0.69 (95% CI 0.51 to 0.92) ( Figure 7 ), which we subsequently combined with the absolute effect of enhanced TAU, in order to estimate the absolute effect of DBT-A.

Figure 7. Forest plot for DBT-A versus enhanced TAU for treatment of RSH in CYP: risk ratio at 6 months follow-up. (PDF, 136K)

The baseline risk and the transition probabilities of self-harm repetition in CYP used in the model were estimated using data from Cottrell 2018 . This UK-based randomised controlled trial aimed to assess the effectiveness and cost-effectiveness of family therapy (FT) compared with treatment as usual (TAU) in adolescents aged 11 to 17 years who self-harmed prior to assessment by the CAMHS team (n=832) during the 18-month study period. Table 27 summaries the risks that have been used in the Markov model as transition probabilities between the RSH and the non-RSH states for the hypothetical cohort of CYP in a cycle time, plus the baseline probability of RSH in children and young people used in the decision tree part of the model ( Cottrell 2018 ).

Table 27. Baseline risk of RSH and 6-month transition probabilities of self-harm repetition in CYP (based on Cottrell 2018) (PDF, 29K)

Children and young people (CYP) who have repeated self-harm have an increased mortality risk due to suicide relative to the general population. A prospective cohort study followed children and young people aged 10–18 years presenting to emergency departments in the UK after non-fatal self-harm between 2000 and 2013 (n=9173 individuals who had 13,175 presentations for self-harm), to estimate the increased risk of suicide associated with self-harm. This study showed that in CYP the increased likelihood of premature death by suicide after self-harm was more than 30 times higher (standardised mortality ratio: 31.0, 95% CI 15.5 to 61.9) relative to that of CYP in the general population ( Hawton 2020 ).

Table 28 reports the 6-month mortality risks adopted at each 6-month period of the model. The standardised mortality ratios (SMRs) of CYP presented with RSH relative to CYP in the general population was applied onto the most recent age-specific suicide rate statistics for the population in England ( ONS 2020 ), to estimate the absolute mortality risk due to suicide in CYP who self-harmed in the last 6 months (RSH state) relative to those who did not self-harm in the last 6 months (non-RSH state). CYP in the RSH state were assumed to be at increased mortality risk due to RSH only over the time during which they remained in the RSH state. CYP in the non-RSH state were assumed to carry the mortality risk of the general UK population. While in the decision-tree, all children and young people in the model were assumed to have an increased mortality risk due to suicide following RSH, equal to that of the RSH state, regardless of their response to treatment, given that they were assumed to have self-harmed at model initiation.

Table 28. 6-month mortality by suicide probabilities for each 6-month model cycle in the study population (PDF, 154K)

In order to express outcomes in the form of QALYs, the health states of the economic model (RSH, non-RSH, death by suicide) needed to be linked to appropriate utility scores. Utility scores represent the HRQoL associated with specific health states on a scale usually from 0 (death) to 1 (perfect health); they are estimated using preference-based measures that capture people’s preferences on the HRQoL experienced in the health states under consideration.

To estimate QALYs for children and young people in the non-RSH state, the EQ-5D-derived utility value for young adults under 25 years of age in the general UK population was used (0.94 - Kind 1999 ). The utility value for children and young people who RSH was estimated using the EQ-5D-derived utility value reported in a UK study for 754 adolescents who self-harmed (0.68 - Tubeuf 2019 ). This study was a secondary analysis of a randomised controlled trial comparing family therapy with treatment as usual as an intervention for self-harming adolescents (Cottrel 2018). These EQ-5D-derived utility values were selected due to lack of more relevant data and were presented to the committee when developing the economic model. The committee expressed the view that both values were overestimates of the utility relating to each of the two health states, as they noted that people who have previously self-harmed (even though they have not self-harmed over the previous 6 months) are unlikely to reach the utility value of the general population (0.94 - Kind 1999 ), and people who have recently self-harmed (in the last 6 months) are unlikely to have a utility as high as 0.68 ( Tubeuf 2019 )], but noted that the difference in utility values between the two health states of RSH and non-RSH (0.93–0.68=0.25) is probably reflective of changes in HRQoL between these two states in children and young people, thus confirming the face validity of the differential utility data used in the model. Alternative utility data reported in a recent UK economic evaluation were tested in a sensitivity analysis (utility values were 0.76 and 0.80 for non-RSH and RSH health states, respectively) ( Cottrell 2018 ). These utility values were collected by administering the EQ-5D questionnaire to the sample of children and young people (n=832) included in the RCT at 6, 12, and 18 months follow-up. When observing this evidence, the committee considered this difference in utility between the two health states to be very narrow and unlikely to be reflective of the true difference between the utility in the non-RSH and RSH health states; nevertheless, these data were still tested in sensitivity analysis to explore the impact of a potentially (even though unlikely) small change in HRQoL between the two health states on the results.

Relative cost effectiveness between DBT-A vs enhanced TAU was estimated using the incremental cost-effectiveness ratio (ICER). The ICER was calculated using the following formula: ICER = ΔC / ΔE where ΔC is the difference in total costs between two treatment options and ΔE the difference in their effectiveness (QALYs). The ICER expresses the extra cost per extra unit of benefit (QALY) associated with one treatment option relative to its comparator. If an option has an ICER of up to £20,000–£30,000/QALY relative to its comparator (NICE lower and upper cost-effectiveness threshold, respectively) then the intervention is considered to be cost-effective ( NICE 2013 ). Estimation of such a ratio allowed consideration of whether the additional benefit was worth the additional cost when choosing one treatment option over another.

intensity and frequency of DBT-A: 1) extending the average number of intended sessions (individual psychotherapy and group skills training) delivered as part of the DBT-A intervention; 2) varying the average length of each DBT-A session; 3) assuming a different band for health professionals delivering the intervention
healthcare cost associated with self-harm: increasing/decreasing the values used in the base-case analysis by 50%, as for the costs associated with using healthcare services for CYP who RHS and for CYP who did not RHS
low DBT-A delivery costs: 1) reducing the average length of each individual psychotherapy session (50 minutes); 2) reducing the average length of each group skills training session (60 minutes); and 3) assuming a lower professional’s salary (AfC 6)
QALY valuation: using alternative utility weights to attach to the RHS and no RSH health states (utility weights were 0.76 for RSH and 0.80 for no RSH – Cottrell 2018 )
risk of RSH after having RSH, either the baseline risk of RSH in the model and the risk of RSH after RSH after post-intervention
healthcare cost associated with RSH versus no RSH
DBT-A delivery cost

Table 29 provides information on the distributions assigned to input parameters in probabilistic sensitivity analyses.

Results of probabilistic analyses were presented in the form of cost effectiveness acceptability curves (CEACs), which demonstrated the probability of each of the 2 treatment options being the most cost effective at different levels of willingness-to-pay per QALY (that is, at different cost effectiveness thresholds the decision maker may set). Also, the cost effectiveness plane (CEP), which depicts the incremental costs and QALYs of DBT-A versus enhanced TAU alone (placed at the origin) was used to show the uncertainty around mean cost effectiveness outcomes of the model, represented as a cloud of points on the plane corresponding to the different 10,000 iterations of the economic model in the probabilistic analysis.

Table 29. Point estimates and probability distributions assigned to input parameters of the guideline economic model. (PDF, 198K)

The average total costs from the 10,000 iterations were £8,494 and £10,292 per person for the enhanced TAU and DBT-A arms, respectively; the average incremental QALY was 0.01 for the DBT-A intervention compared to enhanced TAU ( Table 30 ). Accordingly, the average ICER was £268,601 per QALY gained, which is well above the NICE cost-effectiveness threshold of £20,000/QALY.

Table 30. Probabilistic cost effectiveness estimates for DBT-A compared with enhanced TAU at 5-years time horizon (PDF, 197K)

Figure 8 shows the cost effectiveness plane for DBT-A compared with enhanced TAU at 5-years based on 10,000 iterations. The diagonal line represents the willingness to pay per QALY threshold of £20,000. Nearly all the simulation estimates are on the right of the y-axis, showing that the DBT-A is most likely to be more effective than enhanced TAU. Also, almost all of the ICERs are in the north-east quadrant (99.5% of the 10,000 iterations), where DBT-A results in higher costs compared with enhanced TAU. Of these, just 2.5 % are below the line showing the NICE threshold of £20,000 per QALY gained. In addition, only 0.5% of the estimates are in the south-east quadrant (50 of the 10,000 iterations), showing that, in those iterations, DBT-A led to lower costs and higher benefits compared with enhanced TAU. Overall, results suggest that DBT-A is not cost effective compared to enhanced TAU: using a cost per QALY threshold of £20,000, DBT-A had a 3% (2.5% + 0.5%) chance of being cost-effective.

Figure 8. Cost effectiveness plane of DBT-A compared with enhanced TAU over a time horizon of 5 years (PDF, 122K)

A cost effectiveness acceptability curve of the DBT-A intervention compared with enhanced TAU is presented in Figure 9 . At a threshold of £20,000, DBT-A had a 3% chance of being cost effective, and this percentage increased to 6% when the threshold was £30,000. There is a positive relationship between the cost effectiveness threshold and the chance of DBT-A being cost effective, and this is because the DBT-A intervention was, on average, slightly more effective (in terms of QALY gains) than enhanced TAU, while being heavily more costly.

Figure 9. Cost effectiveness acceptability curves for DBT-A compared with enhanced TAU over a 5 years’ time horizon (PDF, 350K)

To account for uncertainty in the incremental costs and QALYs estimation, a number of probabilistic univariate sensitivity analyses were conducted ( Table 31 ). The first sensitivity analyses included making different assumptions about the delivery of the DBT-A intervention: 1) varying the average number of individual psychotherapy and group skills training sessions delivered, as defined earlier in the methods (section ‘ Handling uncertainty and presentation of the results ’); 2) varying the average length of each DBT-A session, either individual or group; 3) assuming different healthcare professional’s salary bands. By exploring these model’s assumptions, the delivery of DBT-A remained unlikely to be cost effective in children and young people who RHS at 5 years time horizon in all cases ( Table 31 ). The second probabilistic univariate sensitivity analyses included making different assumptions about the healthcare costs associated with no RSH or incurred by CYP following an episode of RSH. Also by exploring these assumptions, the delivery of DBT-A remained unlikely to be cost-effective compared to enhanced TAU. As for the base-case analyses, these results suggest that DBT-A is slightly more effective and heavily more costly than enhanced TAU, and so, as the value placed on a QALY increases, the likelihood that the intervention is cost effective rises marginally.

Table 31. Probabilistic cost effectiveness estimates for DBT-A compared with enhanced TAU – Univariate sensitivity analysis (PDF, 494K)

Besides univariate sensitivity analyses, two probabilistic multivariate sensitivity analyses were conducted to study the combined effect of some input parameters on the results of the economic model ( Table 32 ). The first analysis included reducing simultaneously the average length of each individual and group session of DBT-A and assuming a lower professional’s salary. Under such a scenario of low delivery costs, DBT-A remained not cost-effective ( Table 32 ) compared with enhanced TAU, but its probability of being a cost-effective intervention increased to some extent. By means of the second multivariate sensitivity analysis, the usage of alternative QALY valuation has been explored (using utility weights to attach to the RHS and no RSH health states of 0.76 and 0.80, respectively – Cottrell 2018 ); over this scenario, DBT-A remained not cost effective compared to enhanced TAU, with a lower probability of being cost-effective compared to the base-case analysis ( Table 32 ).

Table 32. Probabilistic cost effectiveness estimates for DBT-A compared with enhanced TAU – Multivariate sensitivity analysis (PDF, 251K)

Finally, as suggested by the findings of the threshold sensitivity analysis ( Table 33 ), compared to enhanced TAU the DBT-A intervention will be cost effective if: 1) the risk of RSH after RSH in the model population would be at least 69% (in the base-case analysis this value was 14% under enhanced TAU, in the decision tree component, and 26% in the Markov model component); or the delivery cost of DBT-A would be at maximum £1,135 (instead of £2,801 with the base-case scenario); or the healthcare costs incurred by children and young people following an episode of RSH would be at least £55,000 (in base-case analysis this value was £1,859)

Table 33. Cost effectiveness estimates for DBT-A compared with enhanced TAU – Threshold sensitivity analysis (PDF, 229K)

The primary purpose of this economic model was to assess the relative cost-effectiveness of DBT-A versus enhanced TAU for children and young people following an episode of RHS. Our results suggest that the ICER for DBT-A is well above the NICE threshold of £20,000 per QALY over 5 years; therefore, DBT-A is not a cost-effective psychological therapy compared to the enhanced TAU. Secondly, starting with our base-case economic scenario, we aimed to simulate costs and effectiveness data exploring a number of scenarios; such as a different delivery mode of DBT-A, or varying the most relevant model’s assumptions (for example, NHS cost parameters, clinical input parameters, and QALY valuation). By exploring all these model’s assumptions, the delivery of DBT-A remained unlikely to be cost effective in children and young people who RHS, suggesting confidence around models’ results when model assumptions varied. According to the committee’s advice, the only plausible change in input parameters that would make DBT-A cost-effective is when the baseline risk of self-harm repetition combined with the risk of RSH following RSH in the model population would be at least 69%, which would be reflecting the healthcare circumstances and needs of a particular sub-group of CYP who RSH, such as those CYP at very high risk of self-harmrecurrence. Summing up, the present economic model shows that DBT-A is a very costly intervention with relatively low benefits for the overall population of CYP who RSH. On the other hand, the present analysis suggests that DBT-A might be a cost-effective treatment in the specific subgroup of CYP who RSH and have a very high risk of repeating self-harm over time, incurring high management costs, such as CYP with significant emotional dysregulations who have frequent episodes of self-harm, as noted by the committee. When discussing the evidence and drafting the recommendations for this area of the guideline, the committee pointed out all the above considerations.

None of the analyses identified in the economic evidence review were focused on DBT for people who RSH, except for Haga (2018) and Priebe (2012) ; both studies were cost-effectiveness analyses conducted alongside RCTs; with the one study from Norway and ( Haga 2018 ) and the other one from the UK ( Priebe 2012 ). Haga (2018) compared the cost-effectiveness of DBT-A to enhanced TAU in adolescents who self-harmed, mostly individuals with borderline personality disorder, with its results suggesting that DBT-A had a high probability of being a cost-effective psychological treatment. Priebe (2012) compared the cost-effectiveness of DBT with TAU in adults with borderline personality disorder who have self-harmed in the UK. The results were inconclusive mostly because DBT was found to be more effective in reducing self-harm and more costly than TAU, but no QALYs were estimated. The committee found both economic analysis partially applicable to the decision-making context as they included mostly people who self-harmed with borderline personality disorder and they did not use the QALY as the measure of outcome. Therefore, the present analysis makes an important contribution to the existing evidence on the cost effectiveness of DBT-A in children and young people who RSH using incremental costs per QALY gained as the primary outcome measure, adopting a longer-term analytical time horizon; and obtaining effectiveness data from the Cochrane review and meta-analysis of clinical evidence ( Witt 2021b ), which informed the guideline.

The findings of the present model may be restricted by the paucity of self-harm related utility data. In the economic model, 2 different sets of utility data were used to reflect the health-related quality of life associated with RSH and no RSH. The first set of utility data (No RSH: 0.94 and RSH: 0.68; Kind 1999 and Tubeuf 2019 respectively) were considered by the committee to reflect the difference in utility between the two health states, although each value appeared to be an overestimate of the HRQoL in the respective health state. The difference between the two health states of the second set of utility data were considered by the committee too narrow (RSH: 0.76 and no RSH: 0.80 – Cottrell 2018 ). Nevertheless, no alternative utility data were available, and therefore, after considering the available data, it was suggested to use the first set of utility values in the base-case analysis, and investigate the second set of utility data ( Cottrell 2018 ) in sensitivity analysis.

The results of the guideline economic analysis suggest that DBT-A for CYP who have self-harmed is not cost-effective from a NHS and personal social services perspective, compared to enhanced TAU. Based on the findings of the economic model and supplemented by the results of the clinical review, the committee pointed out the important role played by DBT-A only in the management of self-harm recurrence in CYP who self-harmed and are at very high risk of self-harm repetition over time, such as CYP with significant motional dysregulations who have frequent episodes of self-harm.

Cooney 2010

Hawton 2012

Hawton 2020

McCauley 2018

Mehlum 2014

NHS England and Health Education England 2016

Santamarina-Pérez 2020

Development and validation of the economic models

People present to an emergency department at a general hospital with self-harm repetition

After having received health care support and treatment, people will either: a) repeat an episode of self-harm; b) not repeat an episode of self-harm

In case of repetition of self-harm, people would re-present to an emergency department at a general hospital; In case people do not repeat self-harm after having received health care assistance and support, there is in place a follow-up programme

After having re-presented, they are managed across different care settings

In the short/medium-term period (for example, 1 to 5 years), people who have self-harmed can die because: a) of suicide -after a repeated episode of self-harm; b) of any other cause of death but suicide -after a repeated episode of self-harm; c) of any other cause of death but self-harm

Figure 10. Illustrative self-harm process model (PDF, 513K)

Patients with a recent episode of RSH (within 6 months) re-present to hospital for self-harm as a result of any type of non-fatal self-poisoning or self-injury;

They receive either CBT-based psychotherapy in addition to TAU or TAU alone after having received a care intervention they are followed-up for an overall period of 5 years.

At the end or during this follow-up period, these patients can either repeat or not an episode of self-harm

In the case of self-harm repetition, they will present to an acute general hospital or primary care, in either way they will receive a comprehensive biopsychosocial assessment

In the case of self-harm repetition, and after having received biopsychosocial assessment: a) patients can require hospital/inpatient care; b) patients who no longer require acute/physical care are discharged from the hospital to other care settings (including primary care, inpatient psychiatric care, social care, and outpatient psychiatric care).

Figure 11. Illustrative self-harm service pathways model (PDF, 758K)

The committee confirmed that both conceptual frameworks ( Figure 10 , Figure 11 ) included explicit reference to all clinically meaningful events and did described the disease process in terms of healthcare resource use comprehensively by not discriminating between different age subgroups of patients (adults and CYP).

Finally, as part of the model validation, the identification of evidence sources and selection of relevant input parameters to inform both economic models was performed by the guideline health economist, checked for accuracy by another health economist and agreed with a health-economics sub-group formed by members of the committee for this purpose ( Kaltenthaler 2011 ). Finally, all inputs and models’ formulae were systematically checked; the models were tested for logical consistency by setting input parameters to null and extreme values and examining whether results changed in the expected direction. The base-case results and results of sensitivity analyses were discussed with the committee to confirm their plausibility.

Kaltenthaler 2011

Tappenden 2016

Appendix J. Excluded studies

Excluded studies for review question: what psychological and psychosocial interventions (including safety plans and electronic health-based interventions) are effective for people who have self-harmed, excluded effectiveness studies.

See the Characteristics of excluded studies table from the Cochrane review of Psychosocial interventions for self-harm in adults and the Characteristics of excluded studies table from the Cochrane review of Interventions for self-harm in children and adolescents .

Excluded economic studies

Excluded studies from the guideline economic review.

Appendix K. Research recommendations

Research recommendations for review question: what psychological and psychosocial interventions (including safety plans and electronic health-based interventions) are effective for people who have self-harmed, research question.

What is the effectiveness of specific psychological interventions including digital vs face-to face (technology use) in different populations and settings?

Why this is important

Although there has been increased research attention on determining the effectiveness of different psychological interventions for people who have self-harmed, it is not clear which interventions work for whom, what the active ingredients are, and the extent to which mode of delivery (digital vs face-to face) affects the effectiveness.

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Final version

Evidence reviews underpinning recommendations 1.11.1 to 1.11.10 and research recommendation 4 in the NICE guideline

Disclaimer : The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.

Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.

NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government , Scottish Government , and Northern Ireland Executive . All NICE guidance is subject to regular review and may be updated or withdrawn.

Cite this Page Evidence reviews for psychological and psychosocial interventions: Self-harm: assessment, management and preventing recurrence: Evidence review J. London: National Institute for Health and Care Excellence (NICE); 2022 Sep. (NICE Guideline, No. 225.)
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Counselling: A problem-solving approach Paperback – January 1, 1993

Print length 197 pages
Language English
Publisher Armour Pub
Publication date January 1, 1993
ISBN-10 9810044240
ISBN-13 978-9810044244
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Publisher ‏ : ‎ Armour Pub (January 1, 1993)
Language ‏ : ‎ English
Paperback ‏ : ‎ 197 pages
ISBN-10 ‏ : ‎ 9810044240
ISBN-13 ‏ : ‎ 978-9810044244
Item Weight ‏ : ‎ 9.6 ounces

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Anthony yeo.

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COUNSELLING: A PROBLEM SOLVING APPROACH

$ 18.00

Written by Anthony Yeo (1993)

Written from the author’s more than 20 years’ experience as a psychotherapist and marriage-and-family therapist, this useful book offers an uncomplicated, four-step approach to problem-solving, as well as knowledge and relevant case studies to deal with difficult situations in counselling.

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Do You Understand the Problem You’re Trying to Solve?

To solve tough problems at work, first ask these questions.

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Problem solving skills are invaluable in any job. But all too often, we jump to find solutions to a problem without taking time to really understand the dilemma we face, according to Thomas Wedell-Wedellsborg , an expert in innovation and the author of the book, What’s Your Problem?: To Solve Your Toughest Problems, Change the Problems You Solve .

In this episode, you’ll learn how to reframe tough problems by asking questions that reveal all the factors and assumptions that contribute to the situation. You’ll also learn why searching for just one root cause can be misleading.

Key episode topics include: leadership, decision making and problem solving, power and influence, business management.

HBR On Leadership curates the best case studies and conversations with the world’s top business and management experts, to help you unlock the best in those around you. New episodes every week.

Listen to the original HBR IdeaCast episode: The Secret to Better Problem Solving (2016)
Find more episodes of HBR IdeaCast
Discover 100 years of Harvard Business Review articles, case studies, podcasts, and more at HBR.org .

HANNAH BATES: Welcome to HBR on Leadership , case studies and conversations with the world’s top business and management experts, hand-selected to help you unlock the best in those around you.

Problem solving skills are invaluable in any job. But even the most experienced among us can fall into the trap of solving the wrong problem.

Thomas Wedell-Wedellsborg says that all too often, we jump to find solutions to a problem – without taking time to really understand what we’re facing.

He’s an expert in innovation, and he’s the author of the book, What’s Your Problem?: To Solve Your Toughest Problems, Change the Problems You Solve .

In this episode, you’ll learn how to reframe tough problems, by asking questions that reveal all the factors and assumptions that contribute to the situation. You’ll also learn why searching for one root cause can be misleading. And you’ll learn how to use experimentation and rapid prototyping as problem-solving tools.

This episode originally aired on HBR IdeaCast in December 2016. Here it is.

SARAH GREEN CARMICHAEL: Welcome to the HBR IdeaCast from Harvard Business Review. I’m Sarah Green Carmichael.

Problem solving is popular. People put it on their resumes. Managers believe they excel at it. Companies count it as a key proficiency. We solve customers’ problems.

The problem is we often solve the wrong problems. Albert Einstein and Peter Drucker alike have discussed the difficulty of effective diagnosis. There are great frameworks for getting teams to attack true problems, but they’re often hard to do daily and on the fly. That’s where our guest comes in.

Thomas Wedell-Wedellsborg is a consultant who helps companies and managers reframe their problems so they can come up with an effective solution faster. He asks the question “Are You Solving The Right Problems?” in the January-February 2017 issue of Harvard Business Review. Thomas, thank you so much for coming on the HBR IdeaCast .

THOMAS WEDELL-WEDELLSBORG: Thanks for inviting me.

SARAH GREEN CARMICHAEL: So, I thought maybe we could start by talking about the problem of talking about problem reframing. What is that exactly?

THOMAS WEDELL-WEDELLSBORG: Basically, when people face a problem, they tend to jump into solution mode to rapidly, and very often that means that they don’t really understand, necessarily, the problem they’re trying to solve. And so, reframing is really a– at heart, it’s a method that helps you avoid that by taking a second to go in and ask two questions, basically saying, first of all, wait. What is the problem we’re trying to solve? And then crucially asking, is there a different way to think about what the problem actually is?

SARAH GREEN CARMICHAEL: So, I feel like so often when this comes up in meetings, you know, someone says that, and maybe they throw out the Einstein quote about you spend an hour of problem solving, you spend 55 minutes to find the problem. And then everyone else in the room kind of gets irritated. So, maybe just give us an example of maybe how this would work in practice in a way that would not, sort of, set people’s teeth on edge, like oh, here Sarah goes again, reframing the whole problem instead of just solving it.

THOMAS WEDELL-WEDELLSBORG: I mean, you’re bringing up something that’s, I think is crucial, which is to create legitimacy for the method. So, one of the reasons why I put out the article is to give people a tool to say actually, this thing is still important, and we need to do it. But I think the really critical thing in order to make this work in a meeting is actually to learn how to do it fast, because if you have the idea that you need to spend 30 minutes in a meeting delving deeply into the problem, I mean, that’s going to be uphill for most problems. So, the critical thing here is really to try to make it a practice you can implement very, very rapidly.

There’s an example that I would suggest memorizing. This is the example that I use to explain very rapidly what it is. And it’s basically, I call it the slow elevator problem. You imagine that you are the owner of an office building, and that your tenants are complaining that the elevator’s slow.

Now, if you take that problem framing for granted, you’re going to start thinking creatively around how do we make the elevator faster. Do we install a new motor? Do we have to buy a new lift somewhere?

The thing is, though, if you ask people who actually work with facilities management, well, they’re going to have a different solution for you, which is put up a mirror next to the elevator. That’s what happens is, of course, that people go oh, I’m busy. I’m busy. I’m– oh, a mirror. Oh, that’s beautiful.

And then they forget time. What’s interesting about that example is that the idea with a mirror is actually a solution to a different problem than the one you first proposed. And so, the whole idea here is once you get good at using reframing, you can quickly identify other aspects of the problem that might be much better to try to solve than the original one you found. It’s not necessarily that the first one is wrong. It’s just that there might be better problems out there to attack that we can, means we can do things much faster, cheaper, or better.

SARAH GREEN CARMICHAEL: So, in that example, I can understand how A, it’s probably expensive to make the elevator faster, so it’s much cheaper just to put up a mirror. And B, maybe the real problem people are actually feeling, even though they’re not articulating it right, is like, I hate waiting for the elevator. But if you let them sort of fix their hair or check their teeth, they’re suddenly distracted and don’t notice.

But if you have, this is sort of a pedestrian example, but say you have a roommate or a spouse who doesn’t clean up the kitchen. Facing that problem and not having your elegant solution already there to highlight the contrast between the perceived problem and the real problem, how would you take a problem like that and attack it using this method so that you can see what some of the other options might be?

THOMAS WEDELL-WEDELLSBORG: Right. So, I mean, let’s say it’s you who have that problem. I would go in and say, first of all, what would you say the problem is? Like, if you were to describe your view of the problem, what would that be?

SARAH GREEN CARMICHAEL: I hate cleaning the kitchen, and I want someone else to clean it up.

THOMAS WEDELL-WEDELLSBORG: OK. So, my first observation, you know, that somebody else might not necessarily be your spouse. So, already there, there’s an inbuilt assumption in your question around oh, it has to be my husband who does the cleaning. So, it might actually be worth, already there to say, is that really the only problem you have? That you hate cleaning the kitchen, and you want to avoid it? Or might there be something around, as well, getting a better relationship in terms of how you solve problems in general or establishing a better way to handle small problems when dealing with your spouse?

SARAH GREEN CARMICHAEL: Or maybe, now that I’m thinking that, maybe the problem is that you just can’t find the stuff in the kitchen when you need to find it.

THOMAS WEDELL-WEDELLSBORG: Right, and so that’s an example of a reframing, that actually why is it a problem that the kitchen is not clean? Is it only because you hate the act of cleaning, or does it actually mean that it just takes you a lot longer and gets a lot messier to actually use the kitchen, which is a different problem. The way you describe this problem now, is there anything that’s missing from that description?

SARAH GREEN CARMICHAEL: That is a really good question.

THOMAS WEDELL-WEDELLSBORG: Other, basically asking other factors that we are not talking about right now, and I say those because people tend to, when given a problem, they tend to delve deeper into the detail. What often is missing is actually an element outside of the initial description of the problem that might be really relevant to what’s going on. Like, why does the kitchen get messy in the first place? Is it something about the way you use it or your cooking habits? Is it because the neighbor’s kids, kind of, use it all the time?

There might, very often, there might be issues that you’re not really thinking about when you first describe the problem that actually has a big effect on it.

SARAH GREEN CARMICHAEL: I think at this point it would be helpful to maybe get another business example, and I’m wondering if you could tell us the story of the dog adoption problem.

THOMAS WEDELL-WEDELLSBORG: Yeah. This is a big problem in the US. If you work in the shelter industry, basically because dogs are so popular, more than 3 million dogs every year enter a shelter, and currently only about half of those actually find a new home and get adopted. And so, this is a problem that has persisted. It’s been, like, a structural problem for decades in this space. In the last three years, where people found new ways to address it.

So a woman called Lori Weise who runs a rescue organization in South LA, and she actually went in and challenged the very idea of what we were trying to do. She said, no, no. The problem we’re trying to solve is not about how to get more people to adopt dogs. It is about keeping the dogs with their first family so they never enter the shelter system in the first place.

In 2013, she started what’s called a Shelter Intervention Program that basically works like this. If a family comes and wants to hand over their dog, these are called owner surrenders. It’s about 30% of all dogs that come into a shelter. All they would do is go up and ask, if you could, would you like to keep your animal? And if they said yes, they would try to fix whatever helped them fix the problem, but that made them turn over this.

And sometimes that might be that they moved into a new building. The landlord required a deposit, and they simply didn’t have the money to put down a deposit. Or the dog might need a $10 rabies shot, but they didn’t know how to get access to a vet.

And so, by instigating that program, just in the first year, she took her, basically the amount of dollars they spent per animal they helped went from something like $85 down to around $60. Just an immediate impact, and her program now is being rolled out, is being supported by the ASPCA, which is one of the big animal welfare stations, and it’s being rolled out to various other places.

And I think what really struck me with that example was this was not dependent on having the internet. This was not, oh, we needed to have everybody mobile before we could come up with this. This, conceivably, we could have done 20 years ago. Only, it only happened when somebody, like in this case Lori, went in and actually rethought what the problem they were trying to solve was in the first place.

SARAH GREEN CARMICHAEL: So, what I also think is so interesting about that example is that when you talk about it, it doesn’t sound like the kind of thing that would have been thought of through other kinds of problem solving methods. There wasn’t necessarily an After Action Review or a 5 Whys exercise or a Six Sigma type intervention. I don’t want to throw those other methods under the bus, but how can you get such powerful results with such a very simple way of thinking about something?

THOMAS WEDELL-WEDELLSBORG: That was something that struck me as well. This, in a way, reframing and the idea of the problem diagnosis is important is something we’ve known for a long, long time. And we’ve actually have built some tools to help out. If you worked with us professionally, you are familiar with, like, Six Sigma, TRIZ, and so on. You mentioned 5 Whys. A root cause analysis is another one that a lot of people are familiar with.

Those are our good tools, and they’re definitely better than nothing. But what I notice when I work with the companies applying those was those tools tend to make you dig deeper into the first understanding of the problem we have. If it’s the elevator example, people start asking, well, is that the cable strength, or is the capacity of the elevator? That they kind of get caught by the details.

That, in a way, is a bad way to work on problems because it really assumes that there’s like a, you can almost hear it, a root cause. That you have to dig down and find the one true problem, and everything else was just symptoms. That’s a bad way to think about problems because problems tend to be multicausal.

There tend to be lots of causes or levers you can potentially press to address a problem. And if you think there’s only one, if that’s the right problem, that’s actually a dangerous way. And so I think that’s why, that this is a method I’ve worked with over the last five years, trying to basically refine how to make people better at this, and the key tends to be this thing about shifting out and saying, is there a totally different way of thinking about the problem versus getting too caught up in the mechanistic details of what happens.

SARAH GREEN CARMICHAEL: What about experimentation? Because that’s another method that’s become really popular with the rise of Lean Startup and lots of other innovation methodologies. Why wouldn’t it have worked to, say, experiment with many different types of fixing the dog adoption problem, and then just pick the one that works the best?

THOMAS WEDELL-WEDELLSBORG: You could say in the dog space, that’s what’s been going on. I mean, there is, in this industry and a lot of, it’s largely volunteer driven. People have experimented, and they found different ways of trying to cope. And that has definitely made the problem better. So, I wouldn’t say that experimentation is bad, quite the contrary. Rapid prototyping, quickly putting something out into the world and learning from it, that’s a fantastic way to learn more and to move forward.

My point is, though, that I feel we’ve come to rely too much on that. There’s like, if you look at the start up space, the wisdom is now just to put something quickly into the market, and then if it doesn’t work, pivot and just do more stuff. What reframing really is, I think of it as the cognitive counterpoint to prototyping. So, this is really a way of seeing very quickly, like not just working on the solution, but also working on our understanding of the problem and trying to see is there a different way to think about that.

If you only stick with experimentation, again, you tend to sometimes stay too much in the same space trying minute variations of something instead of taking a step back and saying, wait a minute. What is this telling us about what the real issue is?

SARAH GREEN CARMICHAEL: So, to go back to something that we touched on earlier, when we were talking about the completely hypothetical example of a spouse who does not clean the kitchen–

THOMAS WEDELL-WEDELLSBORG: Completely, completely hypothetical.

SARAH GREEN CARMICHAEL: Yes. For the record, my husband is a great kitchen cleaner.

You started asking me some questions that I could see immediately were helping me rethink that problem. Is that kind of the key, just having a checklist of questions to ask yourself? How do you really start to put this into practice?

THOMAS WEDELL-WEDELLSBORG: I think there are two steps in that. The first one is just to make yourself better at the method. Yes, you should kind of work with a checklist. In the article, I kind of outlined seven practices that you can use to do this.

But importantly, I would say you have to consider that as, basically, a set of training wheels. I think there’s a big, big danger in getting caught in a checklist. This is something I work with.

My co-author Paddy Miller, it’s one of his insights. That if you start giving people a checklist for things like this, they start following it. And that’s actually a problem, because what you really want them to do is start challenging their thinking.

So the way to handle this is to get some practice using it. Do use the checklist initially, but then try to step away from it and try to see if you can organically make– it’s almost a habit of mind. When you run into a colleague in the hallway and she has a problem and you have five minutes, like, delving in and just starting asking some of those questions and using your intuition to say, wait, how is she talking about this problem? And is there a question or two I can ask her about the problem that can help her rethink it?

SARAH GREEN CARMICHAEL: Well, that is also just a very different approach, because I think in that situation, most of us can’t go 30 seconds without jumping in and offering solutions.

THOMAS WEDELL-WEDELLSBORG: Very true. The drive toward solutions is very strong. And to be clear, I mean, there’s nothing wrong with that if the solutions work. So, many problems are just solved by oh, you know, oh, here’s the way to do that. Great.

But this is really a powerful method for those problems where either it’s something we’ve been banging our heads against tons of times without making progress, or when you need to come up with a really creative solution. When you’re facing a competitor with a much bigger budget, and you know, if you solve the same problem later, you’re not going to win. So, that basic idea of taking that approach to problems can often help you move forward in a different way than just like, oh, I have a solution.

I would say there’s also, there’s some interesting psychological stuff going on, right? Where you may have tried this, but if somebody tries to serve up a solution to a problem I have, I’m often resistant towards them. Kind if like, no, no, no, no, no, no. That solution is not going to work in my world. Whereas if you get them to discuss and analyze what the problem really is, you might actually dig something up.

Let’s go back to the kitchen example. One powerful question is just to say, what’s your own part in creating this problem? It’s very often, like, people, they describe problems as if it’s something that’s inflicted upon them from the external world, and they are innocent bystanders in that.

SARAH GREEN CARMICHAEL: Right, or crazy customers with unreasonable demands.

THOMAS WEDELL-WEDELLSBORG: Exactly, right. I don’t think I’ve ever met an agency or consultancy that didn’t, like, gossip about their customers. Oh, my god, they’re horrible. That, you know, classic thing, why don’t they want to take more risk? Well, risk is bad.

It’s their business that’s on the line, not the consultancy’s, right? So, absolutely, that’s one of the things when you step into a different mindset and kind of, wait. Oh yeah, maybe I actually am part of creating this problem in a sense, as well. That tends to open some new doors for you to move forward, in a way, with stuff that you may have been struggling with for years.

SARAH GREEN CARMICHAEL: So, we’ve surfaced a couple of questions that are useful. I’m curious to know, what are some of the other questions that you find yourself asking in these situations, given that you have made this sort of mental habit that you do? What are the questions that people seem to find really useful?

THOMAS WEDELL-WEDELLSBORG: One easy one is just to ask if there are any positive exceptions to the problem. So, was there day where your kitchen was actually spotlessly clean? And then asking, what was different about that day? Like, what happened there that didn’t happen the other days? That can very often point people towards a factor that they hadn’t considered previously.

SARAH GREEN CARMICHAEL: We got take-out.

THOMAS WEDELL-WEDELLSBORG: S,o that is your solution. Take-out from [INAUDIBLE]. That might have other problems.

Another good question, and this is a little bit more high level. It’s actually more making an observation about labeling how that person thinks about the problem. And what I mean with that is, we have problem categories in our head. So, if I say, let’s say that you describe a problem to me and say, well, we have a really great product and are, it’s much better than our previous product, but people aren’t buying it. I think we need to put more marketing dollars into this.

Now you can go in and say, that’s interesting. This sounds like you’re thinking of this as a communications problem. Is there a different way of thinking about that? Because you can almost tell how, when the second you say communications, there are some ideas about how do you solve a communications problem. Typically with more communication.

And what you might do is go in and suggest, well, have you considered that it might be, say, an incentive problem? Are there incentives on behalf of the purchasing manager at your clients that are obstructing you? Might there be incentive issues with your own sales force that makes them want to sell the old product instead of the new one?

So literally, just identifying what type of problem does this person think about, and is there different potential way of thinking about it? Might it be an emotional problem, a timing problem, an expectations management problem? Thinking about what label of what type of problem that person is kind of thinking as it of.

SARAH GREEN CARMICHAEL: That’s really interesting, too, because I think so many of us get requests for advice that we’re really not qualified to give. So, maybe the next time that happens, instead of muddying my way through, I will just ask some of those questions that we talked about instead.

THOMAS WEDELL-WEDELLSBORG: That sounds like a good idea.

SARAH GREEN CARMICHAEL: So, Thomas, this has really helped me reframe the way I think about a couple of problems in my own life, and I’m just wondering. I know you do this professionally, but is there a problem in your life that thinking this way has helped you solve?

THOMAS WEDELL-WEDELLSBORG: I’ve, of course, I’ve been swallowing my own medicine on this, too, and I think I have, well, maybe two different examples, and in one case somebody else did the reframing for me. But in one case, when I was younger, I often kind of struggled a little bit. I mean, this is my teenage years, kind of hanging out with my parents. I thought they were pretty annoying people. That’s not really fair, because they’re quite wonderful, but that’s what life is when you’re a teenager.

And one of the things that struck me, suddenly, and this was kind of the positive exception was, there was actually an evening where we really had a good time, and there wasn’t a conflict. And the core thing was, I wasn’t just seeing them in their old house where I grew up. It was, actually, we were at a restaurant. And it suddenly struck me that so much of the sometimes, kind of, a little bit, you love them but they’re annoying kind of dynamic, is tied to the place, is tied to the setting you are in.

And of course, if– you know, I live abroad now, if I visit my parents and I stay in my old bedroom, you know, my mother comes in and wants to wake me up in the morning. Stuff like that, right? And it just struck me so, so clearly that it’s– when I change this setting, if I go out and have dinner with them at a different place, that the dynamic, just that dynamic disappears.

SARAH GREEN CARMICHAEL: Well, Thomas, this has been really, really helpful. Thank you for talking with me today.

THOMAS WEDELL-WEDELLSBORG: Thank you, Sarah.

HANNAH BATES: That was Thomas Wedell-Wedellsborg in conversation with Sarah Green Carmichael on the HBR IdeaCast. He’s an expert in problem solving and innovation, and he’s the author of the book, What’s Your Problem?: To Solve Your Toughest Problems, Change the Problems You Solve .

We’ll be back next Wednesday with another hand-picked conversation about leadership from the Harvard Business Review. If you found this episode helpful, share it with your friends and colleagues, and follow our show on Apple Podcasts, Spotify, or wherever you get your podcasts. While you’re there, be sure to leave us a review.

We’re a production of Harvard Business Review. If you want more podcasts, articles, case studies, books, and videos like this, find it all at HBR dot org.

This episode was produced by Anne Saini, and me, Hannah Bates. Ian Fox is our editor. Music by Coma Media. Special thanks to Maureen Hoch, Adi Ignatius, Karen Player, Ramsey Khabbaz, Nicole Smith, Anne Bartholomew, and you – our listener.

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Ways to Address or Prevent Therapeutic Inertia for People With Type 1 or Type 2 Diabetes

When to use injectable therapy in type 2 diabetes, use of glucose-lowering medications in the management of type 2 diabetes, to-do list for clinicians treating people with insulin therapy, section 9: pharmacologic approaches to glycemic treatment.

This article is part of a special article collection available at https://diabetesjournals.org/collection/2018/2024-Abridged-Standards-of-Care .

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Section 9: Pharmacologic Approaches to Glycemic Treatment. Clin Diabetes 15 April 2024; 42 (2): 206–208. https://doi.org/10.2337/cd24-a009

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* In people with HF, CKD, established CVD, or multiple risk factors for CVD, the decision to use a GLP- 1 RA or SGLT2i with proven benefit should be independent of background use of metformin;† A strong recommendation is warranted for people with CVD and a weaker recommendation for those with indicators of high CV risk. Moreover, a higher absolute risk reduction and thus lower numbers needed to treat are seen at higher levels of baseline risk and should be factored into the shared decision-making process. See text for details; ^ Low-dose TZD may be better tolerated and similarly effective; § For SGLT2i, CV/renal outcomes trials demonstrate their efficacy in reducing the risk of composite MACE, CV death, all-cause mortality, MI, HHF, and renal outcomes in individuals with T2D with established/high risk of CVD; # For GLP-1 RA, CVOTs demonstrate their efficacy in reducing composite MACE, CV death, all-cause mortality, MI, stroke, and renal endpoints in individuals with T2D with established/high risk of CVD.

ACEi, angiotensin-converting enzyme inhibitor; ACR, albumin-to-creatinine ratio; ARB, angiotensin receptor blocker; ASCVD, atherosclerotic cardiovascular disease; CGM, continuous glucose monitoring; CKD, chronic kidney disease; CV, cardiovascular; CVD, cardiovascular disease; CVOT, cardiovascular outcomes trial; DPP-4i, dipeptidyl peptidase 4 inhibitor; eGFR, estimated glomerular filtration rate; GLP-1 RA, glucagon- like peptide 1 receptor agonist; dual GIP/GLP-1 RA, dual glucose-dependent insulinotropic polypeptide and glucagon-like peptide 1 receptor agonist; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; HHF, hospitalization for heart failure; MACE, major adverse cardiovascular events; MI, myocardial infarction; SDOH, social determinants of health; SGLT2i, sodium-glucose cotransporter 2 inhibitor; T2D, type 2 diabetes; TZD, thiazolidinedione. Adapted from Davies MJ, D’Alessio DA, Fradkin J, et al. Management of hyperglycemia in type 2 diabetes, 2018: a consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care 2018;41:2669–2701.

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Discover an effective problem-solving strategy in counselling
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Problem-Solving Therapy: Definition, Techniques, and Efficacy
Problem-solving therapy is a short-term treatment used to help people who are experiencing depression, stress, PTSD, self-harm, suicidal ideation, and other mental health problems develop the tools they need to deal with challenges. This approach teaches people to identify problems, generate solutions, and implement those solutions.
Problem-Solving Therapy: How It Works & What to Expect
Problem-solving therapy (PST) is an intervention with cognitive and behavioral influences used to assist individuals in managing life problems. Therapists help clients learn effective skills to address their issues directly and make positive changes. PST is used in various settings to address mental health concerns such as depression, anxiety, and more.
Solving Problems the Cognitive-Behavioral Way
One benefit of the cognitive behavioral therapy approach is the behavioral side. The behavioral part of therapy is a wide umbrella that includes problem-solving techniques among other techniques.
10 Best Problem-Solving Therapy Worksheets & Activities
14 Steps for Problem-Solving Therapy. Creators of PST D'Zurilla and Nezu suggest a 14-step approach to achieve the following problem-solving treatment goals (Dobson, 2011): Enhance positive problem orientation. Decrease negative orientation. Foster ability to apply rational problem-solving skills.
Problem-Solving Therapy
Problem-solving therapy is a cognitive-behavioral intervention geared to improve an individual's ability to cope with stressful life experiences. The underlying assumption of this approach is that symptoms of psychopathology can often be understood as the negative consequences of ineffective or maladaptive coping.
Problem-Solving the Solution-Focused Way
Problem-Solving the Solution-Focused Way. In the past few decades, a strength-based movement has emerged in the field of mental health. It offers an alternative to problem-focused approaches that ...
Discover an effective problem-solving strategy in counselling
Identifying the problem. Uncovering essential information as part of your problem-solving strategy in counselling will prevent you from:. solving only part of the problem and the real problem rearing it's ugly head again in the future; solving a problem that's really only a diversion - a red herring. solving a problem that's only a symptom of an underlying issue
5 Problem-Solving Therapy: Theory and Practice
As opposed to the extant medical model of mental health, emerging therapies rooted in the social competence approach focused less on pathologizing those receiving therapy, and more on developing their coping and problem-solving skills (D'Zurilla & Nezu, 1999). While still incorporating theoretical aspects of social problem-solving and stress ...
Egan's Model of Problem-Management
The worldwide acceptance of his approach supports Egan's conviction that learning and problem-solving are the cornerstones of any counselling approach. He has provided (1996) a clear logical basis for the use of his approach for counsellors/helpers: 1. Problem-solving has been intensively researched and is therefore not based on unproven ...
a problem-solving approach to counseling: integrating adler's
This article describes a four-step problem-solving model that integrates. Alfred Adler's (1969) and William Glasser's (1965, 1989) theories. The. model provides a structure that school counselors can use to conceptualize short-term counseling. McClam and Woodside (1994) presented an over-.
What is Solution-Focused Therapy: 3 Essential Techniques
Pinpoint the behaviors a client is already engaging in that are helpful and effective and find new ways to facilitate problem-solving through these behaviors; Focus on the details of the solution instead of the problem; Develop action plans that work for the client (Focus on Solutions, 2013).
PDF Session 2 Problem-Solving Therapy
Problem-Solving Therapy (PST) is an evidenced-based intervention to facilitate behavioral changes through a variety of skill training. PST identifies strategies to support people to cope with difficulties in life and take the initiative to solve everyday problems. Using cognitive behavioral theories, effective and successful problem solving
Counselling: A Problem Solving Approach
Counselling: A Problem Solving Approach. Written from the author's more than 20 years' experience as a psychotherapist and marriage-and-family therapist, this useful book offers an uncomplicated, four-step approach to problem-solving, as well as knowledge and relevant case studies to deal with difficult situations in counselling.
Counselling: A Problem-solving Approach
Counselling: A Problem-solving Approach Anthony Yeo Snippet view - 1993. Common terms and phrases. able accept adopt advice agency approach appropriate Asia assess attempted attention avoid become begin behaviour believe better bring clear client concern consider continue coun counselling counsellor deal decided depression difficult direct ...
Guided discovery: Problem-solving therapy integrated within the
Guided discovery involves a therapeutic dialogue that is designed to assist clients in finding their own solutions to their problems. An integration of problem-solving therapy and the Socratic method can help clients to develop their own coping skills. Problem-solving therapy provides a useful framework for helping clients to manage many of the problems they typically encounter. The Socratic ...
Realistic Approaches to Counseling in the Office Setting
Problem-solving therapy (Table 6 34) is a four-step approach (problem definition, generating alternative solutions, decision making, solution verification and implementation), which was developed ...
Defining the Counseling Process and Its Stages
The counseling process is a planned and structured dialogue between client and counselor. The counselor is a trained and qualified professional who helps the client identify the source of their concerns or difficulties; then, together, they find counseling approaches to help deal with the problems faced (Krishnan, n.d.).
The Effect of Problem-Solving-Approach-Based Counselling on Maternal
Taking a problem-solving approach, counselling was carried out individually in four sessions. The control group received only routine care. The data were collected using adaptation to maternal role questionnaire including 33 items based on a five-point Likert scale ranging in seven areas, in two steps (before counselling and one month after the ...
Evidence reviews for psychological and psychosocial interventions
Summary of the evidence. The Cochrane review of psychosocial interventions for self-harm in adults investigated 12 comparisons, with the following findings: Comparison 1: Cognitive behavioural therapy (CBT)-based psychotherapy (e.g. CBT, problem-solving therapy [PST]) versus TAU or another comparator.
Counselling: A Problem-solving Approach
Counselling: A Problem-Solving Approach is a book by Anthony Yeo, a pioneer of counselling in Asia. It offers practical guidance and strategies for helping clients with various issues, such as depression, anxiety, stress, and relationship problems. The book also reflects the cultural and social context of counselling in Asia, and the challenges and opportunities for counsellors in the region.
Counselling: A problem-solving approach
Paperback - January 1, 1993. Written from the author's over 20 years' experience as a psychotherapist and marriage-and-family therapist, this is a useful book that offers an uncomplicated, four-step approach to problem-solving. The reader is provided knowledge and relevant case studies to deal with difficult situations in counselling.
A cognitive load theory approach to understanding expert scaffolding of
Visual problem-solving is an essential skill for professionals in various visual domains. Novices in these domains acquire such skills through interactions with experts (e.g., apprenticeships). Experts guide novice visual problem-solving with scaffolding behaviours. However, there is little consensus about the description and classification of scaffolding behaviours in practice, and to our ...
COUNSELLING: A PROBLEM SOLVING APPROACH
Written by Anthony Yeo (1993) Written from the author's more than 20 years' experience as a psychotherapist and marriage-and-family therapist, this useful book offers an uncomplicated, four-step approach to problem-solving, as well as knowledge and relevant case studies to deal with difficult situations in counselling. Add to cart.
Do You Understand the Problem You're Trying to Solve?
Problem solving skills are invaluable in any job. ... So, that basic idea of taking that approach to problems can often help you move forward in a different way than just like, oh, I have a ...
Behavioral Sciences
Clinical High Risk for psychosis (CHR) refers to a phase of heightened risk for developing overt psychosis. CHR often emerges during adolescence or early adulthood. CHR has been identified as a group to target for intervention, with the hope that early intervention can both stave off prolonged suffering and intervene before mental health challenges become part of an individual's identity ...
Extra Credit: Culturally Responsive Problem Solving Modules
This module presents school staff with an evidence-based, culturally responsive approach to problem solving with students. This module takes approximately 30 minutes to complete. About the Presenter Dr. Markeda Newell earned her PhD in Educational Psychology from the University of Wisconsin-Madison. She is currently the Interim Dean and an ...
Section 9: Pharmacologic Approaches to Glycemic Treatment
Provide or refer patients for education about injection technique and timing and problem-solving for issues related to insulin therapy (e.g., hypoglycemia, missed or incorrect doses, and dose adjustments).

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Effective problem-identification and problem-solving in counselling – in 4 steps

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Defining the Counseling Process and Its Stages

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Stage one: (Initial disclosure) Relationship building

Stage two: (In-depth exploration) Problem assessment

Stage three: (Commitment to action) Goal setting

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