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Psychological interventions
Systemic family therapy is not superior to treatment as usual in preventing repeat self-harm in adolescents
  1. Shilpa Aggarwal
  1. Correspondence to Dr Shilpa Aggarwal, Department of Psychiatry, Deakin University, Geelong VIC 3125, Australia; shilpazq{at}

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Commentary on: Cottrell DJ, Wright-Hughes A, Collinson M, et al. Effectiveness of systemic family therapy versus treatment as usual for young people after self-harm: a pragmatic, phase 3, multicentre, randomised controlled trial. Lancet Psychiatry 2018;5:203–16.

What is already known on this topic

Families influence self-harm in adolescents by either contributing towards it or offering protection against it.1 With limited evidence for individually focused interventions for repeat self-harm in adolescents, evaluation of interventions making use of family’s strengths and resources is a potential option.2 Attachment-based family therapy (ABFT) and multisystem family therapy (MST) are specific family therapy (FT) frameworks that have been tested for self-harm in adolescents.3 ABFT decreased suicidal ideation (secondary outcome) at the end of treatment over 3 months and over 12 weeks of follow-up after completion of treatment.3 MST found a reduction in suicide attempts in adolescents in the home-based treatment group as compared with the hospital group at 1-year post-treatment completion but was inadequately powered to detect differences in repeat self-harm.3

Methods of study

This is a multicentre randomised controlled trial of systemic FT using modified manual versus treatment as usual (TAU) conducted in 40 UK Child and Adolescent Mental Health Services (CAMHS) centres.4 A total of 832 adolescents referred to CAMHS for self-harm with a history of self-harm at least twice before were enrolled. Four hundred fifteen participants were randomised to the FT group and received 6 to 8 FT sessions over 6 months at approximately monthly intervals . Four hundred seventeen participants were randomised to the TAU group. Hospital attendance for repetition of self-harm in 18 months after group assignment was the primary outcome. Secondary outcomes were the repetition of self-harm leading to hospital attendance in 12 months after group assignment, suicide ideation, quality of life, depression, overall mental health, family functioning, characteristics of further self-harm episodes, emotional traits, health economics and engagement with therapy at 3, 6, 12 and 18 months.

What this paper adds

  • There was no difference between groups in the number of young people attending hospital after repeat self-harm at 18 months (HR for FT versus TAU=1.14 [95% CI 0.87 to 1.49; p=0.33]).

  • Proportion of people attending the hospital after repeat self-harm within 12 months (HR for FT versus TAU 1.15, 95% CI −0.89 to 1.49) or number of recurrent events (HR for FT versus TAU 1.05, 95% CI −0.76 to 1.44) were not significantly different between groups.

  • Beck Scale for Suicidal Ideation scores of adolescents were lower in FT at 12 months but improvement was not maintained at 18 months (mean score difference 12 months 0.64 [95% CI 0.44 to 0.94], p=0.024, 18 months 0.76 [95% CI 0.49 to 1.16], p=0.20).

  • Substantial loss to follow-up at 18 months for secondary outcome assessment (211 in FT and 252 in TAU) warrants careful interpretation of findings. There was a significant increase on prosocial behaviour subscale of young person’s strength and difficulty questionnaire in FT (difference in mean scores 0.3 [95% CI 0.0 to 0.7, p=0.034]). A significant improvement in externalising behaviour subscale on caregiver report in FT was noted (difference in mean scores −0.7 [95% CI −1.3 to 0.0, p=0.045]).

  • FT was less cost-effective than TAU, with an estimated 0.033 more self-harm events (95% CI –0.130 to 0.197; p=0.98) and a cost increase of £1253 (95% CI 725 to 1780; p<0.0001). FT was cost-effective when benefits for the young person and caregiver were combined by aggregating quality adjusted life years.


  • The intensity of FT intervention (median six sessions) was low relative to more intensive family interventions with promising results (ASSIST trial, mean 10.2 attended sessions, dialectical behaviour therapy adolescent adaptation—biweekly sessions for 12–19 weeks).3 5

What next in research

Characteristics such as family functioning in relation to affective involvement and adolescent’s emotionality in self-harming adolescents need further research to identify the best candidates for FT. Long-term benefits of FT for adolescents with recurrent self-harm need to be assessed by longer follow-up with a consideration to health economics of intervention, improvement in social, educational and emotional outcomes, and quality of life of adolescent and caregiver.

Do these results change your practice and why?

No. This study does not suggest FT as a treatment option for adolescents with recurrent self-harm leading to hospital presentation due to the lack of significant difference with TAU.


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  • Contributors SA is the sole contributor.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.

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