Self-harm is a term used to illustrate conscious action (s) of inflicting physical injury on self which can involve actions such as self-poisoning or self-cutting irrespective of the level of suicidal intention (Hawton et al., 1999). However, researchers argue that deliberate self-harm is done by the victims involved without a conscious intention of committing suicide but instead they tend to engage in self-harm behaviour so as to alleviate the psychological distress they are going through (Moorey, 2010). There has been a shortage of empirical research which examines the motivations behind self-harm (Gratz, 2007). The research conducted on mostly clinical adult and adolescent samples have discovered motivations such as depression, feelings of isolation (loneliness), an intention to punish oneself and to unleash anger (Gratz, 2007). Self-harm in adolescents is as a result of complicated links between psychological, biological, psychiatric, cultural, social, and genetic factors (Hawton & James, 2005). Relationship problems with family members and partners are frequent for people who self-harm. Treatment for self-harm can involve pharmacological interventions or psychosocial intervention or a mixture of both. While the use of pharmacological interventions may involve the use of medications such as antidepressants, psychosocial interventions involve the use of wide range of treatments including behavioural therapy, problem-solving therapy, cognitive behavioural therapy, and dialectical behaviour therapy also known as DBT (Tyrer et al., 2003). Other treatments intervention includes talking therapy or counselling which can be done using various approaches including Humanistic or Person centred, Psychodynamic or Cognitive Behavioural approach. Hence, for the purpose of this essay, Cognitive Behavioural Therapy (CBT) will be the main focus and its effectiveness as a psychological intervention on clients who intentionally self-harm will be explored.

Cognitive Behavioural Therapy (CBT) as an intervention is aimed at helping patients identify and evaluate the methods by which they personally interpret their emotionally disturbing experiences (Moorey, 2010) with the focus of helping them change the ways they resolve these problems. The CBT process is achieved in three major steps: firstly, the patients are helped to identify how they interpret and evaluate distressing feelings, secondly they are taught methods that can help them change the ways by which they feel and think about these situations and finally patients are helped to change their behaviour positively in response to these distressing feelings (Tyrer et al., 2004). The effectiveness of CBT as a psychological intervention for the treatment of self-harm has been investigated using series of trials (including clinical and randomised controlled trials) and case studies. Slee, Garnefski, van der Leeden, Arensman, & Spinhoven (2008), conducted a review of the effectiveness of cognitive behavioural therapies and their findings revealed that there are three basic mechanisms of change that seems to match the observable deficits found in people who self-harm and these includes, cognitive vulnerabilities, emotion regulation and problem solving (Borrill et al., 2009). Problem solving is considered to be the vital element of cognitive behavioural interventions for deliberate self-harm and it can also be administered as a treatment on its own. Problem solving therapy believes that the unproductive and faulty coping behaviours exhibited by patients who self-harm can be resolved by assisting them to learn new useful positive skills that can effectively and actively resolve the issues they encounter in their daily lives and this will, in turn, reduce self-harm behaviours (Tyrer et al., 2003).

It is believed that people who engage in self-harm have a deficiency in their problem solving abilities (Hawton & James, 2005). Williams et al (1996) put forward a theory that connected problem solving deficits to autobiographical memory bias (overgeneralised). It was hypothesized that the absence of precision could be linked with distressing effect which is related to specific memories that are involved in traumatic experiences and when people experience this and are unable to tap into any previous personal memories, they become really distressed and the only way they feel they can deal with this distress is by engaging in self-harm. It has been proposed that the use of treatment measures such as CBT that is designed to improve problem solving abilities is the most effective method in the treatment of self-harm. Slee et al. (2008), researched the effect of short term CBT intervention course on young people (with age range of 15 to 35 years old) that has currently got involved in self-harm behaviour. Total of 90 patients were allocated randomly to either usual treatment only or intervention plus usual treatment. Findings from this study revealed that patients who were exposed to cognitive behavioural intervention treatment in addition to usual treatment showed a significantly greater improvement in their self-esteem as well as their problem solving skills, and they also experienced a significantly higher reduction in their practice of self-harm when compared to the control group (Moorey, 2010). This result supports previous research on the effectiveness of CBT in treating self-harm by Tyrer et al. (2003) who conducted a study using a randomized trial involving 480 patients with frequent deliberate self-harm episode across five different centres. Tyrer et al. (2003) study was aimed at comparing the effectiveness of treatment as usual to brief cognitive therapy and manual assisted cognitive behaviour therapy also known as MACT (MACT was developed by Schmidst and Davidson, 2003 and it works by combining CBT to some aspects of DBT techniques). Findings from this study revealed that patients allocated to the MACT reported reduction in self-harm episodes (39%) compared to those patients allocated to treatment as usual group (46%), however this result was not statistically significant due to high dropout level of patients during the corse of the study (not all patients continued with their treatments to the end of the study).

It is believed that some people get involved in self-harm as a result of current stressful situations, but research has shown that the frequency and incidence of self-harm increases as the level of personality disturbance increases (Tyrer et al., 2004). Findings from a study conducted using about 2000 US military recruits revealed that there was a higher report of self-harm among soldiers whose scores was higher on measures of borderline personality disorder (Klonsky, Oltmanns & Turkheimer, 2003). Hence high range of cognitive behavioural approaches have been designed specifically for patients with borderline personality disorder with the aim of reducing deliberate self-harm. Evans et al. (1999) conducted a study which investigated the effectiveness of MACT, problem-focused and brief cognitive-oriented therapy versus treatment as usual, using people with personality disturbance who were reported to have a history of self-harm (within the age range of 16 to 50 years, N=34). Findings from this study showed that there was a reduction in the repetition of self-harm episodes in patients assigned to MACT group compared to treatment as usual group. These findings were supported by Weinberg et al (2006) study who conducted similar research using a sample of participants with borderline personality disorder (within the age range of 18 to 40 years, N=30) and results from this study showed that there was a reduction in self-harm episode in patients assigned to MACT compared to those who received treatment as usual only. However, results from both studies were not significant and this can be as a result of limitations of the studies, for example, both studies made use of small sample sizes which were mostly women and as a result of this, the generalisability of their findings is limited. Furthermore, McAuliffe (2014) investigated 18 trials which compared cognitive behavioural interventions versus treatment as usual and a meta-analysis of these trials showed that the use of CBT as an intervention yielded a reduction in self-harm repetition (6 and 12 months follow up) after the trial. However, in a single trial that compared short term intensive cognitive behavioural therapy to long term therapy showed a non-significant difference in the repetition of self-harm episode in patients involved (Torhorst, 1988).

Based on most research findings on the effectiveness of CBT in the treatment of deliberate self-harm illustrated above, it has been discovered that treatment of deliberate self-harm using a short term intensive CBT intervention is effective in reducing the repetition of self-harm behaviours in patients (McAuliffe, 2014) but research that looked into the long term effectiveness of CBT in the treatment of deliberate self-harm has not been fully successful (Torhorst, 1988). Most research findings that support the effectiveness of CBT as a psychological intervention for self-harm were not statically significant (Evans et al,1999; Torhorst, 1988; Tyrer et al, 2003; Weinberg et al, 2006) as these researches has various limitations such as issues with small sample size used which cannot be generalised and the use of self-report data to assess patients which again may have issues with subjectivity, as well as issues with the use of selected samples which include mostly women or participants with personality disturbances, and this can limit the generalizability of these research findings to the entire population. CBT as an intervention focuses its attention on dealing directly with the issue at hand (here and now) and changing the self-harm behaviour, but does not necessarily focus much attention on exploring the reason and motives behind this self-harm behaviour. As cognitive behavioural therapy is primarily aimed at identifying and directly challenging cognitions that are believed to be faulty in clients who engages in self-harm, this can thereby unconsciously strengthen the client’s perception of himself or herself to be flawed fundamentally (Van Vliet & Kalnins, 2011). Hence, instead of been successfully treated, they might end up been worse as a result of this new perception of themselves due to CBT treatment they have been exposed to. Other treatment methods that look into the motivations and reasons of the self-harm episode in each individual patient can be more effective in treating deliberate self-harm compared to CBT. People that engage in deliberate self-harm are often faced with issues they feel they have no control over and this makes them view stressful situations to be harmful and threatening personally which can also be linked to their early childhood experiences (Moorey, 2010). Motivations must be dealt with when working with people who intentionally self-harm and there is a great requirement to apply counselling approaches that can lead to strengthening client’s self-acceptance, positive way of relating to others and emotion regulation (Van Vliet, & Kalnins, 2011). Researchers have suggested that there is a need for therapeutic interventions that is aimed at helping people improve on how they deal with their emotions as well as developing alternative positive strategies that will help them cope with distressing emotions (Heath, Toste, Nedecheva, & Charlebois, 2008). Acceptance-based intervention is an alternative intervention that is focused on making people aware of their emotions, approach them, accept and tolerate them instead of avoiding the emotions (Gratz, 2007). Laye-Gindu and Schonert-Reichl (2005) has shown that young people who engage in self-harm are more likely to benefit from cooperating with the emotions they are experiencing irrespective of how difficult it may be. In the instance where self-harm is as a result of the craving for an interpersonal relationship, clients may, therefore, benefit from learning more useful and practical ways of relating and communicating to other people instead of engaging in deliberate self-harm actions.

A treatment study of more than one hundred (100) patients has reported short term effectiveness in self-harm reduction using CBT as a psychological intervention (Hawton & Catalan, 1987). However, other studies involving the use of selected populations has shown that self-harm repetition can be reduced by the use of both psychological and pharmacological interventions (Linehan et al., 1991). Treatment of self-harm using pharmacological intervention is less common because there is a risk of self-harm patients developing more suicidal thoughts when treated using pharmacological agents such as anti-depressants, benzodiazepines and other anxiolytics (Miller, 2014). Psychoanalytically oriented day hospital therapy has been noted as a potentially effective treatment for borderline personality disorder. Evidence for the effectiveness of this treatment has been investigated using a randomized control trial in United Kingdom whereby the effectiveness of this treatment was compared to the usual standard care of psychiatric patients with a severe borderline personality disorder (Bateman & Fonagy, 1999). Results from this trial showed that there was a reduction in anxiety symptoms as well as personal and social problems and self-harm acts were also reduced in patients who received the psychoanalytically oriented day hospital therapy. It was also reported that patients showed a greater improvement in almost all outcome measures in an 18- months follow-up study (Bateman & Fonagy, 2001). However, Doering et al. (2010) studied the effectiveness of transference focused psychotherapy compared to usual psychotherapeutic treatments for self-harm reduction in patients using 104 female patients diagnosed with borderline personality disorder. Transference focused psychotherapy is a form of modified psychodynamic psychotherapy which consists of two sessions (50 minutes each) per week for a period of one year and its emphasis is on exploring early childhood dysfunctional relationships in patients. Findings from this study showed that there was a significant difference in the reduction of self-harm in patients who experienced both transference focused psychotherapy and those who were treated with the usual psychotherapeutic interventions. Nevertheless, findings from this study have limited generalisability as patients involved were mostly women and there was a high drop out of patients during the course of the study.

Conclusively, CBT as an intervention is aimed at helping patients identify as well as to analytically evaluate the methods by which they personally interpret their emotionally disturbing experiences with the focus of helping them change the ways they resolve these problems. Various studies have been conducted to investigate the effectiveness of CBT in the treatment of patients who intentionally self-harm and these studies have proven that short term (6 to 12 months) CBT intervention is effective. However, there is less evidence to suggest that CBT is effective in the long term unless combined with additional therapies. Most of these studies that investigated the effectiveness of CBT in the treatment of self-harm has some limitations in the choice of participants as most of the participants were clinical adults who were diagnosed with personality disturbances and most of them were female, hence the generalisability of findings from this study is limited due to these weaknesses. CBT intervention does not place much emphasis on the motivations behind self-harm behaviour on each patient but rather focuses on directly changing the self-harm behaviour. Research has shown that motivations must be dealt with when working with people who self-harm and there is a great requirement to apply counselling approaches that can lead to strengthening client’s self-acceptance, positive way of relating to others and emotion regulation. Hence, other treatment interventions such as the use of Counselling therapies using the psychodynamic approach or humanistic approach might yield more positive outcomes in treating self-harm patients as they tend to place more emphasis on exploring motivations behind self-harm behaviour in each patient. Hence a combination of CBT with other alternative psychological intervention will be more effective in treating clients who intentionally self-harm.