EVIDENCE-BASED RESOURCE GUIDE SERIES

Treatment for Suicidal 

Ideation, Self-Harm, 

and Suicide Attempts 

Among Youth
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

Acknowledgments I

Treatment for Suicidal Ideation, Self-Harm, 

and Suicide Attempts Among Youths

Acknowledgments

This report was prepared for the Substance Abuse and Mental Health Services Administration (SAMHSA) 

under contract number HHSS283201700001/ 75S20319F42002 with SAMHSA. Donelle Johnson served as 

the contracting officer representative.

Disclaimer

The views, opinions, and content of this publication are those of the authors and do not necessarily reflect 

the views, opinions, or policies of SAMHSA. Nothing in this document constitutes a direct or indirect 

endorsement by SAMHSA of any non-federal entity’s products, services, or policies, and any reference to 

non-federal entity’s products, services, or policies should not be construed as such.

Public Domain Notice

All material appearing in this publication is in the public domain and may be reproduced or copied 

without permission from SAMHSA. Citation of the source is appreciated. However, this publication 

may not be reproduced or distributed for a fee without the specific, written authorization of the Office of 

Communications, SAMHSA.

Electronic Access

This publication may be downloaded from http://store.samhsa.gov

Recommended Citation

Substance Abuse and Mental Health Services Administration (SAMHSA): Treatment for Suicidal Ideation, 

Self-harm, and Suicide Attempts Among Youth. SAMHSA Publication No. PEP20-06-01-002 Rockville, 

MD: National Mental Health and Substance Use Policy Laboratory. Substance Abuse and Mental Health 

Services Administration, 2020.

Originating Office

National Mental Health and Substance Use Policy Laboratory, Substance Abuse and Mental Health Services 

Administration, 5600 Fishers Lane, Rockville, MD 20857, SAMHSA Publication No. PEP20-06-01-002.

Nondiscrimination Notice

SAMHSA complies with applicable federal civil rights laws and does not discriminate on the basis of race, 

color, national origin, age, disability, or sex.

SAMHSA cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de 

raza, color, nacionalidad, ni edad.

Publication No. PEP20-06-01-002 Released 2020
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth

Message from Assistant Secretary for Mental Health and Substance Use II

MESSAGE FROM THE ASSISTANT SECRETARY

FOR MENTAL HEALTH AND SUBSTANCE USE, 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

As the U.S. Department of Health and Human Services Assistant Secretary for Mental Health and Substance 

Use at the Substance Abuse and Mental Health Services Administration (SAMHSA), I am pleased to present 

this new resource: Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth.

In response to the charge of the 21st Century Cures Act to disseminate information on evidence-based 

practices and service delivery models, the National Mental Health and Substance Use Policy Laboratory 

developed the Evidence-Based Resource Guide Series focused on the prevention and treatment of substance 

use disorders and mental illnesses. With this specific guide, SAMHSA’s goal is to inform healthcare 

professionals, healthcare system administrators, teachers and school administrators, parents, community 

members, policy makers, and others of the strategies for treating suicidal ideation, self-harm, and suicide 

attempts among youth.

Suicide is the second leading cause of death for youth in the United States. The suicide rate for youth aged 

10 to 24 increased 57.4 percent from 6.8 per 100,000 in 2007 to 10.7 per 100,000 in 2018.1

 Many factors 

contribute to thoughts of suicide in this population, including depression, hopelessness, low self-esteem, 

peer and parental relationship problems, academic difficulties, and substance use. Suicide is preventable, 

suicidal thoughts and behaviors are treatable, and interventions are available and should be accessible to any 

young person who needs help. 

This guide discusses the prevalence of suicide among youth, effective treatment programs, implementation 

considerations and strategies, and examples of the successful use of programs in clinical and communitybased settings. I encourage you to use this guide to identify treatment programs you can implement to 

address suicidal ideation, self-harm, and suicide attempts among youth in your communities.

Elinore F. McCance-Katz, MD, PhD 

Assistant Secretary for Mental Health and Substance Use

U.S. Department of Health and Human Services

1 Curtin, S. C. (2020). State suicide rates among adolescents and young adults aged 10-24: United States, 2000-

2018. National Center for Health Statistics, Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/

data/nvsr/nvsr69/nvsr-69-11-508.pdf.
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth

Evidence-Based Resource Guide Series Overview 1

FOREWORD

Evidence-Based Resource Guide 

Series Overview

The Substance Abuse and Mental Health Services 

Administration (SAMHSA), and specifically, its 

National Mental Health and Substance Use Policy 

Laboratory (Policy Lab), is pleased to fulfill the charge 

of the 21st Century Cures Act to disseminate information 

on evidence-based practices and service delivery models 

to prevent substance misuse and help people with 

substance use disorders (SUD), serious mental illnesses 

(SMI), and serious emotional disturbances (SED) get the 

treatment and support they need.

Treatment and recovery for SUD, SMI, and SED can 

vary based on several geographic, socio-economic, 

cultural, gender, race, ethnicity, and age-related factors 

which can complicate evaluating the effectiveness 

of services, treatments, and supports. Despite these 

variations, however, there is substantial evidence to 

inform the types of resources that can help reduce 

substance use, lessen symptoms of mental illness, and 

improve quality of life. 

The Evidence-Based Resource Guide Series is a 

comprehensive set of modules with resources to 

improve health outcomes for people at risk for, with, 

or recovering from mental and/or substance use 

disorders. It is designed for practitioners, administrators, 

community leaders, and others considering an 

intervention for their organization or community.

A priority topic for SAMHSA is ensuring the availability 

of effective treatment for youth with suicidal ideation 

or who have attempted suicide or engaged in self-harm. 

This guide reviews the related literature and science, 

examines emerging and best practices, identifies gaps in 

knowledge, and discusses challenges and strategies for 

implementation.

Expert panels of federal, state, and non-governmental 

participants provide input for each guide in this series. 

The panels include accomplished scientists, researchers, 

service providers, community administrators, federal and 

state policy makers, and people with lived experience. 

Members provide input based on their knowledge of 

healthcare systems, implementation strategies, evidencebased practices, provision of services, and policies that 

foster change. 

Research shows that implementing new programs and 

practices requires a comprehensive, multi-pronged 

approach. This guide is one piece of an overall approach 

to implement and sustain change. Users are encouraged 

to review the SAMHSA website for additional tools and 

technical assistance opportunities.
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth

Evidence-Based Resource Guide Series Overview 2

Content of the Guide

This guide contains a foreword and five chapters. The chapters stand alone 

and do not need to be read in order. Each chapter is designed to be brief and 

accessible to healthcare providers, healthcare system administrators, community 

members, policy makers, and others working to meet the needs of individuals 

at risk for, experiencing, or recovering from mental and/or substance use 

disorders. 

The goal of this guide is to review the literature on treatment for suicidal 

ideation, self-harm, and suicide attempts among youth, distill the research 

into recommendations for practice, and provide examples of how practitioners 

can use these practices in their programs. The programs included in this 

guide focus on adolescents and young adults who are currently experiencing 

suicidal ideation, self-harm, and/or suicide attempts, and addresses risk factors 

unique to this population. The programs can be implemented by mental health 

professionals in a variety of settings, including schools, community mental 

health centers, residential facilities, or juvenile justice programs.

FW Evidence-Based Resource Guide Series Overview

Introduction to the series.

1 Issue Brief

Overview of current approaches and challenges to addressing 

suicidal ideation, self-harm, and suicide attempts among youth.

2 What Research Tells Us

Current evidence on effectiveness of the following programs 

included in the guide to treat suicidal ideation, self-harm, and 

suicide attempts among youth: Dialectical Behavior Therapy; 

Attachment-Based Family Therapy; Multisystemic TherapyPsychiatric; Safe Alternatives for Teens and Youth; Integrated 

Cognitive Behavioral Therapy; and Youth-Nominated Support 

Team-Version II.

3 Guidance for Selecting and Implementing 

Evidence-Based Programs

Practical information to consider when selecting and 

implementing programs and practices to treat suicidal ideation, 

self-harm, and suicide attempts among youth.

4 Examples of Suicide Treatment Programs

Examples of programs to treat suicidal ideation, self-harm, and 

suicide attempts among youth.

5 Resources for Evaluation and Quality Improvement

Guidance and resources for implementing programs and 

practices, monitoring outcomes, and improving quality.

FOCUS OF THE GUIDE

Suicide is the second leading 

cause of death for youth and young 

adults in the United States. Factors 

contributing to thoughts of suicide 

in this population include mental 

health and substance use problems, 

low self-esteem, peer and parental 

relationship problems, and academic 

difficulties. 

Suicidal ideation, self-harm, and 

suicide attempts are higher among 

youth than adults. Approximately 

17 percent of high school students 

reported suicidal ideation in the past 

year, and 7.4 percent of high school 

students reported a suicide attempt 

in the same period. The prevalence 

of suicidal thoughts and behaviors 

is higher in some groups, including 

LGBTQ+ youth and racial and ethnic 

minorities, particularly American 

Indian and Alaska Native youth and 

youth of more than one race. 

This guide presents programs and 

practices that address effective 

treatment of suicidal thoughts, 

suicidal behaviors, and self-harm 

among youth and young adults. 

Interventions need to be part of a 

comprehensive approach that seeks 

to decrease suicide risk factors 

and increase protective factors. 

In addition, systemic barriers to 

effective treatment for youth need to 

be addressed, including appropriate 

referrals and linkage to treatment 

services, improved education and 

training for healthcare professionals, 

and increased availability of services 

and insurance coverage for diagnosis 

and treatment of mental disorders 

and suicidal behaviors. 
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

Evidence-Based Resource Guide Series Overview 3

The framework below provides an overview of this guide. The review of treatment programs in Chapter 2 of the 

guide includes specific outcomes, practitioner types, and delivery settings for the programs.
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth

Issue Brief 4

1

CHAPTER

Issue Brief

Suicide is now the second 

leading cause of death for 

adolescents and young 

adults aged 15 to 24 in the 

United States,1

 and suicide 

attempts are significantly 

higher among youth, 

compared to adults.2-3

Suicide, suicide attempts, self-harm, and suicidal ideation 

are significant public health concerns in young people. 

Suicide is now the second leading cause of death for 

adolescents and young adults aged 15 to 24 in the United 

States,1

 and suicide attempts are significantly higher 

among youth, compared to adults.2-3 Suicidal ideation, selfharm, and suicide attempts are more common than suicide 

death in young people, and are associated with several 

other negative consequences, such as co-morbid mental 

disorders, poor educational and vocational outcomes, and 

premature death due to other causes.4

 Studies show that 

people who attempt suicide in adolescence have a higher 

likelihood of mental health treatment utilization, mental 

illness diagnosis, and adult suicide.5

The impacts of youth suicide extend beyond the 

individual. Research indicates exposure to a suicide 

(e.g., schoolmate’s suicide and personally knowing 

someone who died by suicide) predicts suicide ideation 

and attempts.6

 The National Longitudinal Survey 

of Adolescent Health reveals that for the first year 

following a friend’s death by suicide, peers experience 

heightened suicidal ideation and attempts, as well as 

higher rates of depression.7

What is Suicide?

Suicide is a death caused by self-directed injurious 

behavior with any intent to die as a result of the behavior.8

A suicide attempt is a non-fatal, self-directed, and 

potentially injurious behavior with any intent to die 

as a result of the behavior.8

 Previous suicide attempts 

significantly increase a youth’s risk of death by suicide9

 and 

often lead to subsequent and more lethal suicide attempts.10

Suicidal ideation refers to thinking about or planning 

suicide. The thoughts lie on a continuum of severity 

from a wish to die with no method, plan, intent, or 

behavior, to active suicidal ideation with a specific 

plan and intent.12 Although suicidal ideation does not 

include physically harmful behaviors, over one third 

of adolescents who experience suicidal ideation will 

attempt suicide within their lifetimes.13

Self-harm is behavior that is self-directed and deliberately 

results in injury or the potential for injury to oneself.8

 The 

term, also referred to as self-directed violence, encompasses 

both suicidal and non-suicidal self-injury (NSSI), and 

self-harm with unclear intent. NSSI is distinguished from 

a suicide attempt or suicide because it does not include 

suicidal intent.14 NSSI is considered a significant risk factor 

for both suicide attempts and death by suicide and may or 

may not accompany suicidal ideation.15

Suicide contagion is a process where 

exposure to the suicide or suicidal behaviors 

of others influences people who are already 

vulnerable and considering suicide. Exposure 

to suicide by a close friend, family member, or 

another person within one’s social network is 

considered a significant suicide risk factor for 

individuals and communities.11
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth

Issue Brief

5

Prevalence

The suicide death rate for adolescents and young adults 

has increased in the past two decades. In 2018, the suicide 

death rates for adolescents and young adults were 2.85 

per 100,000 for ages 10 to 14, 11.39 per 100,000 for ages 

15 to 19, and 17.4 per 100,000 for ages 20 to 24.

1

 In all 

age groups, males have a higher suicide death rate than 

females. However, from 1999 through 2018, the suicide 

death rate doubled for females aged 15 to 19 and 20 to 

24. For youth aged 10 to 14, the suicide death rate more 

than tripled from 2001 to 2018.16-17 Explanations for the 

increase in suicide may include bullying, social isolation, 

increase in technology and social media, increase in 

mental illnesses, and economic recession.

Suicidal ideation, self-harm, and suicide attempts are 

significantly higher in youth compared to adults, despite 

adult suicide death rates being higher.1,3,18 In 2019, 

approximately 18.8 percent of high school students 

reported suicidal ideation in the past year, and 8.9 percent 

of high school students reported a suicide attempt in 

the past year.

3

 Rates of high school students reporting 

purposefully hurting themselves without wanting to die 

over the past 12 months ranged from 6.4 to 14.8 percent for 

males and 17.7 to 30.8 percent for females in 2015.19
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth

Issue Brief 6

Prevalence of suicidal thoughts and behaviors is 

particularly high in lesbian, gay, bisexual, transgender, 

and questioning or queer youth and youth with other 

sexual and gender minority identities (LGBTQ+). 

Lesbian, gay, and bisexual adolescents and young adults 

are two to four times more likely to report suicidal 

ideation, self-harm, and a suicide attempt compared to 

their heterosexual peers.3

 Transgender youth are four 

to five times more likely to attempt suicide compared 

to their peers who exclusively identify as their sex 

assigned at birth (i.e., cisgender), with about 34.6 

percent reporting a suicide attempt in the past year.20 

LGBTQ+ youth often experience unique stressors 

related to their identity, such as discrimination, violence, 

trauma, expectations of rejection, concealment of their 

identity, and internalized homo- and trans-negativity, that 

increase risk for mental disorders and suicide.21

Some racial and ethnic minority youth also experience 

higher rates of suicidal behaviors. In 2017, American 

Indian and Alaska Native (AI/AN) youth, as well as 

youth of more than one race, reported the highest rates 

of both suicidal ideation and suicide attempts.22 While 

suicide attempt rates decreased among most racial and 

ethnic groups between 1991 and 2017, Black youth 

experienced an increase in suicide attempts and injury 

by suicide attempt.22 Differences in suicide attempt 

rates may be attributed to disparities in access to mental 

health treatment and other factors that AI/AN and Black 

youth disproportionally experience, including poverty, 

historical trauma, and adverse childhood experiences.22-23

Importance of Prevention

While the primary focus of this guide is on treatment 

approaches, it is necessary to highlight the importance 

of prevention strategies in stopping young people from 

engaging in suicidal behaviors. This chapter provides 

context regarding risk and protective factors and some 

core prevention strategies critical to treatment program 

planning and implementation.

Risk and Protective Factors

Risk factors are characteristics that potentially increase an 

individual’s level of suicide risk, whereas protective factors 

are factors that mitigate against risk. Adolescents and young 

adults are in a state of transition, facing new independence, 

identity formation, and changing social situations at school 

and home. The significant physical, hormonal, and social 

changes of adolescence can increase the likelihood of a 

young person experiencing anxiety or depression.24

Mental and substance use disorders, including depression, 

anxiety, bipolar disorders, eating disorders, marijuana use, 

and alcohol use or misuse, also increase the likelihood and 

severity of suicidal ideation,25 as well as risk of suicide 

attempts26 and deaths.27-28 Other individual-level risk 

factors include but are not limited to:

•	 Previous suicide attempts

•	 Childhood trauma, such as physical, sexual, and 

emotional abuse

•	 Being in the child welfare system

•	 Being a victim or perpetrator of bullying

•	 Experiencing a stressful event

•	 Consistent low-level or toxic stress

•	 Dysregulated sleep

•	 Hopelessness

•	 A sense of losing control

•	 Emotional reactivity or pattern of aggressive or 

aggressive-impulsive behavior

•	 Access to non-secure firearms

•	 Access to lethal means of suicide, including 

medications11,13,29-31

Family-level risk factors include parental depression, 

suicidal behavior, and substance use disorders.32-33

Marijuana use and depression are associated 

with suicidal ideation34 and a greater likelihood 

of suicide attempts among adolescents.35-36

Adolescents who use marijuana are also at 

increased risk of developing depression and 

suicidal thoughts and behaviors later in life.37 The 

associations between marijuana, depression, and 

suicide are growing concerns. Marijuana use, 

marijuana use disorder, and major depressive 

episodes increased among adolescents aged 12 

to 17 between 2016 and 2019.

The association between alcohol use and 

suicidal thoughts and behaviors is of concern, 

since more than 21 percent of youth aged 12 

to 17 used alcohol in 2019, and 9.4 percent 

reported past month use.2
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth

Issue Brief 7

Knowledge of risk factors helps clinicians and program 

administrators understand chronic risks clients have. 

Although single risk factors are severely limited in 

their ability to accurately predict suicidal thoughts and 

behaviors,38 recent studies suggest that combinations 

of risk factors predict more effectively.39 Nevertheless, 

there is considerable heterogeneity among youth at risk 

for suicide, and risk levels can increase or decrease over 

time. Therefore, there is no one-size-fits-all approach to 

prevention or treatment.38,40

Factors that reduce risk for suicidal thoughts, attempts, 

and deaths are referred to as protective factors. 

Recognizing them is just as important, if not more so, as 

understanding factors that increase risk.41 Adolescence 

offers a period of developmental opportunity to discover 

new outlooks, form positive relationships, and explore 

one’s identity. It is also a period that can increase 

resilience when youth overcome challenges and thrive as 

they develop and mature.42
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth

Issue Brief 8

•	 Talking about or making plans for suicide 

•	 Expressing hopelessness about the future

•	 Displaying severe/overwhelming emotional 

pain or distress

•	 Showing worrisome behavioral cues or 

marked changes in behavior, particularly in 

the presence of the warning signs above. 

This includes significant:

– Withdrawal from or change in social 

connections/situations

– Changes in sleep (increased or 

decreased)

– Anger or hostility that seems out of 

character or context

– Recent increased agitation or irritability43

For more information, visit 

www.youthsuicidewarningsigns.org

Protective factors that discourage suicide include 

interpersonal and community connectedness, problem 

solving skills, adaptability, effective clinical care for 

physical and mental disorders, and cultural and religious 

beliefs.44 By decreasing risk factors and bolstering 

protective factors, youth have a better opportunity to heal, 

process, receive support, and grow to be healthy adults.45

Many of the interventions reviewed in this guide focus on 

strengthening these and other protective factors found in the 

youth suicide prevention and treatment literature. 

In addition to understanding risk and protective factors, 

the suicide prevention field is also moving towards a 

deeper understanding of the specific risks in the months, 

weeks, days, and hours before a suicidal event occurs. 

These more immediate risks are often described as 

suicide warning signs. 

Functions Associated with Self-Harm and 

Suicide Attempts

Different functions and motivations underlie self-harm 

and suicidal thoughts and behaviors. An understanding 

of these functions can help inform prevention and 

intervention approaches. Internal motivators, referred 

to as intrapersonal functions, include emotional pain, 

hopelessness, and a desire to escape. External factors, 

referred to as interpersonal functions, include conflicts 

with parents, friends, and significant others, social 

pressures promoting suicide, and a desire for help from 

others.46-47 There can be different factors or motivations 

related to suicidal behavior and self-harm, but the one 

defining feature of the suicide attempt is at least some 

desire to die.

Prevention and Early Intervention

A core set of suicide prevention strategies 

for communities and states can be found in 

Preventing Suicide: A Technical Package of 

Policy, Programs, and Practices, developed by 

the Centers for Disease Control and Prevention.48

The 2012 National Strategy for Suicide Prevention (the 

National Strategy) is a call to action that is intended to 

guide suicide prevention actions in the United States. 

The National Strategy recognizes that everyone—

businesses, educators, healthcare institutions, government, 

communities, and individuals—has a role in preventing 

suicide. Prevention and early intervention policies, 

programs, and services are critical to addressing suicide 

risk factors. Population-based prevention approaches 

throughout childhood and adolescence have the potential 

to reduce youth suicide rates. These include:

•	 Preventing trauma and adverse childhood 

experiences

•	 Promoting parenting skills training

•	 Establishing good family supports

•	 Strengthening positive coping norms

•	 Implementing policies and laws that reduce 

binge drinking and access to lethal means

Other prevention and early interventions focus on 

identifying those at risk and in crisis, implementing 

programs in settings where at-risk youth are most likely 

to be, and increasing access to care. Routine screening 

for mental disorders and suicide risk, suicide risk and 

safety assessments, and gatekeeper trainings49 allow 

the people most likely to encounter youth experiencing 

suicidal thoughts and behaviors to identify risk and 

respond appropriately. 
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth

Issue Brief 9

Universal screening for suicide risk using a 

standardized tool is an essential component 

of a comprehensive suicide prevention 

program. Screening helps providers identify 

individuals who may be at risk and implement 

appropriate care plans. Suicide screening 

can be done independently or as part of a 

more comprehensive health or behavioral 

health screening. The Ask Suicide-Screening 

Questions (ASQ), the Columbia Suicide Severity

Rating Scale (C-SSRS), and the Patient Health 

Questionnaire-9 Modified for Teens (PHQ-A) 

are all validated screening tools for use in 

medical and other settings for youth. A positive 

screen is typically followed by a comprehensive 

suicide risk assessment and safety planning if 

warranted. 

Schools, justice programs, healthcare systems, child 

welfare agencies, community-based organizations, and 

other settings and systems youth access can implement 

prevention programs and services. These can include 

crisis interventions that address imminent risk and 

connect people to services, such as hotlines or safety 

planning. Education and mental health awareness 

programs also help destigmatize mental health concerns 

and normalize seeking help. 

The Substance Abuse and Mental Health Services 

Administration’s Garrett Lee Smith (GLS) Suicide 

Prevention and Early Intervention Grant Program 

provides campuses, states, and tribes support to implement 

comprehensive suicide prevention and early intervention 

strategies. The grant program has been associated with 

long-term, lower than expected rates of suicide attempts 

and deaths.50 The GLS program emphasizes the use of 

the Zero Suicide framework in youth suicide prevention 

efforts. The Zero Suicide framework outlines a systematic 

approach for suicide risk identification and care in health 

and behavioral health care systems and is a key tenet of the 

National Strategy.51

Treating Suicidal Ideation, Suicide 

Attempts, and Self-Harm in Youth 

The National Strategy also promotes implementation 

of treatment interventions for those at risk for suicide. 

Evidence-based treatment approaches for adolescents 

who present with suicidal ideation or who have made 

FDA-Approved Medications for 

Children and Teenagers

Medication53-54 

(common brand 

name)

Age 

(in 

years) Diagnosis

Clomipramine 

(Anafranil)

10 and 

older

Obsessivecompulsive 

disorder (OCD)

Duloxetine 

(Cymbalta)

7 and 

older

Generalized 

anxiety disorder

Escitalopram 

(Lexapro)

12 and 

older

Major depressive 

disorder

Fluoxetine 

(Prozac)

8 and 

older

Major depressive 

disorder

Fluoxetine 

(Prozac)

7 and 

older

OCD

Fluvoxamine 8 and 

older

OCD

Olanzapine 

and fluoxetine, 

combination drug 

(Symbyax)

10 and 

older

Bipolar 

depression

Sertraline

(Zoloft)

6 and 

older

OCD

Depression and other mental illnesses in 

children should be treated. A treatment course 

often includes psychotherapy and medication.55

Medications can affect the adolescent brain 

differently than the adult brain.56 In 2004, the 

U.S. Food and Drug Administration issued a 

boxed warning (also referred to as “black box 

warning”) indicating certain antidepressants 

were associated with an increased risk of 

suicidal ideation and behaviors in young 

people. For many youth experiencing 

depression or anxiety disorders, the benefits of 

antidepressants outweigh the risks. However, 

for others, especially those under age 25, the 

risk for suicide when taking antidepressant 

medications may be greater.57 Therefore, 

prescribers, clients, and their families should 

closely monitor for adverse behavioral changes 

among youth receiving antidepressant therapy 

in order to reduce the risk of suicidal thoughts 

and behaviors.56
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth

Issue Brief 10

Safety planning is a collaborative process in 

which an individual and provider work together to 

develop a personalized list of coping strategies 

the individual can use during times of increased 

suicide risk. Safety planning is brief, effective, 

and can be done by any health professional with 

training. Safety planning should be universally 

available for youth at risk of suicide.

Family Intervention for Suicide Prevention 

(FISP), also referred to as SAFETY-Acute, is 

a developmentally-informed safety planning 

intervention for youth that focuses on building 

hope and reasons for living, helping youth 

understand their signs and patterns of emotional 

escalation, and identifying strategies to 

stay safe. The intervention assists parents, 

caregivers, and other caring adults in supporting 

youth to use their safety plans and restrict 

access to dangerous suicide/self-harm methods. 

Caring follow-up contacts are provided until 

youth successfully link to needed follow-up 

care.52 

a suicide attempt aim to reduce the frequency and 

intensity of suicidal ideation and prevent recurrence of 

self-harm behaviors and premature death. Most effective 

treatments are conducted by a licensed mental health 

professional (e.g., psychologist, psychiatrist, clinical 

social worker, or marriage and family therapist) and take 

place over multiple sessions. Treatment may occur in 

a variety of settings, primarily as outpatient, intensive 

outpatient, and partial hospital programs. In some cases, 

treatment is initiated in an emergency department or 

psychiatric hospital following a suicide attempt and 

continues on an outpatient basis following discharge. 

Interventions may primarily focus on treating suicidal 

thoughts and behaviors directly, but should also address 

self-harm as a potential symptom of one of the disorders 

that commonly co-occur with suicidal thoughts and 

behaviors (e.g., depression, borderline personality 

disorder). When self-harm behavior or suicide risk 

is associated with a mental illness, providers need to 

identify that condition and modify treatment plans to 

specifically address the risk of suicide. 
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth

Issue Brief 11

Medications that are approved for youth by the U.S. 

Food and Drug Administration (FDA), including 

antidepressants, anti-anxiety medications, stimulants, 

antipsychotics, and mood stabilizers, may be helpful 

in managing underlying mental illness. Individuals 

should be closely monitored for changes in thoughts of 

suicide or suicidal behaviors after medications have been 

initiated or the medication dose is changed. 

The focus of this guide is suicide treatment. Therefore, it 

does not review treatments or medication effectiveness 

for mental disorders, such as depression, that commonly 

co-occur with suicidal thoughts. 

Clinical management of suicidal behaviors can be 

complex, and specific evidence-based interventions 

to address suicidal ideation and self-harm behaviors 

are often underutilized or not available. Numerous 

individual- and systems-level barriers to treatment for 

suicidal ideation, suicide attempts, and self-harm exist. 

At the individual level, many youth and families have 

limited knowledge of what treatment options are 

available and what options are considered evidencebased. Additional barriers include: 

•	 Stigma associated with seeking help, mental 

illness, and suicide

•	 Practical barriers to engaging in treatment (e.g., 

cost, transportation, time)

•	 Lack of parental support for treatment

•	 Resistance or limited readiness and motivation 

to seek treatment 

When individuals feel they do not have acceptable 

treatment options, they are less likely to engage in 

treatment and adhere to care plans.58

At the systems level, noted barriers include: 

•	 Insufficient access to evidence-based treatment

•	 Lack of culturally responsive treatments

•	 Limited transportation options (e.g., 

accessibility/affordability)

•	 Insurance limitations

•	 Absence of affordable treatment options59-60

Furthermore, clinicians are often uncomfortable with 

their skill set for treating of youth experiencing suicidal 

thoughts and behaviors, or are not adequately trained to 

address these concerns in this age group.61

Summary

Suicide is complex, and a comprehensive approach is 

needed to address different aspects of this preventable 

public health problem. Evidence-based treatment to 

address suicidal ideation, self-harm, and suicide attempts 

is one key aspect of a broader set of programs, practices, 

and policies that aim to decrease youth suicide risk 

factors and increase protective factors. Other critical 

elements to addressing this issue include:

•	 Effective suicide risk screening, assessment, 

referrals, and linkage to evidence-based 

programs

•	 Improved education and training for mental 

health care professionals in these interventions

•	 Increased health insurance coverage for 

diagnosis and treatment of mental disorders and 

suicidal behaviors

This guide synthesizes and disseminates current evidence 

on treatment interventions for youth suicide to make it 

readily accessible by those on the frontlines helping youth 

at risk. 
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth

Issue Brief 12

Reference List

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34 Chadi, N., Li, G., Cerda, N., & Weitzman, E. R. 

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35 Carvalho, A. F., Stubbs, B., Vancampfort, D., 

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36 Schmidt, K., Tseng, I., Phan, A., Fong, T., & Tsuang, 

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37 Gobbi, G., Atkin, T., Zytynski, T., Wang, S., 

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39 King, C. A., Grupp-Phelan, J., Brent, D., Dean, J. 

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40 Goldston, D. B., Erkanli, A., Daniel, S. S., 

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42 National Academies of Sciences, Engineering, 

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43 American Association of Suicidology, National 

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45 Suicide Prevention Resource Center. (2019). 

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resources-programs/understanding-risk-protectivefactors-suicide-primer-preventing-suicide

46 O’Connor, S., Brausch, A., Ridge Anderson, A., 

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47 Taylor, P. J., Jomar, K., Dhingra, K., Forrester, R., 

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48 Stone, D. M., Holland, K. M., Bartholow, B. N., 

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49 Burnette, C., Ramchand, R., & Ayer, L. (2015). 

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51 Labouliere, C. D., Vasan, P., Kramer, A., Brown, 

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52 Asarnow, J., Baraff, L., Berk, M., Grob, C., 

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53 Mayo Clinic Staff. (2019, June 25). Antidepressants 

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54 Heiber, R. (2013). Toolbox: Psychotropic 

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55 U.S. Food & Drug Administration. (2014, September 

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56 Goodman, W. K., & Storch, E. A. (2020). 

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57 Stone, M., Laughren, T., Jones, M. L., Levenson, M., 

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59 Moskos, M. A., Olson, L., Halbern, S. R., & Gray, 

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60 Crepeau-Hobson, F., & Estes, J. (2019). Removing 

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61 Schmidt, R. C. (2016). Mental health practitioners’ 

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Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

What Research Tells Us 16

2

CHAPTER

What Research

Tells Us

Suicidal ideation, self-harm, and suicide attempts among 

youth are significant public health concerns. This review 

of the research literature identified practices and programs 

used to treat suicidal thoughts and behaviors. The chapter 

provides an overview of six evidence-based programs, 

including a discussion of the typical settings, demographic 

groups, intensity and duration, and outcomes attributed to 

receipt of the intervention: 

•	 Dialectical Behavior Therapy (DBT)

•	 Attachment-Based Family Therapy (ABFT)

•	 Multisystemic Therapy-Psychiatric (MST-Psych)

•	 Safe Alternatives for Teens and Youth (SAFETY)

•	 Integrated Cognitive Behavioral Therapy (I-CBT)

•	 Youth-Nominated Support Team-Version II (YST-II)

Each program or practice description also provides a 

rating based on its evidence of impacting one or more of 

the following outcomes: suicidal ideation, self-harm, and 

suicide attempts among youth. DBT was rated as having 

strong support for causal evidence, and the other five 

programs were rated as having moderate support. These 

programs require more research. 

Program Selection 

To ensure inclusion of the most useful interventions for 

addressing suicidal thoughts and behaviors among youth, 

authors required programs meet the following criteria: 

•	 Clearly defined and replicable 

•	 Address the target outcomes of a reduction in 

suicidal ideation, self-harm, suicide attempts, 

and/or death by suicide

•	 Developed or adapted specifically for youth

•	 Currently in use

•	 Demonstrate evidence of impact on the above 

targeted outcomes 

•	 Include accessible implementation resources

Evidence Review and Rating

Authors conducted a comprehensive review of published 

research for each selected intervention to determine its 

strength as an evidence-based practice. Eligible studies 

had to:

•	 Employ a randomized or quasi-experimental 

design, or 

•	 Be a single sample pre-post design or an 

epidemiological study with a strong counterfactual 

(i.e., a study that analyzes what would have 

happened in the absence of the intervention). 

Descriptive studies, implementation studies, and 

meta-analyses were not included in the review but 

were documented to provide context and identify 

implementation strengths and challenges for the programs.

Each individual study included in this chapter was 

reviewed for evidence of measurable reductions in the 

following outcomes: 

•	 Suicide attempts

•	 Suicidal ideation

•	 Self-harm, including non-suicidal self-injury 

(NSSI)

•	 Self-harm with unknown intent 
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

What Research Tells Us 17

Causal Impact: Evidence demonstrating that 

an intervention causes, or is responsible for, 

the outcome measured in the study’s sample 

population.

In addition, trained reviewers checked each study to 

ensure rigorous methodology by asking questions such as:

•	 Are experimental and comparison groups 

demographically equivalent, with the only 

difference being that participants in the 

experimental group received the intervention 

and those in the comparison group received 

treatment as usual or no or minimal 

intervention?

•	 Was baseline equivalence established between 

the treatment and comparison groups on 

outcome measures?

•	 Were missing data addressed appropriately?

•	 Were outcome measures reliable, valid, and 

collected consistently from all participants?

Using these criteria, authors used a two-step process 

to assess the strength of each study’s methodology and 

the causal evidence associated with each practice. Each 

study was given a rating of low, moderate, or high based 

on the research methods. Only randomized controlled 

trials, quasi-experimental designs, and epidemiological 

studies with a strong comparison were eligible to receive 

a high or moderate rating. 

After all studies for a practice were assessed and rated, the 

practice was placed into one of three categories based on its 

causal evidence level: strong evidence, moderate evidence, 

or emerging evidence.

This chapter includes an outcomes table for each 

intervention that summarizes study findings. For each 

outcome, the table identifies: 

•	 Whether the studies reviewed for that 

intervention measured the outcome

•	 Whether the intervention was found to produce a 

measurable positive impact on the outcome

•	 Whether the impact persisted for 6 months or 

more

•	 Any additional details that could clarify the 

evidence behind the intervention’s impact on the 

outcome

This chapter also includes additional findings from 

studies that may be relevant for mental healthcare 

professionals to consider when addressing the needs 

of individual clients, but these outcomes did not count 

towards the rating of the study or program. It also 

identifies limitations in evidence and describes the 

need for further research to strengthen the evidence on 

programs intended to treat youth with suicidal thoughts 

and behaviors. 

See Appendix 2 for more information about the evidence 

review process. 
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

What Research Tells Us 18

Identification of Programs Associated with Treatment 

of Suicidal Ideation, Self-Harm, and Suicide Attempts 

Among Youth

Dialectical Behavior 

Therapy (DBT)

Overview 

DBT is a manualized, cognitive-behavioral treatment that 

includes concurrent individual therapy, family therapy, 

multifamily skills training, and telephone coaching. DBT 

therapists hold regular team consultation meetings to 

address treatment adherence, continue training, and manage 

caseloads and potential burnout. DBT was designed for 

treatment of adult patients with chronic suicidal ideation 

diagnosed with borderline personality disorder (BPD). 

Emotional dysregulation caused by BPD can result in 

self-harm and suicidal behaviors.1-2 The goal of DBT is 

to help individuals develop more effective behavioral, 

emotional, and interpersonal patterns.1-2 DBT emphasizes 

the development of four skills:

1. Mindfulness

2. Interpersonal effectiveness

3. Emotion regulation

4. Distress tolerance 

Adolescents with symptoms of BPD exhibit frequent 

suicidal ideation or behavior, and suicide attempts are 

common.3

 DBT was adapted for adolescents due to the 

treatment’s effectiveness with suicidal behaviors in 

adults.4

 The intervention also focuses on retaining clients 

in treatment, which research shows is a challenge for 

youth experiencing suicidal thoughts and behaviors.5-6

As adapted for adolescents, DBT focuses on treating 

youth with repeated self-harm and symptoms of BPD, 

many of whom also meet the Diagnostic and Statistical 

Manual of Mental Disorders (DSM–5) diagnostic criteria 

for depression and other mental disorders. It includes 

parents in treatment through multi-family group skills 

training and some family sessions. These adaptations 

tailor the adult version for the adolescent developmental 

stage and typically include youth ranging from 12 to 18 

years old. 

This review included eight studies conducted in 

outpatient settings with adolescents.3,5-13 While the 

overall treatment approach was similar across studies, 

the two randomized controlled trials (RCTs) used 

slightly different variants of DBT, with one study 

using a sample of youth with more severe needs and a 

longer treatment duration.5

 It is important to note that 

the outcomes below are from implementing the full 

treatment package, which can be challenging to sustain 

in a community setting.

Emotional dysregulation is the inability to 

flexibly respond to and manage emotions.

Outcomes Associated with DBT

Studies included in this evidence review 

demonstrated that use of DBT for youth with 

suicidal thoughts and behaviors was associated 

with reductions in one or more of the following 

outcomes:

•	 Suicidal ideation

•	 Self-harm (non-suicidal)

•	 Self-harm (intent unknown)

•	 Suicide attempts

The studies included several additional 

outcomes, including improvement in BPD, 

reduced psychiatric hospitalizations, reduced 

depressive symptoms, and improved treatment 

completion rate.3,5-13
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

What Research Tells Us 19

Typical Settings

DBT has shown efficacy when delivered in an outpatient 

setting and has been implemented in community 

clinics serving primarily ethnic minority youth with 

low income. Some data also support particular benefits 

among non-white youth and Latino youth.14 However, 

DBT has been used with promising results in a wide 

range of settings, including intensive outpatient 

programs, regular outpatient care, and psychiatric 

inpatient units. 

Of the studies reviewed, two were conducted in 

Norway,6,8,10 two in Germany,3,12 one in Canada,9

 and 

three in the United States.5,7,11

Demographic Groups

DBT is intended for use across all sexual and gender 

identities, races, and ethnicities. All DBT studies 

included in this review comprised adolescents aged 12 to 

19. Participants were predominately female. The criteria 

for participant inclusion varied across all reviewed 

studies. However, common criteria were: 

1. Suicidal thoughts or behavior

2. Meeting at least two criteria of BPD or having a 

previous diagnosis of BPD 

Exclusion criteria varied greatly across the studies 

reviewed. Some of the common exclusion criteria were 

different severities of mania and psychosis, as well as 

substance use and eating disorders. 

Practitioner Types

DBT can be delivered by mental health practitioners, 

including licensed behavioral health professionals such 

as psychiatrists, psychologists, and therapists. At least 

one study included post-doctoral students, psychiatry 

fellows, and graduate students as DBT practitioners, in 

addition to licensed therapists and clinical workers.11

Intensity and Duration of Treatment 

The two variants of DBT tested in RCTs varied in 

duration. One was 19 weeks and the other was 6 

months.5-6 The frequency of DBT for adolescents includes 

one weekly individual session, weekly 2-hour multifamily groups, and some family sessions. Individual 

sessions last 1 hour. Telephone coaching for adolescents 

and parents is also available, 24 hours every day. 

Finally, DBT training is offered free via SAMHSA’s 

Technology Transfer Centers. More information on 

training resources can be found in Chapter 3.
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

What Research Tells Us 20

Programs that Show Promise

Research on youth suicide treatment programs is 

relatively new and more research is needed. Prior to 

2012, no programs had strong evidence to support their 

effectiveness in youth.15 Although the body of research 

is growing, providers continue to face the challenge of 

limited evidence, particularly from RCTs, when selecting 

programs to treat suicidal thoughts and behaviors in youth. 

There are many reasons for this research gap. 

Researchers may not be able to ethically assign youth 

to a no-treatment or treatment-as-usual group if the 

intervention being studied is potentially lifesaving. 

Another reason is that with a relatively uncommon 

outcome, such as suicide attempts, an RCT may not 

be able to enroll enough youth to see a statistical 

improvement, even if the treatment works.16 For these 

reasons, providers may want to consider programs that 

have been studied and show promise of effectiveness, 

but for which multiple RCTs are currently unavailable.

The remainder of this chapter includes five programs 

that are rated moderate: 

•	 Attachment-Based Family Therapy

•	 Multisystemic Therapy-Psychiatric

•	 Safe Alternatives for Teens and Youth

•	 Integrated Cognitive Behavioral Therapy

•	 Youth Nominated Support Team Intervention for 

Suicidal Adolescents-Version II 

Each program has shown positive study outcomes and 

received a moderate rating after undergoing the evidence 

review process. Technical experts agree that these 

programs include key elements important for treatment 

of suicidal thoughts and behaviors. However, they have 

various limitations in their current evidence base, such as: 

•	 Program has not yet been studied in multiple 

RCTs

•	 Findings of subsequent RCTs are not yet 

published

•	 Multiple RCTs have been conducted for other 

outcomes, but not yet for suicidal thoughts and 

behavior

This information is important at a time when additional 

research is needed, youth suicide rates are rising, and 

relatively few programs are available for youth that have 

demonstrated well-established effectiveness for treating 

suicidal thoughts and behaviors.
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

What Research Tells Us 21

Attachment Based Family 

Therapy (ABFT)

Overview 

ABFT is a manualized family therapy model specifically 

designed to treat depression and suicidal thoughts 

and behaviors in adolescents.17 ABFT seeks to protect 

adolescents against suicidal ideation and risk behaviors 

by improving family processes and repairing or building 

secure parent-child bonds.18-20

ABFT is designed to be structured while also being 

flexible enough to address the unique challenges each 

family brings to treatment.17,21 The ABFT treatment 

manual outlines five sequential tasks the therapist will 

lead the client and family through during the course 

of treatment. To accomplish each task, the practitioner 

employs a primarily process-oriented, emotion-focused 

approach, using strategies identified for each.17 Each 

task builds on the one preceding it, leading to the 

desired treatment outcome. Multiple sessions may be 

necessary depending on the needs of the adolescent 

and caregivers.21 Initial sessions focus on repairing or 

building attachment bonds, and later sessions focus on 

promoting adolescent autonomy.20

This review included three rigorous studies conducted in 

outpatient treatment facilities with adolescents scoring 

above a threshold on validated measures for suicidal 

ideation, depression, or both.17-18,22-23 Studies of ABFT 

have demonstrated an impact on severity of suicidal 

ideation but not suicidal behavior.

Typical Settings

ABFT can be administered as either an inpatient or 

outpatient treatment. Typical settings for conducting 

treatment include the family home, hospitals, outpatient 

clinics, community-based organizations, group or 

residential care facilities, and schools.24 All studies 

included in this review administered ABFT as outpatient 

treatment in a research clinic setting.17-18,22-23

ABFT’s Five Treatment Tasks18

1. Relational Reframe Task

2. Adolescent Alliance Task

3. Parental Alliance Task

4. Attachment Task

5. Autonomy Promoting Task

Demographic Groups

ABFT is designed to treat youth aged 12 to 25 and 

engages family members of all ages in treatment. The 

treatment has been useful for adolescents with diverse 

gender, sexual, racial, and cultural identities, in addition 

to adolescents with a history of sexual abuse.25

The studies in this review include two primarily 

female, African American samples, as well as a sample 

comprised entirely of racial and ethnic minority 

adolescents with low income who identify as lesbian, 

gay, or bisexual. All studies excluded youth with current 

psychosis or severe cognitive impairment. For purposes 

of research methodology (not clinical purposes), RCTs 

enforced additional exclusion criteria, including: 

•	 Imminent risk of harm to self or others that 

could not be safely treated on an outpatient basis 

•	 Participating parent who was non-Englishspeaking 

•	 Treatment with psychotic medication within 3 

weeks of the initial pretreatment screening17-18,22-23
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

What Research Tells Us 22

Practitioner Types

ABFT practitioners are typically licensed and possess a 

minimum of a master’s degree in the mental health field. 

If a therapist is not licensed, he or she must be practicing 

under a supervisor’s license at their organization. ABFT 

has been used in teams with co-practitioners who have 

an undergraduate degree.

Practitioners participating in this review’s studies were 

doctoral or master’s level therapists trained and certified 

in ABFT.17-18,22-23

Intensity and Duration of Treatment 

ABFT is designed to last approximately 12 to 16 weeks 

and span 10 to 20 sessions.21 In practice, therapists 

have adapted the model to fit the context and families 

with whom they work. The studies included in this 

review lasted from 12 to 16 weeks and averaged 8 to 12 

sessions.17-18,22-23

Findings

Outcomes

Some studies included in this evidence review 

demonstrated that use of ABFT for youth with 

suicidal thoughts and behaviors was associated 

with reductions in:

•	 Suicidal ideation

Studies also demonstrated improved outcomes 

related to treatment retention, reduced 

depressive symptoms, and improved attachmentrelated anxiety and avoidance.17-18,22-23

Limitations

One of the studies included suicide attempts as 

an outcome. Although there were fewer suicide 

attempts in the group receiving ABFT than in 

the group receiving treatment as usual, the 

difference was not statistically significant.23 The 

studies did not measure self-harm (non-suicidal 

or intent unknown) outcomes.

Additional studies with self-harm and suicide 

attempt outcomes could improve understanding 

of ABFT’s impact on suicidal behaviors.
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

What Research Tells Us 23

Multisystemic Therapy–

Psychiatric (MST-Psych)

Overview 

MST is an intensive manualized treatment developed 

for youth aged 12 to 17 with serious antisocial behavior, 

most of whom have had involvement with the criminal 

justice system.26 Youth diagnosed with conduct disorder, 

the childhood disorder most associated with antisocial 

behaviors, have a greater rate of suicide attempts 

compared to youth without conduct disorder.27 MST 

provides a useful approach in that it draws from the 

social-ecological theory of human development, which 

emphasizes that treatment must address the strengths 

and challenges of the systems with which youth interact 

(e.g., family, peer, school, larger society).28 The socialecological theory recognizes that all of these systems 

affect youth, and that youth, in turn, affect many 

different systems. 

MST-Psych is an adaptation of MST specifically 

designed for adolescents with high-risk symptoms, such 

as suicidal, self-injurious, and aggressive behavior.29

Treatment focuses on improving caregiver and family 

functioning and working with the family to address risk 

factors present in the systems with which the adolescent 

interacts.29

Some studies have demonstrated MST-Psych’s 

effectiveness in reducing serious behaviors, such as 

violence, substance use, and criminal activity. One of 

these studies examined the use of MST-Psych with youth 

aged 10 to 17 presenting for emergency hospitalization 

for suicidal intent/planning, attempted suicide, homicidal 

ideation or behavior, psychosis, or other threat of harm 

to self or others. 

Typical Settings

MST-Psych has been used in both home- and 

community-based settings.30 Most families receive 

services for 3 to 6 months, although there is no defined 

length of treatment.28

Demographic Groups

MST-Psych was developed for youth between the ages of 

12 and 17. The majority of participating youth were African 

American and male.29

Practitioner Types

MST-Psych involves teams of therapists, each of 

whom must possess master’s level training in a clinical 

field, and at least one of whom must be an advanced 

master’s or doctoral level supervisor.31 All MSTPsych practitioners must complete a minimum 5-day 

orientation program, and additional training is required 

for specialized MST-Psych adaptations.31

Intensity and Duration of Treatment 

MST-Psych therapists have a very small caseload of 

families, which allows them to be available to the youth 

and family multiple times per week.26 For this reason, 

MST-Psych is a very resource-intensive therapy. Most 

families receive services for 3 to 6 months, although 

there is no defined length of treatment.28

Findings

Outcomes

The study included in this evidence review 

demonstrated that use of MST-Psych for youth 

with suicidal thoughts and behaviors was 

associated with reductions in:

•	 Suicide attempts

Youth who received home-based MST-Psych 

experienced a greater reduction in suicide 

attempts at 1-year follow-up compared to 

youth assigned to inpatient hospitalization. 

However, youth in the MST-Psych group had 

a history of more suicide attempts on average 

than did youth in the hospitalization group. This 

difference may have affected the study results.28

Limitations

MST-Psych did not demonstrate a reduction in 

suicidal ideation. The study did not measure 

self-harm (non-suicidal or intent unknown) 

outcomes.

Additional studies that are focused on suicidal 

ideation, self-harm, and suicide attempt 

outcomes could strengthen the body of 

evidence for use of MST-Psych in treating 

suicidal thoughts and behaviors. 
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

What Research Tells Us 24

Safe Alternatives for 

Teens and Youth (SAFETY)

Overview

SAFETY is a 12-week family-oriented treatment 

designed to build skills, increase safety, and reduce risk 

of suicide attempts. This cognitive-behavioral program 

is informed by DBT and grounded in social-ecological 

theory. It enhances protective factors and reduces risk 

factors within individual youth, family, and other social 

systems. 

Elements of SAFETY include: 

1. Youth work with one therapist while parents 

simultaneously work with a different therapist 

2. Youth and family come together to practice skills 

identified as important to prevent repeat suicide 

attempts32-33

When the family is not available or involvement of 

the young person’s parents is not feasible or otherwise 

inadvisable, the therapist may include other protective 

adults in treatment. 

The 12-week SAFETY program builds upon an emergency 

intervention called SAFETY-Acute (SAFETY-A), initially 

described in the literature as Family Intervention for Suicide 

Prevention (FISP).34-35 When delivered with community 

treatment as usual, SAFETY-A/FISP has demonstrated 

benefits for improving continuity of care after an emergency 

department (ED) visit for suicidal ideation and behavior, 

with some data supporting benefits on suicidal ideation at 

discharge from the ED.35-36

Findings

Outcomes

Studies included in this evidence review 

demonstrated that use of SAFETY for youth with 

suicidal thoughts and behaviors was associated 

with reductions in:

•	 Suicidal ideation

•	 Self-harm (non-suicidal)

•	 Suicide attempts

One of the studies demonstrated significant 

reductions in depression and hopelessness for 

youth and significant reductions in depression 

for parents involved in the intervention.33

Limitations

The RCT included in the evidence review did not 

find statistically significant improvements in nonsuicidal self-harm.32 The studies reviewed did not 

measure self-harm (intent unknown) outcomes.

The inclusion of more gender diverse youth 

would improve SAFETY’s evidence base.
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

What Research Tells Us 25

SAFETY-A is included as the first session in the full 

SAFETY program and emphasizes a developmentally 

nuanced, trauma-informed, family-centered, and 

strengths-based approach to safety planning. Upon 

conclusion of the SAFETY program, the therapist links 

youth and families to follow-up services and resources to 

encourage ongoing care. 

Typical Settings

SAFETY is a community-based treatment conducted in 

outpatient settings and/or the client’s home. It provides 

treatment after a suicide attempt or recent, repeated 

clinically significant self-harm, and is often used for youth 

with recent emergency, hospital, or crisis visits for suicide 

attempts and/or self-harm.

Demographic Groups

The program is designed for adolescents aged 11 to 18 

and their families. The youth included in the studies had 

a recent suicide attempt or repeated self-harm as their 

primary problem. In the studies reviewed, participants 

were primarily female and represented diverse subgroups 

across racial, ethnic, socioeconomic, and sexual 

orientation categories. 

Practitioner Types

The SAFETY program is delivered by mental health 

therapists, including psychologists and social workers.

Intensity and Duration of Treatment 

The program is designed to be implemented in 12 weeks. 

Phase 1 includes three weekly sessions, with an option 

to increase the number of sessions per week if indicated 

based on safety risk. The number of sessions varies 

across participants in Phases 2 and 3. In the studies 

reviewed, youth received an average of 10 sessions.

Integrated Cognitive 

Behavioral Therapy (I-CBT)

Overview

I-CBT uses cognitive, behavioral 

and affect regulation training to 

address suicidal behaviors and cooccurring substance use disorders 

among adolescents, as well as 

common comorbid conditions 

(e.g., depression, conduct problems) that may interfere 

with treatment progress. The intervention extends 12 

months and consists of three treatment phases involving 

individual, family, and parent training sessions.37

A key component of I-CBT for suicide treatment is that 

it targets common thought processes and behaviors that 

underlie substance use disorders, suicidal thoughts/

behaviors, and comorbid mental health conditions. 

I-CBT provides a framework for teaching youth the 

skills needed to develop self-efficacy to manage their 

emotions, challenge negative thoughts, solve problems, 

and communicate effectively. Parents play a significant 

role in treatment. They learn skills to aid in their 

adolescent’s recovery and promote supportive family 

relationships, such as problem-solving, communication, 

emotional regulation, and monitoring. 

I-CBT has been further adapted by its creators to a 

program called Family-focused Cognitive Behavioral 

Therapy (F-CBT) based on clinical impressions during 

the I-CBT study and emerging research.38 Additional 

session focus areas were added to accommodate a more 

heterogeneous sample of youth experiencing suicidal 
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

What Research Tells Us 26

thoughts or behaviors. Parental involvement and support 

were expanded by adding parental “self-care” sessions 

and an emotional coaching session to improve parentchild interactions.38

This review included a study that tested the efficacy 

of I-CBT in a highly controlled setting.37 The study 

was conducted with participants who had experienced 

recent suicidal ideation or a suicide attempt and had cooccurring alcohol and/or cannabis use disorder.

Typical Settings

The study was conducted in an outpatient setting. 

However, based on the widespread use of traditional CBT, 

the intervention may be suitable for use in other settings. 

Findings

Outcomes

Studies included in this evidence review 

demonstrated that use of I-CBT for youth with 

suicidal thoughts and behaviors was associated 

with reductions in:

•	 Suicide attempts

The study also demonstrated reductions in the 

frequency of marijuana use and heavy drinking 

days, as well as in the number of inpatient 

hospitalizations, ED visits, and arrests. 

Limitations

I-CBT did not demonstrate a reduction in 

suicidal ideation. The study did not measure 

self-harm (non-suicidal or intent unknown) 

outcomes.37

To improve the field’s understanding of I-CBT’s 

effectiveness, additional studies should be 

conducted to:

•	 Observe the treatment in a variety of 

settings

•	 Include more racially, ethnically, and gender 

diverse youth

•	 Establish stronger findings across multiple 

suicide outcomes (i.e., suicidal ideation, 

self-harm, and suicide attempts)

Demographic Groups

The I-CBT study included participants ages 13 to 17 

recruited from a psychiatric inpatient unit who made 

a suicide attempt within the past 3 months or reported 

clinically significant suicidal ideation during the past 

month on a standardized questionnaire and had an 

alcohol and/or cannabis use disorder. The majority were 

White and female and met the diagnostic criteria for 

either alcohol use disorder and/or cannabis use disorder. 

Participants also needed to live in a home with a parent 

or guardian who was willing to participate.

Participants were excluded if they had a Verbal IQ 

estimate less than 70, were actively psychotic, were 

homicidal, had bipolar disorder, or were dependent on 

substances other than alcohol and marijuana.

Practitioner Types

In the study included in this review, sessions were delivered 

by therapists, including doctoral-level practitioners, 

licensed clinical psychologists, clinical psychology postdoctoral trainees, and a master’s level clinician.

Intensity and Duration of Treatment 

The intervention extends 12 months. Participants 

completed an average of 46 sessions (range of 11 to 72 

sessions), including individual and family therapy and 

parent training sessions.
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

What Research Tells Us 27

Youth Nominated Support 

Team Intervention for 

Suicidal Adolescents–

Version II (YST-II)

Overview

YST-II is a psychoeducational 

social support program designed 

for adolescents hospitalized in a 

psychiatric unit who have recently 

reported a suicide attempt or serious 

suicidal ideation. 

As a key component to suicide prevention, the 

intervention supplements routine treatment by 

strengthening existing adolescents’ support networks 

through increasing support from caring adults. 

Adolescents nominate several adults (typically three 

to four per adolescent from family, school, and/

or community settings) to serve as their support 

persons after hospitalization.39 These adults attend 

psychoeducational sessions to learn about:

•	 The adolescent’s psychiatric disorder(s) and 

psychosocial difficulties 

•	 The adolescent’s treatment plan and rationale for 

recommended treatments 

•	 Risk factors for suicidal behavior and warning 

signs of possible acute risk

•	 Strategies for communicating with adolescents

•	 Availability of emergency services (e.g., crisis 

lines, EDs) 

The adults receive weekly, supportive telephone calls 

from YST-II staff for 3 months. 

In their regular contacts with adolescents, the 

youth-nominated caring adults: 

•	 Support the young person’s involvement in 

healthy activities

•	 Inquire about and listen to the adolescent’s 

concerns to engage in collaborative problemsolving

•	 Support treatment adherence and express 

hopefulness about the possibility of positive 

change39

Demographic Groups

In the study reviewed, participants included youth aged 

13 to 17 with significant suicidal ideation or a suicide 

attempt within the past 4 weeks. Most participants were 

White, and three quarters were female. Approximately 

20 percent had a co-occurring alcohol or substance use 

disorder. Socioeconomic status and parental education 

varied among participants.

Participants were excluded if they had extreme cognitive 

impairment, were directly transferred to a medical unit or 

residential placement, or had no legal guardian available. 

Findings

Outcomes

The study included in this evidence review 

demonstrated that use of YST-II for youth with 

suicidal thoughts and behaviors was associated 

with reductions in:

•	 Suicidal ideation

YST-II resulted in more rapid decreases 

in suicidal ideation for youth with multiple 

suicide attempts during the initial 6 weeks 

after hospitalization. For those without multiple 

attempts, it was also associated with greater 

declines in functional impairment at 3 and 12 

months.39

The study found youth who received YSTII attended more outpatient therapy and 

medication follow-up sessions and were more 

likely to participate in outpatient drug or alcohol 

treatment in the 12 months following their initial 

hospitalization. 

Limitations

YST-II did not demonstrate a reduction in 

suicide attempts. The study did not measure 

self-harm (non-suicidal or intent unknown) 

outcomes.

Additional studies with stronger findings across 

multiple suicide outcomes (i.e., suicidal ideation, 

self-harm, and suicide attempts) and the 

inclusion of more racially, ethnically, and gender 

diverse youth would strengthen the field’s 

understanding of YST-II’s effectiveness.
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

What Research Tells Us 28

Practitioner Types

YST-II intervention specialists include mental health 

professionals (e.g., doctoral-level psychologists, master’s 

level social workers, and psychiatric nurses). 

Intensity and Duration of Treatment 

The caring adults participate in 1-hour individual or 

group psychoeducational sessions and maintain weekly 

telephone contact with the intervention specialist. The 

adults are encouraged to have weekly contact with the 

adolescents for at least 3 months following hospital 

discharge. In the study reviewed, the adults were in 

contact with clients an average of 9.5 times over 3 

months. The length of contacts between the caring adults 

and adolescents is not prescribed.

Long-Term Outcomes on SelfInjury Mortality

The secondary analysis conducted more than 

a decade later found YST-II was associated 

with a reduction in mortality across all causes 

of death and a reduction in self-injury mortality 

due to either suicide or drug-related deaths with 

unknown intent.40
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

What Research Tells Us 29

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31 Zajac, K., Randall, J., & Swenson, C. C. (2015). 

Multisystemic therapy for externalizing youth. 

Child and Adolescent Psychiatric Clinics of North 

America, 24(3), 601-616. https://doi.org/10.1016/j.

chc.2015.02.007

32 Asarnow, J. R., Hughes, J. L., Babeva, K. N., 

& Sugar, C. A. (2017). Cognitive-behavioral 

family treatment for suicide attempt prevention: A 

randomized controlled trial. Journal of the American 

Academy of Child and Adolescent Psychiatry, 56(6), 

506-514. https://doi.org/10.1016/j.jaac.2017.03.015

33 Asarnow, J. R., Berk, M., Hughes, J. L., & 

Anderson, N. L. (2015). The SAFETY Program: 

A treatment-development trial of a cognitivebehavioral family treatment for adolescent suicide 

attempters. Journal of Clinical Child & Adolescent 

Psychology, 44(1), 194-203. https://doi.org/10.1080/

15374416.2014.940624

34 Asarnow, J. R., Berk, M. S., & Baraff, L. J. (2009). 

Family Intervention for Suicide Prevention: A 

specialized emergency department intervention 

for suicidal youths. Professional Psychology: 

Research and Practice, 40(2), 118-125. https://doi.

org/10.1037/a0012599

17 Diamond, G. S., Wintersteen, M. B., Brown, G. K., 

Diamond, G. M., Gallop, R., Shelef, K., & Levy, 

S. (2010). Attachment-based family therapy for 

adolescents with suicidal ideation: A randomized 

controlled trial. Journal of the American Academy 

of Child and Adolescent Psychiatry, 49(2), 122-131. 

https://doi.org/10.1097/00004583-201002000-00006

18 Diamond, G. M., Diamond, G. S., Levy, S., Closs, C., 

Ladipo, T., & Siqueland, L. (2012). Attachment-based 

family therapy for suicidal lesbian, gay, and bisexual 

adolescents: A treatment development study and open 

trial with preliminary findings. Psychotherapy, 49(1), 

62-71. https://doi.org/10.1037/a0026247

19 Drexel University Center for Family Intervention 

Science. (n.d.). Attachment-based family therapy. 

https://drexel.edu/familyintervention/attachmentbased-family-therapy/overview/

20 Diamond, G., Diamond, G., & Levy, S. 

(2014). Attachment-based family therapy for 

depressed adolescents. https://psycnet.apa.org/

doi/10.1037/14296-000

21 Krauthamer Ewing, E. S., Levy, S. A., BoamahWiafe, L., Kobak, R., & Diamond, G. (2016). 

Attachment-based family therapy with a 13-year-old 

girl presenting with high risk for suicide. Journal of 

Marital and Family Therapy, 42(1), 91-105. https://

doi.org/10.1111/jmft.12102

22 Diamond, G. M., Diamond, G. S., Levy, S., Closs, 

C., Ladipo, T., & Siqueland, L. (2013). “Attachmentbased family therapy for suicidal lesbian, gay, and 

bisexual adolescents: A treatment development study 

and open trial with preliminary findings”: Correction 

to Diamond et al. (2011). Psychotherapy, 50(4), 596-

596. https://doi.org/10.1037/a0034920

23 Diamond, G. S., Kobak, R. R., Krauthamer 

Ewing, S., Levy, S. A., Herres, J. L., Russon, J. M., 

Gallop, R. J. (2019). A Randomized Controlled 

Trial: Attachment-Based Family and Nondirective 

Supportive Treatments for Youth Who Are Suicidal. 

Journal of the American Academy of Child & 

Adolescent Psychiatry, 58(7), 721-731. https://doi.

org/10.1016/j.jaac.2018.10.006

24 The California Evidence-Based Clearninghouse 

for Child Welfare. (2020). Attachment-based 

family therapy. https://www.cebc4cw.org/program/

attachment-based-family-therapy/

25 Diamond, G., Creed, T., Gillham, J., Gallop, R., & 

Hamilton, J. L. (2012). Sexual trauma history does 

not moderate treatment outcome in attachment-based 

family therapy (ABFT) for adolescents with suicide 

ideation. Journal of Family Psychology, 26(4), 595-

605. https://doi.org/10.1037/a0028414
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

What Research Tells Us 31

35 Asarnow, J. R., Baraff, L. J., Berk, M., Grob, C. 

S., Devich-Navarro, M., Suddath, R., Piacentini, 

J. C., Rotheram-Borus, M. J., Cohen, D., & Tang, 

L. (2011). An emergency department intervention 

for linking pediatric suicidal patients to followup mental health treatment. Psychiatric Services, 

62(11), 1303-1309. https://doi.org/10.1176/ps.62.11.

pss6211_1303

36 Rotheram-Borus, M. J., Piacentini, J., Van Rossem, 

R., Graae, F., Cantwell, C., Castro-Blanco, D., 

Miller, S., & Feldman, J. (1996). Enhancing 

treatment adherence with a specialized emergency 

room program for adolescent suicide attempters. 

Journal of the American Academy of Child and 

Adolescent Psychiatry, 35(5), 654-663. https://doi.

org/10.1097/00004583-199605000-00021

37 Esposito-Smythers, C., Spirito, A., Kahler, C. 

W., Hunt, J., & Monti, P. (2011). Treatment of 

co-occurring substance abuse and suicidality 

among adolescents: A randomized trial. Journal of 

Consulting and Clinical Psychology, 79(6), 728-739. 

https://doi.org/10.1037/a0026074

38 Esposito-Smythers, C., Wolff, J. C., Liu, R. T., 

Hunt, J. I., Adams, L., Kim, K., Frazier, E. A., Yen, 

S., Dickstein, D. P., & Spirito, A. (2019). Familyfocused cognitive behavioral treatment for depressed 

adolescents in suicidal crisis with co-occurring 

risk factors: A randomized trial. Journal of Child 

Psychology and Psychiatry and Allied Disciplines, 

60(10), 1133-1141. https://doi.org/10.1111/jcpp.13095

39 King, C. A., Klaus, N., Kramer, A., Venkataraman, 

S., Quinlan, P., & Gillespie, B. (2009). The youthnominated support team-version II for suicidal 

adolescents: A randomized controlled intervention 

trial. Journal of Consulting and Clinical Psychology, 

77(5), 880-893. https://doi.org/10.1037/a0016552

40 King, C. A., Arango, A., Kramer, A., Busby, D., 

Czyz, E., Foster, C. E., & Gillespie, B. W. (2019). 

Association of the youth-nominated support 

team intervention for suicidal adolescents with 

11- to 14-year mortality outcomes: Secondary 

analysis of a randomized clinical trial. JAMA 

Psychiatry, 76(5), 492-498. https://doi.org/10.1001/

jamapsychiatry.2018.4358
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

Guidance for Selecting and Implementing Evidence-based Programs 32

3

CHAPTER

Guidance for Selecting 

and Implementing 

Evidence-based 

Programs

This chapter provides information for clinicians, 

program administrators, and other stakeholders 

interested in implementing evidence-based programs to 

treat suicidal ideation, self-harm, and suicide attempts 

among youth. The chapter:

•	 Reviews the steps to implementing a new 

program

•	 Identifies common elements of effective 

programs to treat suicidal thoughts and 

behaviors

•	 Includes key program selection and 

implementation considerations and strategies

•	 Provides implementation resources for the 

treatment programs described in Chapter 2 

Implementation of 

Evidence-Based Programs

A number of general frameworks and guidelines provide 

insight into how to implement new programs and 

practices.1-2 A comprehensive youth suicide treatment 

program planning and implementation process typically 

includes the following steps: 

1. Plan: Identify populations of focus, current 

treatment gaps, and internal capacity to implement 

a new program through an organizational readiness 

and needs assessment process. This process should 

include a review of qualitative and quantitative 

data and budget requirements. 

2. Engage Youth with Lived Experience: Within 

the limits of the program, practitioners should 

involve youth suicide attempt survivors and 

young people with a range of relevant lived 

experience, including graduates of treatment 

programs, as an integral resource and voice 

to inform the implementation, adaptation, and 

evaluation of programs. Provide leadership roles 

for youth to serve on agency boards of directors 

and community councils, as appropriate.

3. Build Buy-in and Capacity: Communicate 

goals and expectations, facilitate understanding 

about program theory and build support among 

staff. Select and train staff and supervisors to 

support implementation of the new program. 

Offer trainings to new staff and booster training 

or coaching sessions for existing staff to enhance 

skills. 

4. Implement: Pilot test the program and refine, if 

needed, before scaling up to full implementation. 

5. Evaluate: Monitor practice change and quality of 

program delivery through observation, staff input, 

and data. Evaluate the implementation process 

and assess whether the program is achieving the 

desired outcomes (see details in Chapter 5). 
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

Guidance for Selecting and Implementing Evidence-based Programs 33

Prior to initiating treatment or during the first sessions, 

a comprehensive clinical assessment or history of a 

client’s thoughts, behaviors, mood, previous suicide 

attempts, trauma, health history, and home life should 

be completed using a structured or semi-structured 

approach (e.g., using a combination of assessment tools 

and/or clinical interviews).This initial assessment can 

assist providers in identifying suicide risk, determining 

appropriate next steps, and tailoring specific treatment 

modules to meet specific needs. Clinicians should also 

regularly administer one or a sub-set of brief tools 

based on the patient’s presenting problems to track the 

youth’s progress over time and adjust the treatment plan 

accordingly, consistent with measurement-based care.3

An example of a free assessment tool for identifying 

youth at risk for suicide during an initial assessment is 

the Ask Suicide-Screening Questions (ASQ) Toolkit.4

HealthMeasures includes PROMIS® and the NIH 

Toolbox®, two free comprehensive sets of neurobehavioral measurements that assess a broad range of 

symptoms and risk and resilience factors that could be 

used at intake and to monitor patients over time.5

Common Elements of 

Effective Treatment 

Programs

The evidence base for treatment of suicidal ideation, 

self-harm, and suicide attempts continues to emerge. 

There is no one-size-fits-all treatment approach. Care 

should be taken to select the program that best fits 

the characteristics and needs of the youth who will be 

served. 

Regardless of the specific program selected, this guide’s 

review of relevant research and discussions with content 

experts identified a set of common elements that should 

be strongly considered prior to treatment and within 

treatment programs: 

•	 Comprehensive assessment to inform treatment

•	 Safety planning

•	 Family involvement in separate or joint sessions

•	 Coping skills training to match needs identified 

in the assessment

•	 Promotion of continuity of care

Measurement-based care is the systematic 

administration of symptom rating scales and use 

of the results to drive clinical decision making at 

the level of the individual patient.3

The Collaborative Assessment and 

Management of Suicidality (CAMS) is a 

therapeutic framework in which the client and 

provider work together to assess the client’s 

suicidal risk and use that information to plan 

and manage suicide-specific treatment. CAMS 

is a widely used intervention but it’s efficacy for 

youth has not been tested. CAMS incorporates 

the Suicide Status Form (SSF) to assess the 

client and guide the development of a treatment 

plan. The SSF has been validated for use with 

youth aged 12 to 17.6
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

Guidance for Selecting and Implementing Evidence-based Programs 34

Safety planning is an essential intervention and component 

of an evidence-based treatment approach. Research has 

shown that individuals who receive safety planning are 

less likely to experience suicidal behavior, less likely 

to be hospitalized in the following year, and more than 

twice as likely to receive mental health services.7

 A 

safety plan is a prioritized list of coping strategies and 

sources of support that youth can use before or during 

a suicidal crisis and is often completed before starting 

treatment and/or during the first session. Safety plans 

are based on clear communication and a collaborative 

relationship between the client and provider, and are 

differentiated from previously used safety contracts 

– which the evidence has found are not effective – by 

including clear direction and support for addressing a 

suicidal crisis. Clinicians should collaborate with youth 

and their parents (if it is safe and appropriate to involve the 

family) at the beginning of a treatment program to develop 

a safety plan that is brief, in the youth’s own words, and 

easy to read.8-9

Parents or other adult family members should also 

receive instruction on how to monitor for suicidal 

thoughts and behavior, recognize warning signs, and 

support their child in using the safety plan. In addition, 

parents should be taught when, where, and how to 

access emergency care for their child when needed. 

For individuals at higher risk, safety plans should be 

revisited over the course of treatment.

Clinicians should also counsel the youth’s family on 

ways to reduce access to lethal means, such as removing 

firearms, medications, or sharp objects from the home. 

Counseling on Access to Lethal Means (CALM) is one 

example of a training resource for clinicians in this 

area.10

Involving parents, caregivers, or other supportive adults 

in the youth’s treatment program can help strengthen 

a youth’s support system, increasing the youth’s help 

seeking behaviors and creating positive interpersonal 

relationships. The literature shows that different aspects 

of family life and relationships can serve as either risk 

or protective factors for suicide and self-harm. Separate 

parent or integrated family sessions may focus on 

emotional regulation, improving communication, parent 

monitoring, and resolving family conflicts that have 

strained the parent-child bond. 

When involving family, some programs use two 

therapists throughout the treatment process, one focused 

on the adolescent and one focused on the parents or 

caregivers. 

Skills training during treatment involves youth learning, 

practicing, and applying a variety of coping skills 

that help youth better navigate everyday challenges 

and stressors. Skills training sessions may focus on 

emotional regulation, distress tolerance, cognitive 

restructuring, communication skills, help seeking, 

problem-solving, and/or conflict resolution.11

This training should be calibrated with what put that 

youth at risk for suicide. For example, if an adolescent 

male client tends to experience suicidal thoughts after 

interpersonal conflicts with his friends, parents, and 

significant other, a clinician might prioritize different 

coping skills than for an adolescent female who suffers 

from perfectionism, anxiety, depression, and feelings of 

failure.

After acute treatment, it is important to consider 

additional treatment and service (e.g., mental health, 

health, school, housing, transportation) needs. Treatment 

that employs a collaborative approach that links the 

adolescent, as well as their family, to primary health 

care, behavioral health care, or community and school 

services and supports, can help engage and motivate the 

adolescent. This can increase retention in therapy and 

decrease suicidal thoughts and behavior.11

Addressing barriers to care can also be helpful. Research 

shows that individuals experiencing suicidal thoughts 

and behaviors are less likely to initiate treatment, to 

attend only a few sessions, or to drop out of treatment 
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

Guidance for Selecting and Implementing Evidence-based Programs 35

early.12 Continuity of care strategies can improve 

connectedness, motivation, and treatment adherence, 

which help prevent future episodes of suicidal behaviors, 

and, in turn, relapse. Relapse prevention strategies also 

include enhancing youths’ self-esteem, autonomy, and 

resilience to distress, as well as avoiding alcohol and 

other drugs.13-14

Standard care for youth should include brief, nondemanding, repeated caring contacts expressing care, 

interest, and support following discharge. A case 

manager who provides assistance and follow-up support, 

especially during times of transition, can also assist with 

other psychosocial needs (e.g., paperwork related to 

housing or education) that impact suicidal thoughts and 

behavior but are not typically the focus of mental health 

interventions. Case managers should work with schools 

and campus counseling offices to engage clinical support 

in learning environments.

Considerations 

When Selecting and 

Implementing Programs 

to Treat Suicidal Ideation, 

Self-Harm, and Suicide 

Attempts

When selecting and implementing optimal interventions 

to address suicidal thoughts and behaviors, there are 

several potential factors to consider, including:

•	 Treatment fidelity 

•	 Adaptation of programs 

•	 Treatment adherence and retention in care

•	 Program sustainability

These factors are described in detail below, along 

with recommended strategies to achieve optimal 

implementation. 

Treatment Fidelity

Consideration: Fidelity is the extent to which a 

practitioner adheres to the core components of the 

program and is crucial to reaching desired outcomes.15

For youth experiencing suicidal thoughts and behaviors, 

this consideration is particularly important given that 

lack of improvement could result in an attempt or death 

by suicide.

Strategies:

•	 Monitor fidelity over time – For even the most 

experienced clinicians, suicide can be one of the 

most uncomfortable and challenging presenting 

problems to address with clients. Without ongoing 

efforts to maintain it, initially high treatment 

fidelity can diminish, even after only a few weeks 

following initial implementation of a program.15

Many programs in this guide have fidelity 

measures that can be implemented either as a 

self-assessment tool, or, if funding is available, 

by external expert evaluators. Practitioners 

should also frequently refresh their knowledge 

of the program by attending trainings, webinars, 

and other continuing education opportunities.

•	 Ensure the organizational environment 

supports fidelity - Organizations can support 

treatment fidelity by examining their existing 

systems and environment to determine whether 

they enable staff to carry out the program 

as intended. The organization must have the 

infrastructure needed to support correct use 

of evidence-based treatment, reduce clinician 

burden, and prevent burnout.

Considerations may include current program 

offerings, the level of staff education, client 

characteristics, client intake processes, funding 

sources, the ability of clinicians to see clients 

on a regular basis (e.g., once a week or more 

often depending on the treatment selected), and 

time for clinicians to further study the treatment 

modules and prepare for each session. It is 

important for the organization and leaders to 

acknowledge how challenging it is to work with 

suicidal clients and to be transparent about the 

fidelity monitoring process.

•	 Develop in-house expertise - It is often 

advantageous for an organization to select 

staff to undergo supervision, trainings, and 

certification. In-house training and clinician 

supervision groups make professional 

development more easily accessible, help 

prevent burnout, and ensure continued treatment 

fidelity over time. They can also help ensure 

a built-in support system and more attention 

to self-care for clinicians working with youth 

experiencing suicidal thoughts or behaviors.
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

Guidance for Selecting and Implementing Evidence-based Programs 36

Adaptation of Programs 

Consideration: While maintaining program fidelity is 

critical to achieving desired outcomes, certain elements 

of a program may not be appropriate or feasible to 

implement in specific contexts. Successful program 

implementation often requires adapting a program so 

it is better suited for a particular population, program 

setting, or organization. 

Strategies:

•	 Develop a plan for adaptations - Practitioners 

and program administrators should plan 

adaptations in advance to ensure core 

components of the program or practice are 

maintained and fidelity is not compromised. 

When possible, they should consult with 

the treatment developers for guidance on 

adaptations. They should also seek input from 

program stakeholders, including participants, 

and monitor program data to ensure the program 

is still achieving desired outcomes. Depending 

on the degree of adaptation of the originally 

validated intervention, the new version may or 

may not be as effective – which underscores the 

need for continued evaluation.

ADAPT-ITT, consisting of eight sequential 

phases, is a systematic framework for adapting 

evidence-based interventions.16 While it was 

initially designed for HIV-related interventions, 

the general process is applicable to many other 

types of programs.

•	 Adapt the program to better serve the 

population of focus - The most commonly cited 

reasons organizations adapt a program are for 

ensuring cultural competency and addressing a 

new population of focus.17

Cultural adaptions - Program implementers 

should consider how to tailor treatments to be 

compatible with the clients’ cultural patterns, 

meanings, and values.18 To make a program 

more culturally appropriate, it is important 

to consider the preferred language, values, 

attitudes, beliefs, practices, and experiences of 

the cultural groups served. 

For example, interventions for Native American 

youth experiencing suicidal thoughts or 

behaviors may need to address cultural beliefs 

and incorporate Native-specific language for the 

concept of suicide, as well as the importance of 

and ways to promote wellness. 

Adaptations for LGBTQ youth - LGBTQ youth 

are youth who identify as lesbian, gay, bisexual, 

transgender, queer, or who are currently 

questioning their sexual orientation or gender 

identity. Programs may need to be adapted to 

better address the additional challenges that 

LGBTQ youth face.19
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

Guidance for Selecting and Implementing Evidence-based Programs 37

For programs that incorporate families into 

treatment, the practitioner will first need to ask 

the youth whether their parents know about their 

gender identity and/or sexual orientation. Second, 

if parents are aware, they will need to assess how 

the parents responded to this information and 

determine how the family is currently interacting 

around issues related to gender identity and/or 

sexual orientation. With this information in mind, 

clinicians can then implement interventions 

to reduce suicidal thoughts and behaviors 

while ensuring they do not result in further 

stigmatization and rejection of gender and/or 

sexual minority youth by their families.

•	 Consult Best Practices in Telehealth - Treating 

clients in-person is not always possible, especially 

in more rural regions that may have a shortage 

of behavioral health practitioners and during 

public health emergencies, such as the COVID-19 

pandemic. Virtual treatment approaches may be 

more accessible and cost-effective. 
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

Guidance for Selecting and Implementing Evidence-based Programs 38

When adapting programs to be delivered 

virtually, program administrators should 

consult best practices in delivering telehealth 

services, such as the American Telemedicine 

Association’s Practice Guidelines for VideoBased Online Mental Health Services,

20

in addition to following the ADAPT-ITT 

framework or a similar model for adapting 

evidence-based programs. Clinicians should take 

extra precautions to ensure the safety of clients 

experiencing suicidal thoughts or behaviors 

when receiving treatment virtually. Strategies 

for ensuring safety include developing a plan 

for how to contact emergency support while 

remaining on the line with the individual, asking 

for the client’s location at the outset of the 

treatment session, and staying on the line with 

the client until care arrives if risk is imminent.21

The interventions reviewed in this guide have 

not been evaluated with telehealth service 

delivery, and more research is needed to identify 

and address potential barriers and determine the 

effectiveness.

Treatment Adherence and Retention in Care

Consideration: The effectiveness of a program depends 

on the participant’s adherence to the recommended 

treatment plan and retention in care.

Strategies:

•	 Engage youth as active partners 

in their own care - Practitioners 

should engage youth in 

collaborative treatment planning 

and goal setting and also engage 

the family when appropriate. Everyone should 

agree to expectations and responsibilities for the 

clinician and the participant. 

•	 Assess adherence behaviors and 

potential barriers, such as low selfefficacy, stigma, financial concerns, 

and access to services - Once 

barriers are identified, clinicians 

should work with families to address immediate 

clinical concerns, such as low self-efficacy and 

stigma. Simultaneously, they can provide support 

to address other obstacles to care, including case 

management to access insurance, transportation 

to services, and referrals to social services. 

Application of problem-solving skills training 

and/or motivational interviewing can be helpful 

strategies for the clinician to use. 

•	 Build a therapeutic alliance by 

demonstrating positive regard 

for the youth and family, showing 

empathy, and communicating 

clearly - Research suggests 

therapeutic alliance is a strong predictor of 

retention in treatment.22

Program Sustainability 

Consideration: Implementation of treatment programs 

requires sustainable funding mechanisms. Estimates 

of implementation costs should include staff time and 

resources for planning, training, materials, technology 

needs, and service delivery. Clinicians may experience 

challenges receiving adequate reimbursement due to the 

longer duration of services needed to implement some 

of these interventions, as well as limited coverage for 

comprehensive components such as team-based care. 

Strategies:

•	 Review insurance policies - State Medicaid, 

the Children’s Health Insurance Program, 

and private insurance policies differ in 

their requirements for reimbursement of 

behavioral health services, including diagnostic 

assessments, psychiatric care, psychotherapy, 

partial hospitalization programs, intensive 

outpatient programs, and family therapy. 

Reimbursement policies can be confusing and 

complex. Program administrators should seek 

and provide clarification around common billing 

concerns, such as same-day billing restrictions 

and billing for family therapy when the client 

with the presenting problem (e.g., youth with 

suicidal thoughts) is not present.

•	 Coordinate with state and local suicide 

prevention partners - State agencies and local 

organizations may have funding to provide 

training and technical assistance related to 

program implementation.23-24 For example, the 

Substance Abuse and Mental Health Services 

Administration supports state and local 

prevention efforts through the Garrett Lee Smith 

Suicide Prevention and the Zero Suicide grant 

programs.
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

Guidance for Selecting and Implementing Evidence-based Programs 39

Program Resources

In addition to the overarching implementation guidance 

provided above, several resources are available to help 

individuals and organizations implement the programs 

described in Chapter 2. Some of the programs have 

not been widely disseminated or implemented. The list 

below provides a sample of available resources for each 

program.

Dialectical Behavior Therapy

SAMHSA’s Technology Transfer Center Network

provides free training and resources on DBT.

DBT-Linehan Board of Certification oversees DBT 

certification and includes a directory of certified clinicians 

and programs. The site includes additional resources, such 

as book recommendations.

Psychwire offers online DBT training courses, free 

training videos, and a DBT newsletter.

Behavioral Tech, founded by the developer of DBT, 

Marsha Linehan, PhD, ABPP, provides comprehensive 

DBT information, categorizes global DBT research, and 

offers DBT training, certification, and consultation. The 

site also includes resources for children and families.

Treatment Implementation Collaborative offers 

DBT implementation assistance, as well as training, 

consultation, and supervision.

Attachment-Based Family Therapy

The ABFT Training Program at Drexel University’s 

Center for Family Intervention Science provides a 

variety of resources, including an ABFT treatment 

manual, trainings to achieve ABFT certification, 

webinars, supervisor and trainer trainings to help 

organizations build internal capacity for implementation, 

and a free ABFT Dissemination and Implementation 

Starter Packet.

The American Psychological Association offers an online 

introductory workshop on ABFT for a nominal fee.

Multisystemic Therapy-Psychiatric

MST Services, founded by the Multisystemic Therapy 

(MST) developers, provides ongoing implementation 

support for organizations. Supports available from 

MST Services and its network of partners include: 

development of a process to track key outcomes, 

semiannual program reviews and problem solving 

support, centralized MST database for collection of 

therapist and supervisor adherence to model and youth 

clinical outcomes, initial 5-day orientation and quarterly 

booster trainings, weekly consultation with an MST 

expert and MST psychiatrist expert, and supplemental 

trainings for MST–Psychiatric programs. The website 

includes free videos, fact sheets, and webinars. 

Safe Alternatives for Teens and Youths

The UCLA-Duke Center for Trauma-Informed 

Adolescent Suicide, Self-Harm, and Substance Abuse 

Treatment and Prevention (ASAP Center) is part of the 

National Child Traumatic Stress Network. The ASAP 

Center offers information, trainings, and other resources 

for implementing Safe Alternatives for Teens and 

Youth (SAFETY) and SAFETY-Acute (SAFETY-A), 

also referred to as Family Intervention for Suicide 

Prevention. Available resources include: free webinars; 

manuals; tip sheets with clinical guidance; standardized 

patient case demonstrations; other training materials 

and resources for implementing components of these 

programs; and information on the development and 

evidence base for SAFETY and SAFETY-Acute. 

Information and resources can also be accessed 

through the Youth Stress & Mood Program within the 

Department of Psychiatry at the University of California 

Los Angeles.

Integrated Cognitive Behavioral Therapy

In this book chapter, the developers of I-CBT provide 

guidance on how to select treatment candidates for I-CBT, 

and a case study example of how to implement I-CBT: 

Esposito-Smythers, C., Spirito, A., & Wolff, J. (2019). 

CBT for co-occurring suicidal behavior and substance 

use (I-CBT). In M. Berk (Ed.) Evidence-Based Treatment 

Approaches for Suicidal Adolescents: Translating Science 

into Practice. American Psychiatric Publishing.

Youth-Nominated Support Team – Version II

The Youth and Young Adult Depression and Suicide 

Prevention Research Program at the University 

of Michigan’s Department of Psychiatry provides 

information and resources related to Youth-Nominated 

Support Team – Version II, including access to the free 

intervention manual.
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

Guidance for Selecting and Implementing Evidence-based Programs 40

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Brownson, R.C. (2012). Tools for implementing an 

evidence-based approach in public health practice. 

Preventing Chronic Disease, 9, 110324. http://

dx.doi.org/10.5888/pcd9.110324

2 Suicide Prevention Resource Center. (2019). A 

strategic planning approach to suicide prevention. 

https://training.sprc.org/enrol/index.php?id=31

3 Fortney, J., Unützer, J., Wrenn, G., Pyne, J., Smith, 

G., Schoenbaum, M., & Harbin, H. (2017). A tipping 

point for measurement-based care. Psychiatric 

Services, 68(2), 179-188. https://doi.org/10.1176/

appi.ps.201500439

4 Achenbach System of Empirically Based 

Assessment. (2020). School-Age (CBCL, TRF, YSR, 

BPM/6-18). https://aseba.org/school-age/

5 Northwestern University. (2020). HealthMeasures. 

https://www.healthmeasures.net/

6 Brausch, A. M., O’Connor, S. S., Powers, J. T., 

McClay, M. M., Gregory, J. A., & Jobes, D. A. 

(2019). Validating the Suicide Status Form for 

the Collaborative Assessment and Management 

of Suicidality in a psychiatric adolescent sample. 

Suicide and Life-Threatening Behavior, 50(1), 263-

276. https://doi.org/10.1111/sltb.12587

7 Stanley, B., Chaudhury, S. R., Chesin, M., Pontoski, 

K., Bush, A. M., Knox, K. L., & Brown, G. K. 

(2016). An emergency department intervention 

and follow-up to reduce suicide risk in the VA: 

Acceptability and effectiveness. Psychiatric 

Services, 67(6), 680-683. https://doi.org/10.1176/

appi.ps.201500082

8 Brown, G., Stanley, B., Western Interstate 

Commission for Higher Education, & Suicide 

Prevention Resource Center. (2009). Safety planning 

guide: A quick guide for clinicians. Education 

Development Center, Inc. https://www.sprc.org/

resources-programs/safety-planning-guide-quickguide-clinicians

9 Hughes, J. L., & Asarnow, J. R. (2013). Enhanced 

mental health interventions in the emergency 

department: Suicide and suicide attempt prevention 

in the ED. Clinical Pediatric Emergency 

Medicine, 14(1), 28-34. https://doi.org/10.1016/j.

cpem.2013.01.002

10 Suicide Prevention Resource Center. (2018). CALM: 

Counseling on access to lethal means. http://www.

sprc.org/resources-programs/calm-counselingaccess-lethal-means

11 Stone, D. M., Holland, K.M., Bartholow, B., Crosby, 

A.E., Davis, S., & Wilkins, N. (2017). Preventing 

suicide: A technical package of policies, programs, 

and practices. Centers for Disease Control and 

Prevention. https://www.cdc.gov/violenceprevention/

pdf/suicideTechnicalPackage.pdf

12 Donaldson, D., Spirito, A., & Boergers, J. (2010). 

Treatment engagement with adolescent suicide 

attempters. In D. Castro-Blanco & M. S. Karver 

(Eds.), Elusive alliance: Treatment engagement 

strategies with high-risk adolescents. (pp. 207-225). 

American Psychological Association.

13 Daniel, S. S., & Goldston, D. B. (2009). 

Interventions for suicidal youth: A review of the 

literature and developmental considerations. Suicide 

and Life-Threatening Behavior, 39(3), 252-268. 

https://doi.org/10.1521/suli.2009.39.3.252

14 Wu, P., Hoven, C. W., Liu, X., Cohen, P., Fuller, 

C. J., & Shaffer, D. (2004). Substance use, suicidal 

ideation and attempts in children and adolescents. 

Suicide and Life-Threatening Behavior, 34(4), 408-

420. https://doi.org/10.1521/suli.34.4.408.53733

15 Wilczynski, S. M. (2017). Chapter 8 - Treatment 

feasibility and social validity. In S. M. Wilczynski 

(Ed.), A Practical Guide to Finding Treatments That 

Work for People with Autism (pp. 47-57). Academic 

Press. http://www.sciencedirect.com/science/article/

pii/B978012809480800008X. 

16 Wingood, G. M., & DiClemente, R. J. (2008). The 

ADAPT-ITT model: A novel method of adapting 

evidence-based HIV Interventions. Journal 

of Acquired Immune Deficiency Syndromes, 

47(Suppl 1), S40-46. https://doi.org/10.1097/

QAI.0b013e3181605df1

17 Escoffery, C., Lebow-Skelley, E., Haardoerfer, 

R., Boing, E., Udelson, H., Wood, R., Hartman, 

M., Fernandez, M. E., & Mullen, P. D. (2018). A 

systematic review of adaptations of evidence-based 

public health interventions globally. Implementation 

Science, 13(1), 125. https://doi.org/10.1186/s13012-

018-0815-9
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

Guidance for Selecting and Implementing Evidence-based Programs 41

18 Bernal, G., Chafey, M., & Domenech Rodríguez, M. 

(2009). Cultural adaptation of treatments: A resource 

for considering culture in evidence-based practice. 

Professional Psychology: Research and Practice, 40, 

361-368. https://doi.org/10.1037/a0016401

19 Society for Adolescent Health and Medicine. (2013). 

Recommendations for promoting the health and 

well-being of lesbian, gay, bisexual, and transgender 

adolescents: A position paper of the Society for 

Adolescent Health and Medicine. Journal of 

Adolescent Health, 52(4), 506-510. https://doi.

org/10.1016/j.jadohealth.2013.01.015

20 American Telemedicine Association. (2009). 

Practice guidelines for video-based online mental 

health services. https://www.americantelemed.

org/resources/practice-guidelines-for-video-basedonline-mental-health-services-2/

21 Center for Practice Innovations at Columbia Psychiatry 

New York State Psychiatric Institute, & SP-TIE: Suicide 

Prevention-Training Implementation Evaluation. 

(2020). Telehealth tips: Managing suicidal clients 

during the COVID-19 pandemic. http://zerosuicide.edc.

org/sites/default/files/Telehealth%20Tips%20with%20

Suicidal%20Clients%20-%20FINAL.pdf

22 Dunster-Page, C., Haddock, G., Wainwright, L., & 

Berry, K. (2017). The relationship between therapeutic 

alliance and patient’s suicidal thoughts, self-harming 

behaviours and suicide attempts: A systematic review. 

Journal of Affective Disorders, 223, 165-174. https://

doi.org/10.1016/j.jad.2017.07.040

23 Suicide Prevention Resource Center. (2020). States. 

https://www.sprc.org/states

24 Suicide Prevention Resource Center. (2020). 

Grantees. https://www.sprc.org/grantees
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

Examples of Suicide Treatment Programs 42 4

CHAPTER

Examples of Suicide 

Treatment Programs

This chapter highlights four examples of organizations 

that provide treatment services to address suicidal 

ideation, self-harm, and suicide attempts among youth. 

Each organization is implementing an intervention with 

strong or moderate support for causal evidence detailed 

in Chapter 2, including: 

•	 Dialectical Behavior Therapy (DBT)

•	 Attachment-Based Family Therapy (ABFT)

•	 Safe Alternatives for Teens and Youth (SAFETY)

•	 Integrated Cognitive Behavioral Therapy (I-CBT)

This chapter does not include an example for 

Multisystemic Therapy-Psychiatric or Youth Nominated 

Support Team Intervention for Suicidal AdolescentsVersion II. The chapter documents how each setting 

has implemented these treatment programs as part of 

a comprehensive strategy to address the needs of their 

populations. Programs should implement interventions 

with fidelity to evaluated models. Fidelity is the degree 

to which a program delivers a practice as intended 

and must be maintained for desired therapy outcomes. 

However, many programs, including those highlighted 

in this chapter, adapt chosen interventions to better 

serve their clients. As clinical providers and program 

administrators modify these interventions to address 

the needs and constraints of their population, budget, 

setting, and other local factors, they should adhere to the 

evidence-based program’s foundational principles and 

core components. 
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

Examples of Suicide Treatment Programs 43

The examples highlighted in this chapter were identified 

through an environmental scan and in consultation 

with subject matter experts. While there are additional 

programs that could have been featured in this 

chapter, the programs described below are considered 

representative examples of current adaptations of 

evidence-based treatment protocols for suicidal thoughts 

and behaviors and serve diverse populations of youth.

The examples detailed in this chapter: 

•	 Include interventions identified in Chapter 2

•	 Can be replicated (are well-defined with 

guidance materials or a manual)

•	 Have preliminary evaluation data to show 

promise of impact on suicide-related outcomes 

•	 Exemplify implementation in varying geographic 

areas, practice settings, and diverse populations
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

Examples of Suicide Treatment Programs 44

Indian Health Service – Desert Visions and Nevada 

Skies Youth Wellness Centers

Sacaton, Arizona and Wadsworth, Nevada 

Desert Visions and Nevada Skies are residential 

treatment centers for American Indian/Alaska Native 

(AI/AN) youth aged 12 to 18. About one-third of youth 

present at intake with suicidal ideation or behavior. The 

centers offer a multi-disciplinary treatment approach that 

includes biopsychosocial, health, education, and cultural 

activities. 

DBT-A is the primary treatment modality, with 

adaptations to incorporate cultural and spiritual 

practices, including talking circles, sweat lodges, 

smudging, and drumming.1

 In addition, a Native 

American traditional spiritual counselor comes from the 

community weekly to provide traditional acupuncture 

and medicinal preparations. 

The centers are owned and operated by the Indian Health 

Service (IHS), with about half of funding for the DBT-A 

program from the federal government and half from 

billing to private insurance plans.

Model Features and Elements

•	 Manualized (Rathus & Miller, 2014) 16-week 

DBT-A program is operated alongside with 

traditional healing practices. 

•	 Youth receive individual therapy weekly, group 

therapy daily, and family therapy at least twice 

monthly. 

•	 Family therapy is an integral part of treatment 

and takes place in-person when the family is 

located close to the facility or virtually if inperson meetings are not possible. However, 

multifamily skills groups have not been 

implemented due to feasibility issues in the 

residential setting. 

•	 The centers employ full-time medical staff, 24-

hour nursing support, and a medical director.

•	 All counselors (primarily master’s level) 

complete a two-week intensive DBT training 

and receive weekly consultation. 

•	 Training in the originally developed DBT 

(for adults) is readily available and provides a 

foundation for implementing DBT-A. Following 

the two-week DBT training, counselors receive 

training specific to implementation with 

adolescents.

•	 Counselor aides and nursing staff also 

participate in DBT training.

•	 DBT mindfulness module incorporates cultural 

and spiritual practices, such as talking circles, 

sweat lodges, and smudging.

•	 Safety planning is conducted with youth at risk 

of harming themselves or others.

•	 Empirically supported, standardized measures 

are administered throughout the program.

•	 Columbia-Suicide Severity Rating Scale,2

 Youth 

Outcome Questionnaire-SR (YOQ-SR),3

 and 

the Linehan Risk Assessment and Management 

Protocol (LRAMP)4

 are administered at program 

entry. All three measures include assessment of 

suicidal risk.

Program Implemented

Dialectical Behavior Therapy for Adolescents 

(DBT-A) 

Setting

Two residential treatment centers serving AI/AN 

youth aged 12 to 18 for a minimum of 120 days.

Population of Focus 

AI/AN youth with a primary diagnosis of 

substance use disorder. Most youth have cooccurring diagnoses of depression, anxiety, eating 

disorders, serious mental illness, or conduct 

disorders.

Program Duration

Youth receive the 16-week DBT-A program as 

part of their residential stay of at least 120 days. 

Related Resources

Program Website
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

Examples of Suicide Treatment Programs 45

•	 YOQ-SR is re-administered every two weeks 

and before discharge, and LRAMP is readministered when clinically indicated, for 

example if youth expresses suicidal ideation or 

engages in self-harm. 

•	 Youth can serve in a leadership role as peer 

mentors, which includes orienting new clients to 

the program.

Findings and Outcomes 

Desert Visions reports positive outcomes related to: 

•	 Treatment completion

•	 Improved delivery and coordination of care by 

all staff

•	 Improved ability by the adolescents to utilize 

skillful/effective behavior instead of selfdestructive/harmful behavior

In a pilot study of 229 participants, 96 percent had 

statistically significant changes on the YOQ-SR.5

 The 

YOQ-SR asks specifically about self-harm and suicidal 

ideation, in addition to emotional and physical distress 

and interpersonal problems.

Lessons 

Learned 

•	 It is possible to integrate traditional, 

spiritual, and cultural practices 

seamlessly into DBT-A.

•	 In a residential setting, it is critical that the 

frontline staff, who spend the most time with 

youth, are trained in DBT-A at the same level as 

the counselors and other staff. With this training, 

frontline staff can provide real-time coaching of 

skills. This is a critical part of strengthening skill 

acquisition and also generalizing the skills to 

multiple settings. 

•	 Follow-up training and ongoing support systems 

for staff, such as weekly team meetings, improve 

job satisfaction and reduce burnout.6

•	 DBT case consultation is essential to ensure 

that therapists and staff maintain fidelity to the 

DBT-A model.

•	 Therapists and staff may benefit from a one-time 

training in the basics of behavior therapy, such 

as the concepts of reinforcement, extinction, and 

contingency management.
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

Examples of Suicide Treatment Programs 46

Central Toronto Youth Services – Outpatient Family 

Therapy

Toronto, Ontario 

Central Toronto Youth Services (CTYS) is a community 

mental health center serving youth aged 12 to 24 and 

their families through in-office and outreach programs—

including home- and school-based services—and 

individual, family, and group counseling. School-aged 

youth are often referred by schools when they would 

benefit from more support than their school social 

workers can provide. 

ABFT is offered to youth with a variety of clinical 

presentations, including concerns about suicidal thoughts 

or self-harm. Programming is tailored to specific groups. 

For example, a program specifically for Black youth 

acknowledges the role of systemic racism and helps 

youth reconnect with their identity and culture. 

CTYS also offers programming specific to the needs of 

lesbian, gay, bisexual, transgender, queer, or questioning 

youth, and youth with other sexual and gender minority 

identities (LGBTQ+). Services recognize the impact 

of systemic oppression for these youth on their mental 

health.7

 Youth are welcomed for individual sessions 

intended to prepare for family sessions. Parents and 

caregivers receive education and counseling around 

sexual orientation and/or gender identity, including 

through a support group for families in the process of 

accepting their youth’s sexual orientation and/or gender 

identity. 

CTYS has worked with the ABFT developers at Drexel 

University to implement ABFT, and new family-focused 

workers attend ABFT Level 1 training through Drexel. 

ABFT developers provide monthly consultation. 

 Model Features and Elements

•	 ABFT staff are graduate-level social workers, 

marriage and family therapists, or counselors.

•	 CTYS has made some adaptations to ABFT to 

meet the needs of LGBTQ+ youth; for example, 

parents may not be included in the youth’s 

therapy sessions until it is safe for the youth. 

Often there is a repair session that needs to occur 

regarding parents’ reaction to their youth coming 

out to them. Parents also learn about microaggressions and the ways in which they may 

be inadvertently rejecting their child’s sexual 

orientation and/or gender identity. 

•	 CTYS provides adaptations for youth 

with serious mental disorders that include 

psychoeducation, as well as more intensive case 

management, to help youth gain independence.

•	 Staff receive Applied Suicide Intervention Skills 

Training (ASIST), a suicide first aid program 

that addresses suicidal ideation and mitigates 

risk.8

 ASIST training prepares staff to discuss 

suicide in a direct manner with someone at risk, 

to develop a safety plan, to encourage seeking 

further help as needed, and to encourage safe 

community involvement.9

•	 Therapists have low caseloads (12 to 15 

families) to allow them to meet with youth 

individually, as well as accommodate all family 

members’ schedules for family sessions.

•	 A tip sheet is available for staff to help them 

have difficult conversations about suicide with 

youth and parents and to create a safety plan. 

Program Implemented

Attachment-Based Family Therapy (ABFT)

Setting

Community mental health center, funded by the 

Ontario Ministry of Health.

Population of Focus 

Youth aged 12 to 24 served throughout agency; 

some programs have specific age ranges or are 

targeted to specific groups, such as LGBTQ+ 

youth.

Program Duration

Youth participate in ABFT for an average of 18 

months. 

Related Resources

Program Website
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

Examples of Suicide Treatment Programs 47

•	 Through a safety plan, youth are empowered to 

cope with distress without automatically going 

to the hospital. An essential part of the safety 

plan is the crisis plan, for when coping skills are 

not sufficient to ensure safety.

•	 Youth can take on leadership roles through a 

Youth Engagement Program.

Findings and Outcomes 

The program uses the Child & Adolescent Functional 

Assessment Scale (CAFAS) to monitor clinical outcomes. 

The CAFAS assesses youth functioning at home, in 

school, and in the community. It also identifies concerns 

related to antisocial behavior, mood, thought patterns, 

substance use, and self-harm.10 In 2018, participants had 

an average drop of 25 points on the CAFAS following 

treatment. A decrease of 20 points or more is considered a 

clinically meaningful improvement.11

Lessons Learned 

•	 Parents may have a history of 

trauma or neglect themselves. 

ABFT’s psychoeducation materials 

offer resources to help parents 

examine the impact of their own stressors and 

intergenerational history of trauma to understand 

their own parenting behaviors towards their 

children.

•	 Responsibility is shared among the family, as 

opposed to focused on just the youth. 

•	 In a diverse community, such as Toronto, 

some words in the program materials were 

adapted to be responsive to how parents are 

attuned with their children in other cultures, 

specifically for families with intergenerational 

care arrangements. For example, youth may 

have been parented by a grandparent who may 

be included in family sessions through video 

conference. 

•	 Family therapy for LGBTQ+ youth is appropriate 

for affirming and somewhat supportive parents. 

It is not an included service when parents have 

not affirmed their child’s sexual orientation and/

or gender identity. CTYS uses a reflection tool at 

the beginning of the program to better understand 

how well the parent understands the youth’s 

sexuality and gender identity. In addition, every 

youth is asked their pronouns and gender identity 

when beginning services. 

•	 Therapists need regular peer or individual 

supervision around the nuances of family 

therapy to attend to the needs of everyone in the 

room. 
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

Examples of Suicide Treatment Programs 48

Children’s Health System of Texas – Inpatient Psychiatry 

and Intensive Outpatient Programs

Dallas, Texas 

Children’s Health System of Texas incorporates elements 

of SAFETY in both its inpatient and intensive outpatient 

programs (IOP) for youth. SAFETY-Acute (also known 

as the Family Intervention for Suicide Prevention, or 

FISP), the first session of SAFETY, is implemented in 

the health system’s emergency department. The system 

serves youth throughout the Dallas metropolitan area, as 

well as rural East Texas. 

The Suicide Prevention and Resilience at Children’s 

Health (SPARC) IOP program offers individual, family, 

and group therapy, and medication management. Parents 

also attend a weekly parent group to understand the skills 

that youth learn. SPARC is specifically designed to target 

risk factors associated with suicide attempts in youth. 

Model Features and Elements

•	 Clinical staff are master’s or doctoral-level 

therapists, doctoral-level trainees, or postdoctoral 

fellows. In the case of the inpatient setting, 

nurses have also received training on the model. 

•	 Inpatient unit:

– Inpatient stays are typically short; therefore, 

the complete 3-month SAFETY intervention 

is not possible to implement. Phase 1 of 

SAFETY: Establishing safety and treatment 

planning (i.e., SAFETY-A) is the focus in 

the inpatient setting.

– Inpatient participants receive two to three 

individual therapy sessions per week and 

two family sessions per week. 

– Parents of youth in the inpatient program 

typically participate in a first session 

separate from youth, in which they receive 

psychoeducation on suicide risk factors and 

lethal means restriction. 

•	 Intensive outpatient program:

– SPARC IOP participants receive the 

following interventions, which incorporate 

aspects of SAFETY: two 3-hour group 

therapy sessions per week and one individual 

therapy session per week, while parents 

attend a multifamily group for the first two 

weeks that their youth attends the program. 

– A Spanish language multifamily group may 

be offered in the SPARC program if several 

Spanish-speaking families have entered the 

program around the same time. If this is not 

the case, a bilingual therapist will review 

materials individually with a Spanishspeaking family. 

•	 Parents in both settings receive a handout on 

how to restrict access to lethal means in their 

homes, which takes the place of the in-home 

walk-through that would occur in an outpatient 

implementation of SAFETY. 

•	 The second family session, with youth and 

parents together, focuses on safety planning. 

•	 Therapists work with both youth and parents 

on addressing risk drawn from aspects of the 

“safety pyramid,” which encourages increased 

time spent with safe settings, safe people, safe 

activities, safe thought patterns, and safe stress 

reactions.12

•	 Families receive referrals at program completion 

(e.g., to a DBT program) and youth are 

encouraged to remember the skills that they have 

worked on as they transition to other services.

Program Implemented

Safe Alternatives for Teens and Youth 

(SAFETY)

Setting

Inpatient psychiatric unit; intensive outpatient 

program (IOP).

Population of Focus 

Youth aged 12 to 18 for the SPARC IOP; younger 

youth may be served in the inpatient setting; 

youth with various diagnoses are served.

Program Duration

Average inpatient stay is 1-2 weeks; average 

length of time in the IOP is 3-6 weeks. 

Related Resources

Program Website
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

Examples of Suicide Treatment Programs 49

Findings and Outcomes 

The IOP uses the Concise Health Risk Tracking SelfReport scale to assess risk of participating youth.13-14

Outcome data on 364 adolescents who completed at 

least one group session are available. The majority of 

adolescents went on to complete the program, indicated 

satisfaction with the program, and showed improvement 

in depressive symptoms and suicidal ideation and 

behavior.13

Lessons Learned 

•	 Programs implementing elements 

of SAFETY outside of the settings 

in which it was designed should 

consider the scope of their level of 

care and treatment goals.

•	 Organizations may face billing and logistical 

challenges to offering individual therapy for 

both the youth and parent and family therapy all 

in the same day. 
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

Examples of Suicide Treatment Programs 50

Fairfax-Falls Church Community Services Board – 

Healthy Minds Fairfax

Fairfax County, Virginia 

The Fairfax-Falls Church Community Services Board 

(CSB) provides outpatient and intensive services for 

emotional disability, mental illness, substance use, and 

co-occurring disorders for children and youth from 

ages 3 to 22 and their families. Services are offered at 

multiple locations throughout Fairfax County, Virginia. 

Families unable to pay the full fee for services, or who 

lack insurance coverage for services, may be eligible for 

a subsidy and/or an extended payment plan. 

Healthy Minds Fairfax15 is a system of care created 

to improve access to and quality of mental health and 

substance use disorder services for children, youth, and 

families through coordination of services across county 

agencies, the school system, and a network of private 

providers. The Fairfax Consortium for Evidenced-Based 

Practice provides training in evidence-based interventions, 

as well as consultation, fidelity monitoring, and outcome 

assessment to behavioral health providers. Training in a 

community-adapted version of I-CBT, renamed “Core 

Competency CBT”, began in 2018.

Model Features and Elements

•	 The program provides manualized and 

modularized cognitive-behavioral treatment 

that includes individual, parent, and family 

cognitive-behavioral skills-based modules, as 

well as a motivational enhancement module, that 

can be used with the adolescent or parent.16

•	 Adaptations were made to the training and 

consultation protocol, as well as the I-CBT 

treatment manual, to improve dissemination in 

community settings. Key adaptations include:

– Adding more general therapeutic skills, 

didactics, and role plays to the training 

– Increasing the structure of consultation by 

using case-conceptualization and treatment 

planning worksheets developed for 

community-adapted I-CBT

– Creating client handouts from the treatment 

manual text 

– Adding “therapist tips” and “brief guides” to 

the treatment modules 

– Widening the scope of substance specific 

modules to other types of high-risk 

behaviors and adding modules to meet 

additional behavioral concerns for this 

population

– Translating client handouts into Spanish

– Adding flexibility around the use of a twotherapist model and length of care

•	 All clinicians complete a four-day training 

followed by twice monthly consultation calls 

for six months provided by the trainers. On-site 

clinical supervisors also complete the training 

and many participate in consultation calls to 

learn the treatment model.

•	 Selection of treatment modules is guided by 

ongoing evidence-based assessment and case 

conceptualization.

•	 A brief assessment tool is administered at every 

treatment session and scores are graphed to track 

progress and guide treatment planning. This 

tool includes brief validated depression, anxiety, 

Program Implemented

Integrated Cognitive Behavioral Therapy 

(I-CBT)

Setting

Continuum of services across multiple county 

agencies, the school system, and a network of 

private providers.

Population of Focus 

Youth aged 12 to 18 with suicidal ideation, 

suicidal behavior, non-suicidal self-injury, 

depression, anxiety, conduct problems, and/or 

substance use disorders.

Program Duration

Length of treatment is dictated by client needs. 

Related Resources

Program Website
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

Examples of Suicide Treatment Programs 51

sleep, and anger subscales from 

NIH PROMIS measures, as well as 

individual items that assess suicidal 

ideation, attempts, non-suicidal 

self-injury, substance use, and 

medication compliance.

•	 The suicide risk assessment and safety planning 

module is family-based and incorporates the use 

of the Columbia Suicide Severity Rating Scale.

•	 Concurrent psychiatry services are provided, as 

needed, through the CSB.

Findings and Outcomes 

Clinicians trained in the community adapted I-CBT 

protocol report statistically significant increases in 

knowledge and self-efficacy in the use of I-CBT 

skills from pre- to post-training. Clinicians also report 

statistically significant increases in use of I-CBT skills 

with clients at 3-month follow-up, as well as good 

fidelity to the treatment modules. Collection of client 

outcome data is underway. 

Lessons Learned 

•	 It is possible to integrate use of the community 

adapted I-CBT protocol into community mental 

health settings, including behavioral health 

centers, schools, juvenile forensic programs, and 

home-based services.

•	 Consultation by trainers is needed for clinician 

competency and fidelity in the use of the 

community adapted I-CBT.

•	 Training on-site clinical supervisors increases 

use of and fidelity to community-adapted I-CBT. 

•	 Given the range of clinician backgrounds across 

community settings, incorporating training in 

diagnostic interviewing, cognitive-behavioral case 

conceptualization, evidence-based assessment, 

parental engagement, and management of family 

dynamics into the core I-CBT training improves 

clinician use of community adapted I-CBT.

•	 It is important to work together with leadership 

across practice settings and systems to address 

barriers to successful implementation of evidencebased treatments, including community-adapted 

I-CBT. 
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

Examples of Suicide Treatment Programs 52

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Administration. (2018). Behavioral health services 

for American Indians and Alaska Natives. Treatment 

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samhsa.gov/sites/default/files/d7/priv/tip_61_aian_full_

document_020419_0.pdf

2 The Columbia Lighthouse Project. (2016). About the 

protocol. https://cssrs.columbia.edu/the-columbiascale-c-ssrs/about-the-scale/

3 OQ Measures. (n.d.). Y-OQ 2.0. https://www.

oqmeasures.com/y-oq-sr-2-0/

4 Harned, M. S., Lungu, A., Wilks, C. R., & Linehan, 

M. M. (2017). Evaluating a multimedia tool for 

suicide risk assessment and management: The 

Linehan suicide safety net. Journal of Clinical 

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jclp.22331

5 Beckstead, D. J., Lambert, M. J., DuBose, A. P., & 

Linehan, M. (2015). Dialectical behavior therapy 

with American Indian/Alaska Native adolescents 

diagnosed with substance use disorders: Combining 

an evidence based treatment with cultural, traditional, 

and spiritual beliefs. Addictive Behaviors, 51, 84-87. 

https://doi.org/10.1016/j.addbeh.2015.07.018

6 National Indian Health Board. (n.d.). Desert Visions 

Youth Wellness Center. https://www.nihb.org/

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7 Central Toronto Youth Services. (2020). Pride & 

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suicide intervention skills training (ASIST). https://

www.sprc.org/resources-programs/applied-suicideintervention-skills-training-asist

10 Functional Assessment Systems. (2020). Child 

and Adolescent Functional Assessment Scale - 

CAFAS. http://www2.fasoutcomes.com/Content.

aspx?ContentID=12

11 Central Toronto Youth Services. (2018). Central 

Toronto Youth Services (CTYS): Our annual report 

2017-2018. https://ctys.org/wp-content/uploads/

CTYS_Annual_Report_2017-2018_Rev_10.26_

Email.pdf

12 Asarnow, J. R., Berk, M., Hughes, J. L., & Anderson, 

N. L. (2015). The SAFETY Program: A treatmentdevelopment trial of a cognitive-behavioral family 

treatment for adolescent suicide attempters. Journal of 

Clinical Child and Adolescent Psychology, 44(1), 194-

203. https://doi.org/10.1080/15374416.2014.940624

13 Kennard, B., Mayes, T., King, J., Moorehead, A., 

Wolfe, K., Hughes, J., Castillo, B., Smith, M., 

Matney, J., Oscarson, B., Stewart, S., Nakonezny, P., 

Foxwell, A., & Emslie, G. (2019). The development 

and feasibility outcomes of a youth suicide 

prevention intensive outpatient program. Journal 

of Adolescent Health, 64(3), 362-369. https://doi.

org/10.1016/j.jadohealth.2018.09.015

14 Mayes, T. L., Killian, M., Rush, A. J., Emslie, G. J., 

Carmody, T., Kennard, B. D., Jha, M. K., King, J., 

Hughes, J. L., & Trivedi, M. H. (2020). Predicting 

future suicidal events in adolescents using the 

Concise Health Risk Tracking Self-Report (CHRTSR). Journal of Psychiatric Research, 126, 19-25. 

https://doi.org/10.1016/j.jpsychires.2020.04.008

15 County of Fairfax Virginia. (n.d.). Healthy 

minds fairfax. https://www.fairfaxcounty.gov/

healthymindsfairfax/

16 Esposito-Smythers, C., Spirito, A., & Wolff, J. 

(2019). CBT for co-occurring suicidal behavior and 

substance use (I-CBT). In M. Berk (Ed.), Evidencebased treatment approaches for suicidal adolescents: 

translating science into practice (pp. 155-190). 

American Psychiatric Publishing.
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

Resources for Evaluation and Quality Improvement 53

5

CHAPTER

Resources for 

Evaluation and Quality 

Improvement

Evaluating an intervention can answer critical questions, 

provide information about how well a program has 

been implemented, and determine what may or may not 

working. Evaluation can also show how programs benefit 

clients overall, including impacts on suicidal thoughts 

and behaviors. Evaluation data can also be helpful 

in making program adjustments, justifying program 

continuation, and securing funding by providing evidence 

of program effectiveness. In addition, stakeholders can 

use information gathered via evaluation to encourage 

implementation interventions in other settings or 

communities.

This chapter provides an overview of approaches to 

evaluate implementation and results of programs that 

treat suicidal ideation, self-harm, and suicide attempts 

among youth. The chapter also includes information on 

implementing a continuous quality improvement (CQI) 

process and concludes with specific evaluation resources 

and potential suicide and suicide-related outcomes to 

track. 

Types of Evaluations and Study Designs

Evaluation is typically conducted before a practice is 

implemented to determine its feasibility (formative 

evaluation), during implementation (process evaluation), 

and after the intervention has been delivered to at least 

one client (outcome and impact evaluations). All four 

types of evaluations are necessary to be able to make 

judgments about an intervention’s effectiveness on 

reducing suicidal thoughts and behaviors.

Although often overlooked, formative evaluation

is an integral part of the implementation process and 

should be conducted when an organization is exploring 

the feasibility of implementing a suicide treatment 

program. This type of evaluation assesses readiness of 

an organization and its staff to implement the program, 

articulates a theory of change, and determines the extent 

to which a program can be evaluated in a reliable and 

credible fashion. During the formative evaluation, 
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

Resources for Evaluation and Quality Improvement 54

program managers and clinicians also establish a way of 

collecting or obtaining data on program implementation, 

outcomes, and impact on suicide-related indicators. 

The final product of formative evaluation is a written 

implementation and evaluation plan.

Process or implementation evaluation collects data 

about program implementation. It enables program 

managers and clinicians to assess whether a program 

was implemented as planned and informs program 

improvements. For example, the process evaluation 

might consist of qualitative interviews or surveys with 

clinicians and/or youth and their families to assess their 

satisfaction with the program. A process evaluation is 

also important for multi-component interventions to 

better understand if all components are being delivered 

by the clinicians and similarly attended by clients. For 

instance, reviewing the clinic records might indicate that 

the individual and group sessions have good retention, 

but the family sessions are less well-attended. 

An outcome evaluation might assess a client’s 

attitudes toward treatment and help-seeking 

and/or reasons for living pre- and postintervention; whereas an impact evaluation

might focus on health system data to examine 

potential decreases in re-attempt rates or 

emergency department visits for suicide.

Outcome evaluations collect baseline data from clients 

on outcomes of interest that can be compared with 

data collected at the program’s end. These outcome 

data provide program managers and clinicians with 

information to assess changes or improvements in client 

attitudes and behaviors that can be associated with a new 

program. 

Impact evaluations assess a program’s effectiveness 

in achieving its ultimate goals. Impact evaluations 

determine the extent to which changes in outcomes can 

be attributed to the new program. 

Data Used for Evaluations

Evaluations use a variety of data to assess the impact 

of interventions. Qualitative and quantitative data are 

complementary, and each provides critical insight into if 

and how the youth suicide intervention is operating and 

achieves the intended objectives. 

Qualitative data include any non-numeric, text-based 

information, such as verbal, visual, or written data. 

Qualitative data collection methods include interviews, 

focus groups, observations, gathering data from 

documents and images, and open-ended survey questions 

and polling responses. 

Quantitative data are any numeric data that can be 

processed by mathematical or statistical analysis. 

Quantitative data collection includes close-ended survey 

questions and polling responses, services and utilization 

data, and claims and encounter data. 

Qualitative and quantitative research

enables managers and clinicians to learn from 

clients and obtain the perspective of those 

with lived experiences. They also can involve 

collecting data from staff using the suicide 

treatment program to obtain their perspective on 

facilitators and challenges to implementation.

Continuous Quality Improvement (CQI)

The U.S. Department of Health and Human Services 

(HHS) defines CQI as, “the systematic process of 

identifying, describing, and analyzing strengths and 

problems and then testing, implementing, learning from, 

and revising solutions.” 

Most of the interventions discussed in this guide have 

multiple components, making CQI an important tool 

for an organization focusing on suicide prevention. CQI 

is an essential process for successfully implementing a 

program.
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

Resources for Evaluation and Quality Improvement 55

CONTINUOUS QUALITY IMPROVEMENT (CQI)

What is CQI?

CQI involves a systematic process of assessing program or practice implementation and short-term outcomes 

and then involving program staff in identifying and implementing improvements in service delivery and 

organizational systems to achieve better treatment outcomes. CQI helps assess practice fidelity, the degree to 

which a program delivers a suicide intervention as intended.

CQI differs from process evaluation in that it involves quick assessments of program performance, timely 

identification of problems and potential solutions, and implementation of small improvements to enhance 

treatment quality. CQI is usually conducted by internal staff. Process evaluation involves longer-term 

assessments and is best conducted by an external evaluator. 

The Institute for Healthcare Improvement’s PDSA Model for Improvement identifies a scientific method for 

testing small-scale changes in an action-oriented, cyclical manner. The stages are: planning it (Plan), trying it 

(Do), observing the results (Study), and acting on what is learned (Act).

Why use CQI? 

CQI takes a broader look at the systems in which programs or practices 

operate. Because of the pivotal role it plays in performance management, 

organizations treating individuals with suicidal thoughts and behaviors are 

encouraged to implement CQI procedures. 

What are the steps involved in CQI?

Although steps in the CQI process may vary based on objectives, typical CQI 

steps are:

•	 Identify a program or practice issue needing 

•	 improvement and a target improvement goal

•	 Analyze the issue and its root causes

•	 Develop an action plan to correct the root causes 

•	 Implement the actions in the action plan

•	 Review the results to confirm that the issue and its root causes have been addressed and short-term 

and long-term treatment outcomes have improved

•	 Repeat these steps to identify and address other issues as they arise

Institute for Healthcare Improvement. (n.d.). Science of Improvement: Testing Changes. 

http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementTestingChanges.aspx

New Jersey Department of Children and Families. (n.d.). CQI Framework: Five Stages of Continuous Quality Improvement. 

https://www.nj.gov/dcf/about/divisions/opma/cqi.html

 Office of Adolescent Health. (n.d.). Continuous Quality Improvement, Part 1: Basics for Pregnancy Assistance Fund Programs. U.S. Department of Health & Human Services. 

https://www.hhs.gov/ash/oah/sites/default/files/cqi-intro.pdf 
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

Resources for Evaluation and Quality Improvement 56

Outcomes

One of the final important, but often challenging, steps 

in the process of implementing programs is to determine 

whether they have yielded desired outcomes. An 

outcome is the change a program plans to accomplish 

through the implementation of a practice. 

The table below provides a list of potential outcomes, 

illustrative outcome indicators, and data sources that 

program managers, practitioners, and others may use 

to evaluate practices to reduce suicidal ideation, selfharm, and suicide attempts. Many of these short- and 

intermediate-term outcomes may be tracked at baseline 

and throughout the practice or program duration through 

an electronic health record. Longer-term outcomes may 

be obtained from administrative and survey data. 

If an organization wants to understand the prevalence or 

epidemiology of suicide in a particular state or region, 

it may be helpful to review national surveillance data 

sources, such as the Center for Disease Control and 

Prevention’s Youth Risk Behavior Surveillance System. 

Outcome Illustrative Indicators Illustrative Data Sources

Short-term Outcomes

Implementation of evidencebased treatment programs• Number of providers trained to 

implement evidence-based programs

• Number of providers reporting use of 

the programs

• Perception among providers that 

program is suitable for organization 

and client population

• Administrative data on training 

• Surveys/interviews of providers

• Organizational surveys on practice change 

(e.g., Program Sustainability Assessment 

Tool)

 Program fidelity • Degree to which program is 

implemented as intended

• Surveys/interviews of providers

• Observation checklists

 Treatment initiation • Number of youth initiating treatment 

with new program/practice

• Attendance/administrative data

Intermediate Outcomes

Improved treatment 

engagement and adherence 

• Extent of client engagement in the 

recommended treatment regime 

(e.g., session attendance, premature 

termination)

• Attendance/administrative data

• Youth and family satisfaction surveys

Change in severity of mental 

health concerns

• Measures of clinical depression, 

substance use, antisocial behavior, 

etc.

• Client self-report qualitative data

• Structured clinical interview

• Standardized scales administered by 

clinician (e.g., Patient Health Questionnaire, 

Teen Addiction Severity Index)

Improved skills associated 

with coping and help-seeking 

behaviors

• Engagement with supportive adults 

at home, at school, and in the 

community

• Use of coping skills outside of 

treatment sessions

• Client self-report qualitative data

Reduced incidence of 

suicidal thoughts or 

behaviors

• Measures of suicidal ideation and 

self-harm

• Reduced Emergency Department 

visits and hospitalizations

• Client self-report qualitative data

• Structured clinical interview

• Standardized scales administered by clinician 

(e.g., Columbia Suicide Severity Rating 

Scale, Harkavy-Asnis Suicide Survey)

• Electronic health record data
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

Resources for Evaluation and Quality Improvement 57

Long-term Outcomes and Impacts

Extent to which program is 

maintained over time

• Rates of program completion

• Funding stability for program

• Electronic health record data 

• Organizational surveys on practice change

Reduction in suicidal ideation 

rates

• Rates of suicidal ideation • Electronic health record data

Reduction in self-harm rates Rates of:

– Non-suicidal self-injury

• Self-harm (intent unknown)

• Electronic health record data

Reduction in fatal and 

nonfatal suicide attempt rates

Rates of:

– Reported attempts

– Emergency Department visits

• Hospitalizations due to suicide attempts

• Electronic health record data

Evaluation Resources 

The following section includes guides and resources to 

support program evaluation and quality improvement. 

Organizations may consider partnering with academic 

institutions or local program evaluation experts for 

external evaluation services or for assistance building 

internal evaluation capacity.

Evaluating Program Implementation

•	 A Framework for Program Evaluation from the 

Program Performance and Evaluation Office at 

the Centers for Disease Control and Prevention 

(CDC) summarizes essential elements of 

program evaluation.

•	 Suicide Prevention Program Evaluation Toolkit

from The RAND Corporation helps program 

staff overcome challenges to evaluating and 

planning improvements to their programs.

Evaluating Client-Level Outcomes and 

Population-Level Prevalence 

•	 Healthy Measures includes PROMIS® and the NIH 

Toolbox®, two free comprehensive sets of neurobehavioral measurements that assess a broad range 

of symptoms and risk and resilience factors.

•	 Suicide Prevention Resource Center’s Locating 

and Understanding Data for Suicide Prevention 

Online Course provides an overview of the 

strengths and limitations of data on suicide 

deaths, key suicide data sources, and an 

explanation of how to use the data to inform 

community partners and policymakers.

•	 Suicide Prevention Resource Center’s directory 

of state-specific resources includes contact 

information for state suicide prevention directors 

and suicide prevention strategic plans.

•	 CDC’s Youth Risk Behavior Surveillance 

System is a national survey that measures the 

prevalence of risk behaviors among students in 

grades 9 through 12, including suicidal ideation 

and suicide attempt.

•	 CDC’s WISQARSTM (Web-based Injury 

Statistics Query and Reporting System) is an 

interactive, online database that provides fatal 

and nonfatal injury, including self-harm and 

suicide, and cost of injury data from a variety of 

trusted sources.

Quality Improvement and Continuous 

Performance Monitoring

•	 Zero Suicide’s Data Elements Worksheet

is intended to assist health and behavioral 

healthcare organizations in developing a datadriven, quality improvement approach to suicide 

care. 

•	 Institute for Healthcare Improvement’s Quality 

Improvement Essentials Toolkit includes 

the tools and templates to launch a quality 

improvement project and manage performance 

improvement.

Resources for Evaluating Programs in 

Native American and Alaska Native (AN/AI) 

Communities

•	 The Administration for Children and Families’ 

A Roadmap for Collaborative and Effective 

Evaluation in Tribal Communities provides NA/

AI values and priorities, knowledge of which 

can enhance trust between tribal programs and 

their evaluation partners and other stakeholders.
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

Appendix 1: Acknowledgments 58

Appendix 1: Acknowledgments 

This publication was developed with a significant contribution from Mary Cwik, PhD and Leigh Fischer, MPH. The 

guidance is based on the thoughtful input of SAMHSA staff and the Expert Panel on Treatment for Suicidal Ideation, SelfHarm, and Suicide Attempts Among Youth from October 2019 through September 2020. A series of guide development 

meetings was held virtually over a period of several months. Three expert panel meetings were convened during this time. 

SAMHSA Staff 

Christine Cichetti

National Mental Health and Substance Use Policy 

Laboratory

Thomas Clarke, PhD

National Mental Health and Substance Use Policy 

Laboratory

Steven Dettwyler, PhD*

Center for Mental Health Services 

Daniel Gallardo, MPH* 

National Mental Health and Substance Use Policy 

Laboratory

Tanya Geiger, PhD, MPH*

National Mental Health and Substance Use Policy 

Laboratory

Donelle Johnson, PhD, MHSA* 

National Mental Health and Substance Use Policy 

Laboratory

Richard McKeon, PhD, MPH 

Center for Mental Health Services

Expert Panel 

Joan Asarnow, PhD

University of California, Los Angeles

Mary Cwik, PhD* 

Johns Hopkins University 

Kelly Davis

Mental Health America

Christianne Esposito-Smythers, PhD

George Mason University 

David Goldston, PhD

Duke University

Mike Hogan, PhD

Hogan Health Solutions, LLC

Cheryl King, PhD

University of Michigan

Michael Lindsey, PhD, MSW, MPH

New York University 

Stephen O’Connor, PhD

National Institute of Mental Health

Mary Rooney, PhD

National Institute of Mental Health

Morton Silverman, MD

Suicide Prevention Consultant

Anthony Spirito, PhD

Brown University

Deborah Stone, ScD, MSW, MPH

Centers for Disease Control and Prevention

Brian Thoma, PhD

University of Pittsburgh

Contract Staff

Katherine Armstrong, AB

Abt Associates

Leigh Fischer, MPH*

Abt Associates

Margaret Gwaltney, MBA*

Abt Associates

Caroline Kupersmith, BA

Abt Associates

Cayla Roby, MA, MPH

Abt Associates

Sarah Steverman, PhD, MSW*

Abt Associates 

Brandy Wyant, MPH, MSW, LCSW

Abt Associates 

Daniel Jefferson Smith 

Abt Associates

Korrin Bishop, BS 

Korrin Bishop Writing & Editing

*Members of the Guide Planning Team
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

Appendix 2: Evidence Review Methodology 59

Appendix 2: Evidence Review Methodology 

The authors followed a rigorous, systematic evidence 

review process in the development of this guide. This 

appendix provides an overview of the evidence review 

methodology used to identify the ratings for the programs 

included in the guide. Reviewers, in coordination with 

SAMHSA and experts, conducted a four-step process to 

select programs, identify related studies, review and rate 

studies, and identify program ratings.

Step 1: Program Selection 

The authors identified six programs after a review of the 

literature and in consultation with experts. To include 

interventions that would be most useful to those treating 

suicidal ideation, self-harm, and suicide attempts, 

eligible programs were required to meet the following 

criteria for evidence review: 

•	 Be clearly defined and replicable 

•	 Address the target outcome of reducing suicidal 

thoughts and behaviors 

•	 Be currently in use

•	 Have studies of their effectiveness

•	 Have accessible implementation and fidelity 

supports

At the conclusion of this step, SAMHSA and the guide’s 

Expert Panel reviewed the proposed programs identified 

by the authors and agreed on six for inclusion in the 

evidence review and rating process. 

•	 Employ a randomized or quasi-experimental 

design, or 

•	 Be a single sample pre-post design or 

an epidemiological study with a strong 

counterfactual (a study that analyzes what 

would have happened in the absence of the 

intervention). 

Step 2: Study 

Identification

Once the programs were selected, the reviewers 

conducted a comprehensive review of published 

research on these programs to identify studies of the 

selected programs. This review only included studies 

from eligible sources (i.e., peer-reviewed journals and 

government reports) that avoid clear conflicts of interest. 

The reviewers documented all potential studies identified 

through the literature search.

The studies identified in the literature search varied in 

type and rigor, so the reviewers assessed them further 

for inclusion in the evidence review. To be eligible for 

review and study rating, research studies had to: 

Literature reviews, descriptive reports, implementation 

studies, and meta-analyses were not included in the 

review, but were documented to provide context and 

identify implementation supports for the programs.

Additionally, to be eligible for further review and rating, 

studies had to:

•	 Be published or prepared in or after 2000

•	 Be a publicly available peer-reviewed or 

research report

•	 Be available in English

•	 Include at least one eligible outcome related to 

reduced suicidal thoughts and behaviors

•	 Have a comparison/control group that is 

treatment as usual, or no/minimal intervention 

if using a randomized experimental or quasiexperimental design

Step 3: Study Review and 

Rating

Next, trained reviewers assessed each study to ensure 

the methodology was rigorous and therefore could 

demonstrate causation between the programs and 

the identified outcomes. Reviewers reviewed and 

documented each study to ensure: 

1. Experimental and comparison groups were 

statistically equivalent, with the only difference 

being that participants in the experimental 

group received the intervention and those in the 

comparison group received treatment as usual or 

no/minimal intervention. 
Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth 

Appendix 2: Evidence Review Methodology 60

2. For randomized experiments with high attrition 

and for quasi-experimental designs, baseline 

equivalence was established between the 

treatment and comparison groups. 

3. For randomized experiments, randomization 

was not compromised. For example, ensuring 

that reassignment of treatment status, usually 

made to balance the distribution of background 

variables between treatment and control groups, 

did not occur.

4. Study did not have any confounding factors 

(factors that affect the outcome but are not 

accounted for by the study).

5. Missing data were addressed appropriately:

– Imputation based on surrounding cases was 

considered valid. 

– Complete case analysis was considered valid 

and accounted for as attrition. 

– Using model with dummy for missing as a 

covariate was considered valid. 

– Assuming all missing data points are either 

positive or negative was not considered 

valid. 

– Regression-based imputation was considered 

valid; mean imputation was not considered 

valid.

6. Outcome measures were reliable, valid, and 

collected consistently from all participants.

7. Valid statistical models were used to estimate 

impacts.

8. Program demonstrated improved outcomes 

related to suicidal thoughts and behaviors.

Based on the study design and these study 

characteristics, reviewers gave each study a rating for 

causal impact. Reviewers used the following scoring 

metric for each study, based on the eight factors above, 

to determine if a study rated:

•	 High support of causal evidence

•	 Moderate support of causal evidence

•	 Low support of causal evidence

Only randomized controlled trials, quasi-experimental 

designs, and epidemiological studies with a strong 

comparison were eligible to receive a high or moderate 

study rating.

Step 4: Program Rating

After all studies for a program were assessed for these 

criteria, the reviewers gave each program a rating based 

on the number of studies with strong, moderate, or 

emerging support of causal impact. Causal impact is 

evidence demonstrating that an intervention causes, or 

is responsible for, the outcome measured in the study’s 

sample population. 

The program was placed into one of the following 

categories based on the level of causal evidence of its 

studies:

•	 Strong Evidence - Causal impact demonstrated 

by at least two randomized controlled trials, 

quasi-experimental designs, or epidemiological 

studies with a high or moderate rating.

•	 Moderate Evidence - Causal impact 

demonstrated by at least one randomized 

controlled trial, quasi-experimental design, or 

epidemiological study with a high or moderate 

rating.

•	 Emerging Evidence - No study received a high 

or a moderate rating. The program may have 

been evaluated with less rigorous studies (e.g., 

pre-post designs) that demonstrate an association 

between the program and positive outcomes, but 

additional studies are needed to establish causal 

impact.

The four-step process described above resulted in 

identification and rating of six programs with evidence 

for treating suicidal thoughts and behaviors. The rating 

given to each program is intended to inform decisionmaking about adoption of new practices or clinical or 

system enhancements that will improve outcomes for 

youth. 
Photos are for illustrative purposes only. 

Any person depicted in a photo is a model.

Publication No. PEP20-06-01-002

Released 2020

SAMHSA’s mission is to reduce the impact of substance abuse and mental illness on America’s communities.

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