Art Therapy as an
Intervention for
Adolescent Self-Harm
and Suicidality: A
Guided Curriculum for
Licensed Art Therapists.
Marissa L. Loner
ARTWORK BY JAMES GULLIVER HANCOCK, 2013

Department of Counseling, PennWest University
COUN 7550: Introduction to Art Therapy Research

Dr. Sheila Lorenzo de la Peña
March 17, 2024

Purpose
To expand on the benefits of art
therapy, dialectical-behavioral
therapy for adolescents (DBT-A),
and cognitive-behavioral therapy
(CBT) for the treatment of
adolescent non-suicidal selfharm and suicidality in an
outpatient counseling setting.

To seek existing literature on
adolescent non-suicidal selfharm and suicidality to create a
curriculum for an outpatient
counseling setting.

To provide additional resources
and interventions to reduce
suicidality and non-suicidal selfharm in adolescents.

Justification
• Globally, suicide is found to be a
leading cause of death among youth,
specifically between the ages of 10
and 19 years old (Glenn et al., 2019).
• Non-suicidal self-injury (NSSI) is
found to be the most common
maladaptive behavior reported in
adolescence, with community sample
rates ranging between 18 and 22%
worldwide (Esposito et al., 2022).

Adolescence
The period of development is marked by the beginning of puberty, in which young
people between the ages of 10 and 19 years-old transition from childhood to
adulthood (World Health Organization: WHO, 2024).

Suicide Vs. Non-suicidal self-harm
Suicide

Non-Suicidal Self-Harm

•Suicide Attempt -When an
individual tries to die by suicide but is
unsuccessful and survives (CDC,
2023).
•Suicide - Voluntarily and intentionally
causing one’s own death
(CDC, 2023).

• Non-suicidal self-harm (NSSI) the act of deliberately injuring
oneself without the intention of dying
by suicide (World Health
Organization, 2019).

The Behavioral Therapies
Cognitive-Behavioral Therapy (CBT)
A type of psychotherapy that focuses on assisting the individual with changing the way they think
by looking at their thoughts, behaviors, and actions in situations (Sinyor et al., 2020; Bryan & Rudd,
2018).

Dialectical-Behavioral Therapy for Adolescents (DBT-A)
A type of psychotherapy used with adolescents struggling with mood disorders, suicidal ideation,
and self-harm and their families that focuses on the use of mindfulness and cognitive-behavioral
techniques to change the way they think by looking at their thoughts, behaviors, and actions in
situations (Hiller & Hughes, 2023; Miller et al., 2007).

Literature Review
Suicidality and Non-Suicidal Self-Harm in Adolescence (NSSI)

"Suicide risk is a complex interaction of
social, psychological, and physiological
factors (Weissinger et al., p. 6, 2023).
There is a higher suicide risk among
adolescents belonging to marginalized
groups (Aranmolate et al., 2017; Lindsay
et al., 2019; Stone et al., 2023).
Self-harm is prevalent among 12 to 14year-olds, Females, and Caucasian
patients (Millon, 2022).

There was an increase in suicidality and
NSSI during the Pandemic of 2020 due
to social isolation (Gotlib et al., 2022).

Literature Review (Continued)
Suicide Screening and Non-Suicidal Self-Harm Assessments to Examine Risk

Protective and risk factors of
suicide.

Suicide screenings: Columbia
Suicide Severity Rating Scale (CSSRS) and the Ask SuicideScreening Questions tool (ASQ).

Non-suicidal self-harm (NSSI)
assessments: The Self-Harm
Screening Inventory (SHSI) and
the PHQ-2.

Literature Review (Continued)
Treatments for Adolescent Suicidality and NSSI

Adolescent-based dialectical
behavioral therapy (DBT-A)
Cognitive behavioral therapy
(CBT)
Youth suicide prevention
programs.

Art therapy

Curriculum Overview
For adolescents struggling with suicidality and nonsuicidal self-harm (NSSI).
To be used with adolescents aged 10 to 19 in a
therapeutic outpatient setting.
Interventions aimed at reducing suicidal thoughts and selfharm behaviors.
Adolescents must also be enrolled in a school-based
Partial Hospitalization Program (PHP).
The art-based interventions consist of both CBT and DBTA approaches.

Curriculum Overview
Check-in: homework
assignment &
learning new DBT-A
or CBT skill (10
min.).

Psychoeducation
and intro to topic (10
min.).

Verbal processing
and discussion of
homework for next
session (10 min.).

Art therapy
intervention (30
min.).

Session One - Intake
Session Two – Establishing Safety & Building Rapport
Session Three - Setting Boundaries
Session Four - Setting Goals
Session Five - Visualizing Triggers
Session Six - Creating a Safe Space

Curriculum

Session Seven - Emotion Identification
Session Eight - Distress Tolerance
Session Nine – Urge Surfing
Session Ten – Mindfulness & Relaxation
Session Eleven – DBT States of Mind
Session Twelve – Identifying Emotions and Problem-Solving
Session Thirteen – Cognitive Restructuring
Session Fourteen – Black-and-White Thinking
Session Fifteen – Saying Goodbye & Recap

Session one - intake
Goals:

Note: Offender Personality Disorder Pathway Blog (OPD Pathway, 2023)

•

Complete biopsychosocial,
determining the needs of
the clients.

•

Creating a treatment plan.

•

Creating a safety plan.

Assignment Prompt: In your sketchbook,
please write or draw an image displaying any
worries or concerns about participating in
individual therapy. We will reflect on this in
the next session.

Session Two – Establishing Safety and Building
Rapport Using Protective Containers 1
The purpose of the protective container art
intervention is for the art therapist to get an
idea of what the client’s questions, concerns,
feelings of fear, or nervousness are toward
therapy.
Goals:
•

Establishing safety and rapport.

•

Promoting confidence and empowerment in
asking questions and addressing concerns.

Assignment Prompt: Pause for a moment and think about the
word “boundary.” In your journal, write or draw what this word
means to you. Take a moment to reflect on how you set
boundaries in your daily life.
1.

Mehlomakulu, C. (2019, February 23). Protective containers – using art to strengthen the metaphor. Creativity in Therapy.
https://creativityintherapy.com/2019/02/protective-containers-using-art-strengthen-metaphor/

Session three: setting boundaries &
expectations
Session three focuses on the "Create Your Own
Castle" art therapy prompt. This activity helps the
client express their boundaries and expectations,
both in therapy and in life.
Goals:
• Defining boundaries
• Establishing rapport
Assignment Prompt: Looking at the SMART Goals worksheet,
I want you to brainstorm what your goals are. Then, think about
the small steps you will take to reach these goals. Lastly, what
new skills are you hoping to get out of these goals being made?
You may draw or write your response and create a chart if that
will be helpful for you.

SMART Goals
worksheet

Session four: setting goals
using a vision board 2
Session four involves the use of a vision board for
the client to set realistic, reachable long and shortterm goals.
Goal:
Defining and practicing the goal-making process in
therapy.
Assignment Prompt: Read over the TIPP Skills (Temperature,
Intense Exercise, Paced Breathing, Paired Muscle Relaxation)
handout. Write or draw how these skills may be useful for you
when experiencing intense emotions. Are there any barriers
that may come up for you in practicing any of these skills.

2. Burton, L., & Lent, J. (2016). The use of vision boards as a therapeutic intervention. Journal of Creativity in Mental Health, 11(1), 52–65.

Tipp skills handout

Session Five: visualizing triggers of
self-harm3
Session five focuses on working with the client on visualizing
triggers of self-harm. Triggers can vary and typically consist
of people, places, and things – things typically being
uncomfortable, intense emotions.
Goals:
• Develop an increased awareness of certain emotions,
events, people, etc. that may trigger an urge for them to selfharm.
• Identify coping strategies when having the urge to selfharm.
Assignment Prompt: When doing this assignment, make sure you are sitting
comfortably in a place where you feel safe. Take a moment to visualize in your
mind a real or imaginary place where you feel relaxed and safe. This can be
your bedroom, the beach, a forest, etc.

3. Zakaria, W. P. N. I., & Ahmad, N. (2023). EXPRESSIVE ART THERAPY APPROACH IN REDUCING SELF-HARM AMONG
ADOLESCENT. International Journal of Education Psychology and Counseling, 8(52), 189–200. https://doi.org/10.35631/ijepc.852016

Session Six: creating a safe environment and
finding alternatives to self-harm
Session six empowers the client to make their own
choices in their personal space to make it safer for
themselves when having the urge to self-harm or if
having suicidal thoughts. The "My Safe Space" art
intervention asks the client to create an image of their
bedroom or another space they consider safe.
Goal:
• Gaining knowledge on limiting access to means
in their living environment.
Assignment Prompt: In your journal, draw four to five clouds. Take a moment to
notice your thoughts and emotions that are coming up for you. Just like your
thoughts and mood, the clouds in the sky are constantly changing while the sky
remains unchanged. In the clouds you drew, write down the thoughts and/or
emotions that came up. When complete, take a moment and imagine these
thoughts and emotions passing by on clouds, accepting them as they come rather
than judging them as right or wrong.

Session Seven: emotion identification and acceptance
using a self-made emotion scale or thermometer
Session seven has the client identify their emotions, which will
encourage them to refer to their safe space when needed, which will
consist of their coping strategies and safety plan. The client can be as
creative as they would like in creating this as it is a tool they will be
using in their daily lives and will be used in the next session.
Goal:
• The client will be able to name their emotions and identify what
coping strategy they need in response to each specific emotion.
Assignment Prompt: Find a quiet, comfortable space to sit in private and take the time to
focus on your breathing. When ready, use the 5-4-3-2-1 grounding technique handout to
identify:

Five things you can see.
Four things you can touch.
Three things you can hear.
Two things you can smell.
One thing you can taste.
1. How did it feel for you to use this technique? Is this something that you feel could be useful
when you are having intense emotions? Why or why not?

2. Please take a moment to write down or draw everything you noticed in your space.

Session Eight: distress tolerance
with diy zen Gardens4
Session eight focuses on the DBT skill of distress
tolerance. The Zen Garden created in this session
provides an additional tool for clients to manage
emotional triggers, whether they stem from people,
places, or situations.
Goal:
• Establishing various coping skills to use in response to
suicidal ideation and non-suicidal self-harm.
Assignment Prompt: Draw an image or write a prompt in response to the
following question: When you hear the word urge, what does this mean to you?
What are some urges you have experienced in the past or are currently
experiencing? What triggers these urges? If you give into the urges, how do you
feel? How do you speak to yourself?

4. Clark, S. M. (2017). DBT-Informed Art Therapy: Mindfulness, cognitive behavior therapy, and the creative process. Jessica
Kingsley Publishers.

Session Nine: urge surfing/"riding the
wave"5
Session nine focuses on urge surfing. Urge surfing involves taking
the time to pause, recognize the feeling, and practice an alternative
rather than immediately giving into the urge to self-harm. , the client
will create an image of their urge to self-harm in the image of a
wave. The wave does not need to be water, it can be anything that
resonates with the client.
Goals:
• Establishing various coping skills to use in response to suicidal ideation
and non-suicidal self-harm.
• Normalize urges as a human experience.
• Remove shame from experiencing urges.
Assignment Prompt: Find a quiet, private space where you can comfortably sit or lie
down. Take 5 or 10 minutes to close your eyes (if you are comfortable with this) and
take deep breaths, with your hand on your belly while you focus on the rising and
lowering of your hand. As you are doing this, I want you to think of one word you can
repeat to use as an anchor during moments of distress. For example, “relax,” “calm,”
“peace.” When you finish, I want you to draw an image representing this word, or write
the word down in large letters, decorating them if you would prefer.
5. Clark, S. M. (2017). DBT-Informed Art Therapy: Mindfulness, cognitive behavior therapy, and the creative process. Jessica Kingsley
Publishers.

Session Ten: creating a worry stone for
mindfulness and relaxation
Session ten continues working with the client on exploring and
creating new effective coping skills they can use when having
intense emotions. The worry stone created in this session
provides the client with another tool for their self-soothing
toolbox.
Goal:
• Establishing various coping skills to use in response to suicidal
ideation and non-suicidal self-harm.
Assignment Prompt: After reading the definitions of the different DBT States of Mind
on the provided handout, answer the following question through drawing or writing:
•

How would you describe yourself in terms of the balance of the rational mind and
the emotional mind? Which one is more active and available? Which one tends to
hide in the background?6

6. Pipitone, E., LCSW, & Doel, A., MS. (2020). The DBT Homework Assignment Workbook: 50 worksheets based on Dialectical
Behavior Therapy. In The DBT Homework Assignment Workbook: 50 Worksheets Based on Dialectical Behavior Therapy. Between
Sessions Resources.

DBT States of mind
handout

Session Eleven: exploring and
defining the dbt states of mind
using mandalas 7
Session eleven explores and defines the different
DBT States of Mind: Emotion Mind, Wise Mind, and
Reasonable Mind. The client creates a mandala to
visualize each of the DBT states of mind.
Goal:
• Identify and name examples of own personal
experiences of the three DBT States of Mind to encourage
mindfulness and self-reflection.
Assignment Prompt: Read and complete the handout on the DBT Skill: ACCEPTS.
*Provide the client with the worksheet on ACCEPTS

7. Clark, S. M. (2017). DBT-Informed Art Therapy: Mindfulness, cognitive behavior therapy, and the creative process. Jessica Kingsley
Publishers.

Accepts handout

Session Twelve: Using metaphor for identifying
emotions and problem-solving coping skills
Session twelve focuses on using metaphors to identify emotions and
problem-solving coping skills the client can use when struggling with
intense emotions. The client participates in The Person in the Rain
(PITR) art intervention and assessment. The PITR activity allows the
client to explore emotions such as sadness, anger, and stress. The
client also brainstorms potential healthy coping strategies they can use
when experiencing intense emotions.
Goal:
• To identify emotions and establish effective coping strategies in response to
each emotion.

Assignment Prompt: Next session we will discuss cognitive distortions
(inaccurate ways we think about ourselves) and how we can restructure these
distortions (ways we challenge these thoughts). In your journal, I want you to
answer the following questions:
•
•
•
•

Think about a situation that put you in a bad mood, what happened?
What were you thinking in response to the situation that was happening?
Were the thoughts true?
What were you feeling in response to your thoughts about the situation that was
happening?

Session Thirteen: Cognitive restructuring using collage,
turning negative thoughts into something new

Thoughts

Session thirteen focuses on cognitive restructuring. The art
intervention involves teaching the client about the CBT triangle and
having them think about a tough emotion they have had in the past.
Then, have the client express this emotion using various pieces of
construction paper by crumbling, ripping, and tearing the paper. When
complete, the client will grab a handful of ripped paper and toss it to
the side. With the remaining paper, the client will create a collage. The
client should be encouraged to create something new.

Goals:
• To learn cognitive and behavioral strategies to reduce or alleviate
thoughts of suicide and self-harm.
• To identify negative thought patterns and replace them with
healthier thoughts.
Assignment Prompt: Next session we will be discussing black-and-white
thinking. Please complete the black-and-white thinking handout so you may get
a better understanding of black-and-white thinking.

*Provide client with handout on black-and-white-thinking

Actions

Feelings

Black & white
thinking handout

Session Fourteen: Identifying and
reducing black-and-white thinking
through opposites 8
Session fourteen discusses dichotomous or black-and-white
thinking and exploring the opposites to reduce such thinking to
integrate the black-and-white thinking towards gray. The
following session utilized a line art intervention, creating lines
to symbolize opposite emotions, ripping them up, and
combining them with glue. Allowing the client to see a visual of
opposites and integration.
Goal:
• To learn cognitive and behavioral strategies to reduce or alleviate
thoughts of suicide and self-harm.
Assignment Prompt: The next session is our final session together. In your
journal, I would like you to write or create an image expressing what you
learned from our sessions together. Was there anything specific that stuck out
to you? Was there anything that you did not find helpful? What about it was
unhelpful? Do you have any barriers to practicing anything that we have
worked on together in sessions?
Haeyen, S., Ziskoven, J., Heijman, J., & Joosten, E. (2022). Dealing with opposites as a mechanism of change in art therapy in
personality disorders: A mixed methods study. Frontiers in psychology, 13, 1025773. https://doi.org/10.3389/fpsyg.2022.1025773

Session Fifteen: Write a postcard to your
future self – A summary of therapy
Session fifteen is the final session. The goal is for the client to
summarize and reflect on everything they have learned, whether they
found certain skills to be helpful or not helpful if they have any
critiques, and how they are planning on using the skills they have
learned in their daily life. The use of the postcard will encourage the
client to reflect and summarize their experience and explore the
potential personal growth that has occurred from attending these
therapy sessions.

Goal:
• To terminate therapy and reflect on skills learned and practiced.

Limitations
Small sample sizes of the research on art therapy combined with DBT-A
and CBT with adolescents who self-harm and struggle with suicidality.

A lack of peer-reviewed studies in this specific area suggests a great need
for more robust, large-scale studies.

Future research
Future research with larger populations in a diverse setting.
The need for larger sample sizes in future research looking for
the effectiveness of art therapy combined with CBT and DBT-A
A need for more culturally competent art therapy programs to
address the needs of marginalized youth.

Questions

References
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Aranmolate R, Bogan DR, Hoard T, Mawson AR (2017) Suicide Risk Factors among LGBTQ Youth: Review. JSM
Schizophr 2(2): 1011.
Bryan, C. J., & Rudd, M. D. (2018). Brief cognitive-behavioral therapy for suicide prevention. Guilford
Publications.
Centers for Disease Control and Prevention. (2023, May 8). Facts about Suicide. Retrieved March 22, 2024, from
https://www.cdc.gov/suicide/facts/index.html
Esposito, C., Dragone, M., Affuso, G., Amodeo, A. L., & Bacchini, D. (2022). Prevalence of engagement and
frequency of non-suicidal self-injury behaviors in adolescence: an investigation of the longitudinal course and the
role of temperamental effortful control. European Child & Adolescent Psychiatry, 32(12), 2399–2414.
https://doi.org/10.1007/s00787-022-02083-7
Glenn, C. R., Esposito, E. C., Porter, A. C., & Robinson, D. J. (2019). Evidence Base Update of Psychosocial
Treatments for Self-Injurious Thoughts and Behaviors in Youth. Journal of Clinical Child and Adolescent
Psychology, 48(3), 357–392. https://doi.org/10.1080/15374416.2019.1591281
Gotlib, I. H., Miller, J. G., Borchers, L. R., Coury, S. M., Costello, L. A., Garcia, J. M., & Ho, T. C. (2022). Effects of
the COVID-19 pandemic on mental health and brain maturation in adolescents: Implications for analyzing
longitudinal data. Biological Psychiatry Global Open Science. https://doi.org/10.1016/j.bpsgos.2022.11.002
Hiller, A. D., & Hughes, C. D. (2023). Dialectical Behavior Therapy for Adolescents: Treatment outcomes in an
outpatient community setting. Evidence-Based Practice in Child and Adolescent Mental Health, 8(4), 488–505.

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references
Lindsey, M., Sheftall, A. H., Xiao, Y., & Joe, S. (2019). Trends of suicidal behaviors among high school students in the
United States: 1991–2017. Pediatrics (Evanston), 144(5). https://doi.org/10.1542/peds.2019-1187
Miller, A. L., Rathus, J. H., & Linehan, M. M. (2007). Dialectical behavior therapy for suicidal adolescents. Guilford Press.
Millon, E. M., Alqueza, K. L., Kamath, R. A., Marsh, R., Pagliaccio, D., Blumberg, H. P., Stewart, J., & Auerbach, R. P.
(2022). Non-suicidal self-injurious thoughts and behaviors among adolescent inpatients. Child Psychiatry & Human
Development. https://doi.org/10.1007/s10578-022-01380-1
Sinyor, M., Williams, M., Mitchell, R., Zaheer, R., Bryan, C. J., Schaffer, A., Westreich, N., Ellis, J., Goldstein, B. I.,
Cheung, A., Selchen, S., Kiss, A., & Tien, H. (2020). Cognitive behavioral therapy for suicide prevention in youth
admitted to hospital following an episode of self-harm: A pilot randomized controlled trial. Journal of Affective Disorders,
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Stone, D. M., Mack, K. A., & Qualters, J. R. (2023). Notes from the Field: Recent Changes in Suicide Rates, by Race
and Ethnicity and Age Group — United States, 2021. Morbidity and Mortality Weekly Report (Print), 72(6), 160–162.
https://doi.org/10.15585/mmwr.mm7206a4
Weissinger, G., Myhre, K., Ruan‐Iu, L., Van Fossen, C., & Diamond, G. (2023). Adolescent suicide risk, firearm access,
and family functioning: Screening in primary care. Families, Systems, & Health, 41(1), 16–25.
https://doi.org/10.1037/fsh0000680
World Health Organization: WHO. (2024, October 10). Mental health of adolescents. https://www.who.int/newsroom/fact-sheets/detail/adolescent-mental-health
World Health Organization. (2019). SUICIDE AND SELF-HARM. In WHO-EM/MNH/224/E.
https://iris.who.int/bitstream/handle/10665/333478/WHOEMMNH224E-eng.pdf?sequence=1