Art Therapy for Adolescent Self-Harm and Suicidality

Art Therapy as an Intervention for Adolescent Self-Harm and Suicidality

Marissa L. Loner
Department of Counseling, PennWest University
Dr. Penelope Orr
November 11, 2024

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Abstract
Adolescence is a key developmental period marked by significant social, emotional, and
cognitive changes, which also brings an increased risk of mental health issues such as anxiety,
depression, and suicidal thoughts. Non-suicidal self-injury (NSSI) is common among
adolescents, and suicide is a leading cause of death in youth aged 10-19 worldwide. Additionally,
in the United States alone, suicide death rates have increased dramatically, nearly tripling
between 2007 and 2017 among children between the ages of 10 and 14 years-old (American
Academy of Pediatrics, 2020). Despite these concerns, effective interventions for adolescents
with suicidal thoughts and NSSI are limited. This study aims to explore the use of art therapy to
help reduce NSSI and suicidality in adolescents at an outpatient counseling center. The goal is to
develop a treatment approach that fills gaps in current research and provides additional support
for these adolescents. Art therapy, particularly when combined with techniques from cognitivebehavioral therapy (CBT) and dialectical-behavioral therapy for adolescents (DBT-A), can help
teach skills like emotion regulation, problem-solving, and mindfulness. This review will
contribute to the development of a more effective, integrated approach to address the mental
health needs of adolescents and reduce the risks of suicide and self-harm.
Keywords: Adolescence, art therapy, suicide, non-suicidal self-injury (NSSI), cognitivebehavioral therapy, dialectical-behavioral therapy

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Table of Contents
Section I: Introduction ............................................................................................. 4
Problem ......................................................................................................................................... 5
Purpose of the Study ........................................................................................................................ 5
Justification .................................................................................................................................... 5
Terms Related to the Study ............................................................................................................... 7
Conclusion ..................................................................................................................................... 8

Section II: Review of Literature ................................................................................ 10
Understanding Self-Harm and Suicidality in Adolescents ................................................................... 10
Risk Factors of Suicidality and NSSI in Adolescents ........................................................................... 11
Adolescents and the Pandemic of 2020 ............................................................................................ 12
Suicide Screening and Non-Suicidal Self-Harm Assessments to Examine Risk ..................................... 13
Current Treatment Approaches for Adolescent Self-Harm and Suicidality ............................................ 15
Art Therapy Approaches for Adolescent Self-Harm and Suicidality ...................................................... 16
Art Therapy Ethical Considerations with Adolescents ......................................................................... 17
Conclusion ................................................................................................................................... 18

Section III: Methodology ......................................................................................... 20
Target Audience............................................................................................................................. 20
Curricular Structure ....................................................................................................................... 21
Curricular Outline.......................................................................................................................... 22
Conclusion ................................................................................................................................... 24

Section IV: Curriculum ........................................................................................... 25
Section V: Discussion ............................................................................................. 26
Appendix A ............................................................................................................ 39

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Section I: Introduction
Adolescence is a critical developmental period that comes with various social, emotional,
and cognitive changes that become essential in mental health development. Adolescence can be a
time of growth consisting of complex thinking and self-discovery. Adolescence is also a stage
marked by an increased risk of mental health challenges. According to Call et al., there is an
increase in mental health challenges in adolescents before the age of 25 years old (2002), and
this is because of the physical, cognitive, and social changes and mood fluctuations that occur
during adolescent development (Lahey et al., 2017). These mental health challenges can cause
uncomfortable symptoms like anxiety and depression.
With this increase in mental health symptoms in adolescence there is a concerning
increase in instances of suicidality and maladaptive behaviors like non-suicidal self-harm. Non
suicidal self-harm is one of the most prevalent maladaptive behaviors among adolescents
(Esposito et al., 2022). Also, according to the American Academy of Pediatrics (AAP), suicide is
responsible for more deaths among youth between the ages of 10 and 24 years old compared to
any other medical illness (2020). Additionally, in the United States, suicide rates have nearly
tripled among youth between the ages of 10 and 14 years old between 2007 and 2017 (American
Academy of Pediatrics, 2020).

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Problem
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% (Esposito et al., 2022). Even with these statistics,
there is limited research on effective interventions for adolescents who struggle with suicidal
ideation and engage in NSSI (Gilbert et al., 2020). Exploring more treatment options that will
reduce instances of suicidality and NSSI amongst adolescents is needed due to the limited
research on effective interventions for adolescents who struggle with suicidal ideation and NSSI.
Purpose of the Study
This study expands on the benefits of art therapy as an intervention for adolescent nonsuicidal self-harm and suicidality in an outpatient counseling setting. The purpose of the study is
to seek existing literature on adolescent non-suicidal self-harm and suicidality to create a
curriculum for an outpatient counseling setting to provide additional resources and interventions
to reduce suicidality and non-suicidal self-harm in adolescents.
Justification
Adolescence is a time when mood fluctuations and many physical, cognitive, and social
changes occur which can lead to an increase in psychological distress, crises, or mental health
issues (Lahey et al., 2017). Adolescence involves higher risks relating to “sensation-seeking,
risk-taking behaviors, and susceptibility to influence” (APA, 2019). The higher risk of mental
health disorders in adolescents increases the risk of suicide and self-harm (Gyori et al., 2023;

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Sheftall et al., 2016). To address these factors in adolescence and work towards reducing the risk
of suicide and self-harm, therapeutic interventions like Cognitive-Behavioral Therapy (CBT) and
Dialectical-Behavioral Therapy (DBT)-based art therapies are utilized due to their nature in
providing psychoeducation regarding emotion regulation, problem-solving skills, and
mindfulness. Expressive art therapy allows adolescents to express and explore emotions nonverbally, providing a safe, therapeutic space (Zakaria & Ahmad, 2023). This literature review
will explore art therapy as an intervention for adolescent self-harm and suicidality, focusing on
the use of CBT and DBT-A in an outpatient setting.

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Terms Related to the Study
Adolescence. The period of development marked by the beginning of puberty in which young
people transition from childhood to adulthood.
Art therapy. A type of psychotherapy that utilizes the expressive arts like drawing, painting, clay,
and many more materials that allow individuals to express themselves using artwork rather than
solely focusing on the use of words.
Cognitive-Behavioral Therapy. 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.
Dialectical-Behavioral Therapy for Adolescents. 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.
Expressive Arts Therapy. The combination of psychotherapy and the use of the creative arts that
consists of various media and materials like drawing, painting, and clay.
LGBTQIA+. An abbreviation for Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual,
and “the + holds space for the expanding and new understanding of different parts of the very
diverse gender and sexual identities” (Princeton Gender & Sexuality Resource Center, n.d.).
Maladaptive Behaviors. Actions or behaviors that are harmful or inappropriate and can
negatively impact an individual's development.
Non-Suicidal Self-Harm. Non-suicidal self-harm (NSSI) is the act of deliberately injuring
oneself without the intention of dying by suicide (World Health Organization, 2020).

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Outpatient Setting. A mental health setting outside a hospital setting where the individual is free
to leave after receiving assessment, diagnosis, and treatment.
Protective Factors. Individual and environmental characteristics that reduce the instances of
stress and risks associated with self-harm, suicide attempts, and suicide.
Risk Factors. Individual and environmental characteristics that increase the instances of stress
and mental health challenges, leading to an increased risk of self-harm, suicide attempts, and
suicide.
Self-Concept. What a person perceives about themselves. This can consist of talents, qualities, or
goals.
Self-Esteem. What a person feels about their self-concept, values, and self-worth.
Suicide Attempt. When an individual tries to die by suicide but is unsuccessful and survives.
Suicide. Voluntarily and intentionally causing one’s own death.
Conclusion
Adolescence is a developmental stage where individuals begin to show complex thinking and
self-discovery. Mental health challenges also begin to arise in adolescence, and this is when
symptoms like anxiety and depression start to present. Unfortunately, with the increase of
anxiety and depression symptoms, there is also an increase in instances of self-harm and
suicidality. The increase of self-harm and suicidality is concerning and shows a need for more
effective interventions to build upon the importance of reducing risk through psychoeducation
that provides information on emotion regulation, problem-solving skills, and mindfulness. CBT
and DBT-A are two interventions that can provide information on these skills that will reduce
suicidality and self-harm. The combination of CBT and DBT-A with art therapy will utilize the

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non-verbal, safe, and creative nature of art with the psychoeducational aspects of CBT and DBTA with adolescents who struggle with self-harm and suicidality.

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Section II: Review of Literature
Adolescence is a pivotal stage that occurs before adulthood and involves the development
of various cognitive milestones. Adolescents display an increase in complex thinking that
consists of advanced reasoning skills, abstract thinking, and the ability to consider how they feel
and what they are thinking (McNeely & Blanchard, 2009). Adolescence is also a time of selfdiscovery. Psychoanalyst Erik Erikson referred to adolescence as the stage of Identity vs. Identity
Confusion (Orenstein and Lewis, 2022) and this is when self-discovery and identity development
begin to take place (Sedillo-Hamann, 2021). McNeely and Blanchard (2009) refer to adolescence
as the first time a person begins to ask the question, “Who am I?” Identity consists of two
aspects, self-concept and self-esteem. Self-concept is what a person perceives about themselves.
This can consist of talents, qualities, or goals. Self-esteem is what a person feels about their selfconcept. For adolescents, “self-esteem is affected by approval from parents and other adults, the
level of support received from friends and family, and personal success” (pp.45-46). With the
progression of complex thinking and identity discovery, it is apparent that adolescence is a
pivotal development stage.
Understanding Self-Harm and Suicidality in Adolescents
Adolescence is typically when new mental health symptoms occur. With this emergence
of mental health symptoms in adolescence comes maladaptive, risk-taking behaviors with nonsuicidal self-harm being one of the most prevalent (Esposito et al., 2022). Non-suicidal self-harm
(NSSI) is the act of deliberately injuring oneself without the intention of dying by suicide (World
Health Organization, 2020). Because of the emergence of uncomfortable mental health
symptoms in adolescence, NSSI is a maladaptive behavior that begins to occur to deal with these

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intense emotions (Wood, 2009). Although NSSI is a maladaptive behavior, it is something that
adolescents use to ease the uncomfortable mental health symptoms they experience daily.
Along with self-harm, suicide and suicide attempts are factors that occur from the
emergence of mental health symptoms in adolescence. Call et al. (2002) state that symptoms of
mental illness tend to emerge before the age of 25 due to the physical, cognitive, and social
changes and mood fluctuations that occur during adolescent development (Lahey et al., 2017). A
suicide attempt is when somebody injures themselves with the intent of dying by suicide, but
they do not die, and Suicide is death caused by injuring oneself with the intent to die (CDC,
2023). According to Ong et al. (2021), suicide is a leading cause of death among adolescents, and
“mental health disorders are a contributing factor” (p. 134). Because of the emergence of mental
health symptoms in adolescence, we see an increase in suicide.
Risk Factors of Suicidality and NSSI in Adolescents
There are multiple potential risk factors that can lead to the emergence of suicidality and
NSSI in adolescents. Weissinger et al. (2023) state that “suicide risk is a complex interaction of
social, psychological, and physiological factors (p. 6).” For instance, these factors can include
prior suicide attempts, substance use, bullying, and unstable households (Macalli et al., 2018;
Van Meter et al., 2019). It is also important to recognize the adolescent populations that show a
higher risk of suicidality. Adolescent suicide rates are shown to be higher in specific racial and
ethnic groups. For example, using data between 1991 to 2017 from the Youth Risk Behavior
Survey, Lindsey et al. (2019) found a trend of increasing suicide rates among black adolescents
in which of the 198,000 high school students involved, suicide attempts increased by 73%. There
are also higher rates of suicide in the indigenous communities in the United States. According to

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Stone et al. (2023), American Indian and Alaska Native youth had a rate of suicide consisting of
36.3 per 100,000 in 2021.
Another group that displays a high risk of suicide is adolescents who identify as being a
part of the LGBTQIA+ community. In the United States, The Trevor Project estimates that more
than 1.8 million LGBTQ+ young people consider suicide each year and at least one attempts
suicide every 45 seconds (2024). According to Aranmolate et al. (2017), Adolescents a part of the
LGBTQIA+ community show a higher risk of suicide and self-harm in comparison to their
heterosexual peers. This can be attributed to the lack of peer acceptance, discrimination, family
rejection, and difficulty in school (Aranmolate et al., 2017). Aranmolate also states that
LGBTQIA+ youth struggle with low self-esteem and depression due to the discrimination and
isolation they experience daily, leading to increased instances of suicidal ideation, suicide
attempts, and death by suicide (2017).
Self-harm is also prevalent in specific populations. According to research conducted by
Millon (2022), the populations who reported the most NSSI were females, 12 to 14-year-olds,
and White patients (compared to youth of other races and ethnicities). Also, according to Madge
et al. (2011), NSSI is prevalent in adolescents who have experienced the loss of a loved one or
peer to suicide or self-harm, physical and sexual abuse, and concerns about sexual orientation.
Adolescents and the Pandemic of 2020
With adolescence being a time of social acceptance and belonging, having this ability to
interact with peers can be a protective factor. The protective factor of social interaction was taken
away during the pandemic of 2020. The negative impact of the pandemic on adolescents
continues today. According to Gotlib et al. (2022), comparing the mental health of a pre-

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pandemic adolescent group and a post-pandemic adolescent group, the adolescents in the postpandemic group were found to have increased symptoms of anxiety and depression. Mental
health declined in the adolescent population due to an increase in isolation which led to an
increase in instances of suicidality and self-harm (Mucci et al., 2023). Because of this decline in
mental health and increased instances of suicidality and self-harm after the pandemic, there is an
increased need for mental health support, services, and the use of suicide screening and risk
assessments.
Suicide Screening and Non-Suicidal Self-Harm Assessments to Examine Risk
Looking for both protective and risk factors of suicide is an important tool to prevent
suicide and suicide attempts. Suicide screening and risk assessments look for the potential risks
of suicide consisting of maltreatment, trauma, abuse, and bullying while also looking for the
need for potential hospitalization (Asarnow and Mehlum, 2019). Screening and assessments also
look for protective factors that can be used in forming interventions and a safety plan. Protective
factors can consist of positive social relationships and role models, extra-curricular activities, and
hobbies (Asarnow and Mehlum, 2019).
The Columbia Suicide Severity Rating Scale (C-SSRS) measures suicidal ideation that
has occurred over recent months while providing a scale ranging from low, moderate, and high
risk for suicide (Cwik et al., 2020). The C-SSRS consists of a 5-point scale ranging from 1 “Wish
to be dead” to 5 “Suicide intent with a plan,” each question seeks to find four factors: Severity of
ideation, intensity of ideation, behavior, and actual attempts (Cwik et al., 2020). Strengths of the
C-SSRS consist of uses with both adults and adolescents that show validated results (Gipson et

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al., 2015; Posner et al., 2011) and the ability to “predict short-term suicidal behavior among
high-risk adolescents” (Conway et al., 2016).
Another assessment commonly used in suicide assessment is the Ask Suicide-Screening
Questions tool (ASQ). The ASQ, according to the National Institute of Mental Health (n.d), is a
toolkit that includes a brief suicide safety assessment (BSSA) that helps “triage patients after a
positive screen” and “consists of the best practices from clinical interviews for suicide risk
developed through a combination of consulting the literature and suicide experts” (Cwik et al.,
2020). The ASQ asks questions relating to frequency, plan, and behavior; symptoms such as
isolation, depression, and irritability; support and safety consisting of family, social status at
school, bullying, and reasons for living (Cwik et al., 2020).
In addition to suicide risk assessments, assessments also take place to evaluate the frequency and
intensity of non-suicidal self-harm in individuals. The Self-Harm Screening Inventory (SHSI)
measures self-harm over a duration of the year. The assessment asks the client if they have ever
engaged in intentional self-harm. The SHSI also looks at whether the self-harm that occurred was
suicidal or non-suicidal.
Assessments looking at suicidal ideation and self-harm intensity and frequency are
important, but, with the increase of mental health symptoms in adolescents, it is also important to
utilize assessments that look at the overall mental health symptoms being experienced by the
adolescent. The PHQ-2 is a shorter version of the PHQ-9 that uses the first 2 of the PHQ-9’s
questions. The PHQ-2 asks the patient if they have been struggling with 1. A depressed mood,
and/or 2. A lack of pleasure in usual activities over the past 2 weeks (Pereira et al., 2010). The
PHQ-2 can identify depressive symptoms in adolescents. This is important because teens with
depressive disorders are at a higher risk for suicide (Zuckerbrot et al., 2007; Bhatia and Bhatia,

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2007). With the PHQ-2 being significantly shorter, the assessment is not as time-consuming and
is more likely to be performed during routine medical visits.
Current Treatment Approaches for Adolescent Self-Harm and Suicidality
According to Asarnow and Mehlum (2020), treatments for adolescent NSSI and
suicidality should work toward reducing and treating hopelessness. This is achieved through
providing psychoeducation to teach coping skills, identifying unhelpful behaviors, and relating
these to treatment goals while also instilling hope toward the benefits of treatment. This focus on
psychoeducation regarding coping skills and identifying unhelpful behaviors is found in
Adolescent-based Dialectical Behavioral Therapy (DBT-A) and Cognitive Behavioral Therapy.
Because of this, both are useful interventions for reducing NSSI and suicidal ideation.
Adolescent-based Dialectical Behavioral Therapy (DBT-A) focuses on building skills that
will reduce risk factors of suicidal ideation and NSSI such as mood instability, unstable
relationships, impulsive behaviors, and identity confusion (Hiller and Hughes, 2023; Miller et
al., 2007). Based on research conducted by Hiller and Hughes (2023), DBT-A was shown to
reduce problem behaviors and improve the ability to problem-solve per the results of the survey
taken by the adolescent and caregiver participants.
The use of Cognitive Behavioral Therapy focuses on a goal-oriented approach to reduce
instances of NSSI and suicidal ideation that includes learning skills and implementing tools.
Such tools consist of the development of a safety plan and learning emotion regulation like
relaxation and mindfulness (Sinyor et al., 2020; Bryan and Rudd,Based on research from Alavi et
al. (2013), CBT contributed to a decrease in scores on the inventories used (Scale for Suicidal
Ideation; Beck’s Helplessness Inventory; and Beck’s Depression Inventory).

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Youth Suicide Prevention Programs
In addition to CBT and DBT-A, youth suicide prevention programs are effective in
reducing isolation and increasing peer interaction while increasing mental health awareness,
protective factors, and coping skills for stress and suicidality (Barzilay et al., 2019; Wasserman et
al., 2015). The goal of youth suicide prevention programs is to provide activities and curricula
that focus on building awareness, coping skills, problem-solving, and promoting interactions to
reduce isolation (Stone et al., 2017). For example, The Youth Aware of Mental Health Program
(YAM) is for adolescents between the ages of 14 to 16 years old and places a focus on interactive
dialogue and role-playing to teach adolescents about the risk and protective factors surrounding
suicide (Stone et al., 2017). Another suicide prevention program for adolescents is Signs of
Suicide (SOS). This is a school-based suicide prevention program designed for youths between
11 to 17 years old that teaches students how to recognize the risk of suicide within themselves
and others (Katz et al., 2013). Because both the YAM and SOS prevention programs taught
adolescents various skills and information regarding suicide risk and protective factors, there was
a reduction in suicide attempts and ideation (Calear et al., 2016; Katz et al., 2013).
Art Therapy Approaches for Adolescent Self-Harm and Suicidality
Along with current treatment approaches and youth suicide programs, art therapy is
another tool that can be used for reducing instances of self-harm and suicidality. Art therapy uses
expressive arts to aid clients with expressing their feelings and emotions that may otherwise be
difficult for them to express verbally. The use of expressive arts as a means of communication
can be especially beneficial for adolescents because it allows them to use art to communicate
their powerful emotions and feelings. The benefits of art-therapy-based approaches with

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adolescents consist of developing coping skills, emotion regulation (McGreevy and Boland,
2020), and finding both environments and tools to build hope, confidence, and social supports
(Pavarini et al., 2021). In a study conducted by Zakaria and Ahmad (2023), the participant
expressed her feelings and navigated the challenges of self-harm behaviors (p. 198). Dialectical
Behavioral and Cognitive Behavioral art therapy combine artmaking with psychoeducation
associated with teaching the skills involved with reducing NSSI and suicidality.
The use of Dialectical Behavioral Therapy-based art therapy works toward the reduction
of self-harm and the prevention of suicide. This involves art interventions that are based on the
skills of DBT. DBT skills consist of reducing black-and-white thinking (dialectical thinking),
mindfulness, distress tolerance, emotion regulation, metaphor, mastery (engaging in challenging
and rewarding activities), and opposite action (Schorr, 2022). The use of Cognitive Behavioral
Therapy-based art therapy according to Rosal (2016), focuses on CBT skills in combination with
artmaking. CBT skills consist of reality shaping (organizing dysfunctional thinking using
images), problem-solving, emotion identification and regulation, modeling (positive behaviors
being modeled by the art therapist), relaxation and mindful techniques using mental imagery,
stress reduction, and coping skills.
Art Therapy Ethical Considerations with Adolescents
The American Art Therapy Association’s (2013) Ethical Principles for Art Therapists
seeks to “safeguard the welfare of the individuals, families, groups, and communities with whom
art therapists work and to promote the education of members, students, and the public (p. 1). It is
first important to ensure that the adolescent you are working with has the consent of their parents
or caregivers. Informed consent should also be provided to the child and their parents or

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caregivers, so they are aware that they are participating in art therapy, not art class (Moriya,
2006). Confidentiality is another ethical obligation we have as art therapists. The American Art
Therapy Association (2013, Section 2.0) states that “art therapists do not disclose confidential
information for consultation or supervision without clients’ explicit consent unless there is reason
to believe that those clients or others are in immediate, severe danger to health or life” (p. 4).
Safety is another large aspect that needs to be considered when practicing art therapy
with adolescents. Moon (2000) states that art therapists are ethically responsible for creating a
sense of predictability. The art therapist is responsible for providing a safe space where the client
feels comfortable in the studio and with the art therapist. Safety also applies to the intentionality
of media and materials being used for adolescents with a history of NSSI and suicidality. Art
therapists are required to understand media properties to ensure the safety of clients. This allows
art therapists to pick appropriate media and materials that suit the needs of the client (Hinz,
2016). For example, if we are working with an adolescent who has a history of using sharp
objects to injure themselves with or without the intention of suicide, it would be advisable to
avoid using sharp tools like scissors or X-ACTO knives and instead have the client rip the paper
rather than cutting the paper. The client can also use non-toxic materials like paints, pastels, and
conte crayons.
Conclusion
The rates of suicide among adolescents are at an all-time high, especially among people
of color and individuals of the LGBTQIA+ community due to the discrimination experienced by
both groups. Along with suicide, we have also seen an increase in non-suicidal self-harm (NSSI)
among adolescents. Because of the increase in NSSI and suicidality in adolescents, there is a

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need for interventions that teach various skills that focus on identifying risk factors and
protective factors. An example of interventions that teach these skills are Dialectical Behavioral
Therapy for Adolescents (DBT-A), Cognitive Behavioral Therapy (CBT), and suicide prevention
programs. These interventions have shown a reduction in suicidality and NSSI rates in
adolescents. Alongside the use of DBT-A and CBT, art therapy is also shown to be an effective
form that allows adolescents to freely express themselves and discuss suicidality and self-harm's
impact on their lives. There seems to be limited research on art therapy interventions with
adolescents who struggle with suicidality and NSSI as evidenced by difficult-to-find peerreviewed articles. Due to this increased number of suicides and high prevalence of NSSI among
adolescents, further research on what therapeutic interventions is the most effective for reducing
suicidality and NSSI within adolescents is needed.

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Section III: Methodology
This section discusses a curriculum intended for adolescents who are struggling with
suicidal ideation, past suicide attempts, and self-harm. The curriculum will consist of art therapy
interventions used in individual therapy sessions that focus on the ideas of Cognitive-Behavioral
Therapy and Dialectical-Behavioral Therapy for Adolescents. The art therapy interventions used
will take place for nine weeks in an outpatient setting, with each session taking place once a
week. Each art intervention will focus on mindfulness, emotion regulation, and practicing
problem-solving skills regarding the use of personal protective factors and effective coping skills
such as finding distractors and urge surfing. Various media and materials will be used throughout
the curriculum. The first session will be an intake session involving the Columbia-Suicide
Severity Rating Scale to ensure the client is in the appropriate level of care. The eight sessions
after will consist of the use of art interventions focusing on Cognitive-Behavioral and
Dialectical-Behavioral interventions.
Target Audience
The curriculum is designed for licensed art therapists working with adolescents who selfharm and struggle with suicidality in individual, 1-hour long sessions at an outpatient setting.
The art therapist should be educated and experienced in working with individuals with a history
of suicidal ideation. The art therapist should also have the training to implement appropriate
suicide risk assessments like the Columbia- Suicide Severity Risk Scale to ensure the client is in
an appropriate level of care. The curriculum will begin with an intake process involving the
Columbia-Suicide Severity Rating Scale to assess if there is current ideation, plan, or intent of
suicide. If the results of the C-SSRS show an increased risk of suicidal ideation with plan or

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intent, the client should be referred to a higher level of care. Additionally, the Self-Harm
Screening Inventory (SHSI) will be completed with the adolescent to get a better idea of the
intensity and severity of non-suicidal self-harm based on questions that ask about self-harm that
has taken place over the duration of a year. The SHSI will also help the clinician determine
whether the self-harm that has taken place is non-suicidal or suicidal (Kim et al., 2022). Lastly,
the intake will involve developing a safety plan the client can use in between sessions when
having thoughts of suicide, including providing them with resources they may use in a crisis.
After the intake, eight sessions will take place. Each session will be one hour long and take place
once a week. Each session will focus on using art interventions that teach the client skills based
on aspects of CBT and DBT.
Curricular Structure
Each 1-hour session will occur once a week for fifteen weeks and utilize an art-based
intervention involving psychoeducation based on the components of both Cognitive-Behavioral
Therapy and Dialectical Behavioral Therapy for Adolescents. The factors of CognitiveBehavioral Therapy that will be focused on in sessions are problem-solving, cognitive
restructuring, psychoeducation, and modeling by the therapist. The aspects of DBT that will be
applied in sessions are reducing black-and-white thinking (dialectical thinking), mindfulness,
distress tolerance, emotion regulation, metaphor, and opposite action (Schorr, 2022). Various
media and materials will be used throughout the curriculum.
The curriculum will begin with an intake process involving the Columbia-Suicide
Severity Rating Scale to assess if there is current ideation, plan, or intent of suicide. If the results
of the C-SSRS show an increased risk of suicidal ideation with plan or intent, the client should

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be referred to a higher level of care. After administering the C-SSRS, the clinician will gather
information from the client on the frequency and severity of self-harm. This will involve
questions looking for when the self-harm began and when the last time self-harm occurred, how
often the self-harm is happening, how the self-harm usually occurs, and what emotions arise
before and after self-harm occurs. Lastly, the first initial session will include the development of
a safety plan that consists of warning signs (thoughts, behaviors, mood, situation), internal
coping strategies (things the client can do on their own without contacting another person), and
listing supportive people including personal relationships, professionals, and agencies like the
988 Crisis Hotline.
Curricular Outline
Session One - Intake
Session Two – Establishing safety and building rapport
Session Three – Setting boundaries and expectations
Session Four – Setting goals
Session Five – Visualizing triggers of self-harm
Session Six – Creating a safe environment and finding alternatives to self-harm
Session Seven – Emotion identification and acceptance
Session Eight – Learning distress tolerance skills
Session Nine – Urge surfing
Session Ten – Mindfulness and relaxation
Session Eleven – Exploring the DBT States of Mind
Session Twelve – Using metaphor for identifying emotions and problem-solving

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Session Thirteen – Cognitive restructuring
Session Fourteen – Identifying and reducing black-and-white thinking
Session Fifteen – Termination session, recap of skills learned
The following fifteen sessions will offer various art interventions that utilize the framework of
both Dialectical-Behavioral Therapy and Cognitive-Behavioral Therapy. The goal of the use of
the DBT and CBT frameworks is to provide the client with the necessary knowledge and skills
for identifying the emotions leading to suicidality and self-harm, finding effective coping skills
like mindfulness and urge surfing, emotion regulation and problem-solving skills, and the
importance of reaching out for help and utilizing a support system. The use of art as an
intervention will provide the client with an opportunity to express themselves in a creative
manner rather than solely using verbal communication. This will allow the client to use their
voice in a different way to encourage problem-solving and communication skills to reduce
instances of suicidality and self-harm.
The intake is the first session and involves the therapist using a suicide risk and self-harm
assessment and the creation of a safety plan with the client. Each session will begin with the use
of checking in and a grounding or mindfulness practice that the client can also use in between
sessions on their own. In between sessions, the client will be given a journal or sketchbook
prompt to complete. The prompts will be based on the psychoeducation provided in the session
that has just taken place. Each session will begin with going over the journal or sketchbook
prompt.

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Conclusion
The curriculum provided will be used with adolescent clients with a history of suicidal
ideation and self-harm with the tools and skills needed to reduce and manage the mental health
symptoms that increase in adolescence. These tools and skills gathered from the use of art
interventions using the skills taught from CBT and DBT can provide adolescents with the
confidence to recognize their own signs and symptoms that begin to present themselves when
self-harm and suicidal thoughts occur. These tools and skills provided to adolescents in this
curriculum include a safety plan that can be utilized in between sessions. Adolescents will also
gather information on helpful coping skills, problem-solving skills, and emotion regulation. The
use of art with the skills taught with DBT and CBT provides adolescents with a unique way to
communicate their needs and the powerful emotions they are experiencing daily.

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Section IV: Curriculum
The following curriculum focuses on the use of art therapy in combination with the
behavioral orientations of Cognitive-Behavioral Therapy and Dialectical-Behavioral Therapy for
Adolescents. The goal of using these two orientations with art therapy is to provide
psychoeducation regarding emotion regulation, problem-solving skills, and mindfulness in
combination with creative practices to encourage a safe, healing space for adolescents who may
struggle expressing their emotions with the use of words. The curriculum will take place in an
outpatient setting where each of the eight sessions will provide the client with the necessary
knowledge and skills for identifying the emotions leading to suicidality and self-harm, finding
effective coping skills like mindfulness and urge surfing, emotion regulation and problemsolving skills, and the importance of reaching out for help and utilizing a support system. With
this being in an outpatient setting, clients will be able to leave each session with the newly
attained information and utilize the skills at home.
Conclusion
The goal of this curriculum is to provide a professional art therapist with a guide to utilize
various DBT-A and CBT-based art therapy intervention to assist adolescents with reducing and
eliminating both suicidality and NSSI. CBT and DBT-A are being utilized due to their nature of
focusing on emotion regulation, problem-solving skills, and mindfulness. The combination with
art therapy is to encourage creative practices in a safe and healing space for adolescents who may
struggle with expressing difficult emotions with words.

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26

Section V: Discussion
The purpose of this study was to gain a better understanding of the growing mental health
crisis among adolescents. Rates of suicidality and non-suicidal self-injury (NSSI) continue to
increase at concerning levels, and the intersection of discrimination, social stressors, and mental
health outcomes is a critical area of concern. In response, orientations like dialectical behavioral
therapy for adolescents (DBT-A) and cognitive-behavioral therapy-based programs have
demonstrated an effectiveness in reducing suicidality and NSSI among adolescents. This study
also highlights the gap in literature regarding alternative therapeutic interventions, especially art
therapy, for this population.
Brief Summary of the Research
The effectiveness of DBT-A and CBT in reducing suicidality and NSSI in adolescents has
been well-documented in existing research. These theoretical orientations emphasize emotion
regulation, coping skills, and cognitive restructuring to address the underlying psychological and
emotional factors contributing to NSSI and suicidal behaviors in adolescents. This study also
suggests that the incorporation of art therapy in addition to the behavioral theories offers benefits
for adolescents struggling with suicidal ideation and NSSI. Art therapy gives adolescence the
opportunity to use creativity to communicate difficult and intense emotions and experiences that
may be difficult to express with words alone. This is support with findings discovered by
Kapitan (2014), that art therapy provides the client with an opportunity to process trauma,
promote emotional healing, and encourages self-expression.

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Discussion
The findings of this study highlight the effectiveness of art therapy in combination with
CBT and DBT-A as evident by the literature suggesting and increase of internal coping strategies
utilized by the adolescent participants. For example, McGreevy and Boland (2020) identify the
benefits of art-therapy-based approaches with adolescents that allow for the development of
coping skills, emotion regulation (McGreevy and Boland, 2020), and finding both environments
and tools to build hope, confidence, and social supports (Pavarini et al., 2021). Additionally, in a
study conducted by Zakaria and Ahmad (2023), a participant was able to utilize the creative artmaking process to explore her feelings and navigate the challenges of self-harm behaviors (p.
198).
Limitations
Although the present results support the advantages of combining art therapy with CBT
and DBT-A, it is also important to recognize several potential limitations. First, the sample size
was relatively small. There is a need for further research on the combination of art therapy and
the behavioral-therapies in various populations and environments. Second, there is a lack of peerreviewed studies in this specific area that suggests a great need for more robust, large-scale
studies to further explore the benefits of combining art therapy with the use of CBT and DBT-A.
Further research is needed to understand how art therapy compares with other therapeutic
modalities across diverse populations and setting.

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Future Research
In terms of future research, it would be useful to extend the current findings by
examining larger populations in more diverse setting. Also, it would be useful to have larger
sample sizes in future research to further support the effectiveness of art therapy in combination
with DBT-A and CBT. Lastly, the development of culturally competent art therapy programs that
address the needs of marginalized youth could provide a more inclusive and effective approach
to mental health care. This can be accomplished through establishing environments that are
accessible and affirming while also reducing mental health disparities in vulnerable populations.
Conclusion
This study highlights the growing need for effective ways to support adolescents dealing with
suicidality and self-harm. DBT-A and CBT are therapies found to be useful when used with
adolescence struggling with symptoms of suicidal ideation and NSSI. The use of DBT-A and
CBT in combination with art therapy could offer a unique and valuable approach. It allows
adolescents to express their emotions and struggles in a creative, non-verbal way, which may be
especially helpful for those who find it hard to talk tough emotions. More research is needed to
better understand how art therapy works for adolescents, particularly over time, and in
combination with other therapies. Larger, more diverse studies could help confirm its benefits
and how it might be best integrated into existing treatments. In conclusion, art therapy in
combination with DBT-A and CBT has the potential to help adolescents struggling with
symptoms of suicidality and NSSI express themselves and begin to heal.

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References
Alavi, A., Sharifi, B., Ghanizadeh, A., & Dehbozorgi, G. (2013). Effectiveness of cognitivebehavioral therapy in decreasing suicidal ideation and hopelessness of the adolescents
with previous suicidal attempts. PubMed. https://pubmed.ncbi.nlm.nih.gov/24427502
American Art Therapy Association. (2013). Ethical Principles for Art Therapists.
https://arttherapy.org/wp-content/uploads/2017/06/Ethical-Principles-for-ArtTherapists.pdf
American Psychological Association. (2019, June). Child and adolescent Mental and Behavioral
Health resolution. Retrieved March 19, 2024, from https://www.apa.org/
Aranmolate R, Bogan DR, Hoard T, Mawson AR (2017) Suicide Risk Factors among LGBTQ
Youth: Review. JSM Schizophr 2(2): 1011.
Asarnow, J.R., & Mehlum, L. (2019). Practitioner Review: Treatment for suicidal and selfharming adolescents - advances in suicide prevention care. Journal of child psychology
and psychiatry, and allied disciplines, 60(10), 1046–1054.
https://doi.org/10.1111/jcpp.13130
Ask Suicide-Screening Questions (ASQ) toolkit. (n.d.). National Institute of Mental Health
(NIMH). https://www.nimh.nih.gov/research/research-conducted-at-nimh/asq-toolkitmaterials
Barzilay, S., Apter, A., Snir, A., Carli, V., Hoven, C. W., Sarchiapone, M., Hadlaczky, G.,
Balazs, J., Kereszteny, A., Brunner, R., Kaess, M., Bobes, J., Saiz, P. A., Cosman, D.,
Haring, C., Banzer, R., McMahon, E., Keeley, H., Kahn, J. P., Postuvan, V., …
Wasserman, D. (2019). A longitudinal examination of the interpersonal theory of suicide
and effects of school-based suicide prevention interventions in a multinational study of

Art Therapy for Adolescent Self-Harm and Suicidality

30

adolescents. Journal of child psychology and psychiatry, and allied disciplines, 60(10),
1104–1111. https://doi.org/10.1111/jcpp.13119
Bennett, K., Rhodes, A. E., Duda, S., Cheung, A. H., Manassis, K., Links, P., Mushquash, C.,
Braunberger, P., Newton, A. S., Kutcher, S., Bridge, J. A., Santos, R. G., Manion, I. G.,
Mclennan, J. D., Bagnell, A., Lipman, E., Rice, M., & Szatmari, P. (2015). A Youth
Suicide Prevention Plan for Canada: A Systematic Review of Reviews. Canadian journal
of psychiatry. Revue canadienne de psychiatrie, 60(6), 245–257.
https://doi.org/10.1177/070674371506000603
Bhatia SK, Bhatia SC. Childhood and adolescent depression. Am Fam Physician. 2007; 75:7380.
Bosma, L. M., Orozco, L., Barriga, C. C., Rosas-Lee, M., & Sieving, R. E. (2019). Promoting
resilience during Adolescence: Voices of Latino youth and parents. Youth & Society,
51(6), 735–755. https://doi.org/10.1177/0044118x17708961
Branje, S. (2022). Adolescent identity development in context. Current Opinion in Psychology,
45, 101286. https://doi.org/10.1016/j.copsyc.2021.11.006
Bryan, C. J., & Rudd, M. D. (2018). Brief cognitive-behavioral therapy for suicide prevention.
Guilford Publications.
Calear, A. L., Christensen, H., Freeman, A., Fenton, K., Busby Grant, J., van Spijker, B., et al.
(2016). A systematic review of psychosocial suicide prevention interventions for youth.
European Child and Adolescent Psychiatry, 25(5), 467–482. http
s://doi.org/10.1007/s00787-015-0783-4.
Call KT, Riedel AA, Hein K, McLoyd V, Petersen A, Kipke M (2002) Adolescent health and
well-being in the twenty‐first century: a global perspective. J Res Adolesc, 12:69-98

Art Therapy for Adolescent Self-Harm and Suicidality

31

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
Conway PM, Erlangsen A, Teasdale TW, Jakobsen IS, & Larsen KJ (2016). Predictive validity
of the Columbia-suicide severity rating scale for short-term suicidal behavior: A Danish
study of adolescents at a high risk of suicide. Archives of Suicide Research, 21(3), 1–15.
doi:10.1080/13811118.2016.1222318
Curtin, S. C., Warner, M., & Hedegaard, H. (2019). Suicide rates for females and males by race
and ethnicity: United States, 1999 and 2014. NCHS Health E-Stat.
https://stacks.cdc.gov/view/cdc/39033
Cwik, M. F., O'Keefe, V. M., & Haroz, E. E. (2020). Suicide in the pediatric population:
screening, risk assessment and treatment. International review of psychiatry (Abingdon,
England), 32(3), 254–264. https://doi.org/10.1080/09540261.2019.1693351
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
Giddens JM, Sheehan KH, & Sheehan DV (2014). The columbia-suicide severity rating scale
(C–SSRS): Has the “gold standard” become a liability? Innovations in Clinical
Neuroscience, 11(9–10), 66–80. [PMC free article] [PubMed] [Google Scholar]
Gilbert, A.C., DeYoung, L.L., Barthelemy, C.M. et al. The Treatment of Suicide and SelfInjurious Behaviors in Children and Adolescents. Current Treatment Options Psych 7,
39–52 (2020). https://doi.org/10.1007/s40501-020-00201-3

Art Therapy for Adolescent Self-Harm and Suicidality

32

Gipson PY, Agarwala P, Opperman KJ, Horwitz A, & King CA (2015).
Columbia-suicide severity rating scale: Predictive validity withadolescent psychiatric emergency
patients. Pediatric Emergency Care, 31(2), 88–94. doi:10.1097/PEC.000000000000022
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
Győri, D., Farkas, B. F., Komáromy, D., Horváth, L. O., Kollárovics, N., Garas, P., & Balázs, J.
(2023). The Association between Nonsuicidal Self-Injury and Perfectionism in
Adolescence: The Role of Mental Disorders. European Journal of Investigation in
Health, Psychology and Education, 13(11), 2299–2327.
https://doi.org/10.3390/ejihpe13110163
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.
https://doi.org/10.1080/23794925.2022.2056929
Hinz, D. (2014). Media Considerations in Art Therapy: Directions for Future Research. In E.
Gussak & L. Rosal (Eds.), The Wiley Handbook of Art Therapy (1st ed., p. 135). John
Wiley & Sons, Ltd.

Art Therapy for Adolescent Self-Harm and Suicidality

33

Interian A, Chesin M, Kline A, Miller R, St. Hill L, Latorre M, … Stanley B (2018). Use of the
Columbia-suicide severity rating scale (C-SSRS) to classify suicidal behaviors. Archives
of Suicide Research, 22(2), 278–294. doi:10.1080/13811118.2017.1334610
Katz, C., Bolton, S. L., Katz, L. Y., Isaak, C., Tilston-Jones, T., Sareen, J., et al. (2013). A
systematic review of school-based suicide prevention programs. Depression and Anxiety,
30(10), 1030–1045. https://doi.org/10.1002/da.22114.
Kim, S., Seo, D. G., Park, J., Son, Y., Lee, J., Yoon, D., Kim, J., Yoo, J. H., & Lee, J. (2022).
Development and validation of the Self-Harm Screening Inventory (SHSI) for
adolescents. PloS One, 17(2), e0262723. https://doi.org/10.1371/journal.pone.0262723
Kothgassner, O. D., Robinson, K., Goreis, A., Ougrin, D., & Plener, P. L. (2020). Does treatment
method matter? A meta-analysis of the past 20 years of research on therapeutic
interventions for self-harm and suicidal ideation in adolescents. Borderline Personality
Disorder and Emotion Dysregulation, 7(1). https://doi.org/10.1186/s40479-020-00123-9
Lahey BB, Krueger RF, Rathouz PJ, Waldman ID, Zald DH (2017) Validity and utility of the
general factor of psychopathology. World Psychiatry, 16:142-144.
LGBTQIA+ 101 — Princeton Gender + Sexuality Resource Center. (n.d.). Princeton Gender +
Sexuality Resource Center. https://www.gsrc.princeton.edu/lgbtqia-101
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
Macalli, M., Tournier, M., Galéra, C., Montagni, I.,Soumare, A., Côté, S. M., & Tzourio, C.
(2018). Perceived parental support in childhood and adolescence and suicidal ideation in

Art Therapy for Adolescent Self-Harm and Suicidality

34

young adults: A cross-sectional analysis of the i-Share study. BMC Psychiatry, 18(1),
373. https://doi.org/10.1186/s12888-018-1957-7
Martínez-Alés, G., Pamplin, J. R., II, Rutherford, C., Gimbrone, C., Kandula,S., Olfson, M.,
Gould, M. S., Shaman, J., & Keyes, K. M. (2021). Age, period, and cohort effects on
suicide death in the United States from 1999 to 2018: Moderation by sex, race, and
firearm involvement. Molecular Psychiatry,26(7), 3374–3382.
https://doi.org/10.1038/s41380-021-01078-1
McGreevy, Suzie & Boland, Pauline. (2020). Sensory-based interventions with adult and
adolescent trauma survivors: An integrative review of the occupational therapy literature.
Irish Journal of Occupational Therapy. ahead-of-print. 10.1108/IJOT-10-2019-0014.
McNeely, C., & Blanchard, J. (2009). The Teen Years Explained: A Guide to Healthy Adolescent
Development.
https://openlibrary.org/books/OL26107319M/The_Teen_Years_Explained_A_Guide_To_
Healthy_Adolescent_Development
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
Moon, B. (2000). Ethical issues in art therapy. Springfield, IL: Charles C Thomas.

Art Therapy for Adolescent Self-Harm and Suicidality

35

Moriya, D. (2006). Ethical issues in School art therapy. Art Therapy, 23(2), 59–65.
https://doi.org/10.1080/07421656.2006.10129643
Mucci, F., Bouanani, S., Cerù, A., Mauro, A., & Diolaiuti, F. (2023). Navigating the “Mental
Health Crisis” in Adolescents in the Aftermath of Covid-19 Pandemic: Experience and
Insights from Frontline Psychiatric Service. PubMed, 20(4), 309–315.
https://doi.org/10.36131/cnfioritieditore20230410
Nakkula, M. J., & Toshalis, E. (2020). Understanding youth: Adolescent Development for
Educators. Harvard Education Press.
Ong, M., Lakoma, M. D., Bhosrekar, S. G., Hickok, J., McLean, L., Murphy, M., Poland, R. E.,
Purtell, N., & Ross‐Degnan, D. (2020). Risk factors for suicide attempt in children,
adolescents, and young adults hospitalized for mental health disorders. Child and
Adolescent Mental Health, 26(2), 134–142. https://doi.org/10.1111/camh.12400
Orenstein, G. A., & Lewis, L. (2022). Eriksons Stages of Psychosocial Development.
In StatPearls. StatPearls Publishing.
Pavarini, G., Smith, L. M., Shaughnessy, N., Mankee-Williams, A., Thirumalai, J. K., Russell,
N., & Bhui, K. (2021). Ethical issues in participatory arts methods for young people with
adverse childhood experiences. Health expectations: an international journal of public
participation in health care and health policy, 24(5), 1557–1569.
https://doi.org/10.1111/hex.13314
Pedrini, L., Meloni, S., Lanfredi, M., Ferrari, C., Geviti, A., Cattaneo, A., & Rossi, R. (2022).
Adolescents’ mental health and maladaptive behaviors before the Covid-19 pandemic and
1-year after: analysis of trajectories over time and associated factors. Child and

Art Therapy for Adolescent Self-Harm and Suicidality

36

Adolescent Psychiatry and Mental Health, 16(1). https://doi.org/10.1186/s13034-02200474-x51.
Posner K, Brown GK, Stanley B, Brent DA, Yershova KV, Oquendo MA, … Mann JJ (2011).
The Columbia-suicide severity rating scale: Initial validity and internal consistency findings
from three multisite studies with adolescents and adults. American Journal of
Psychiatry,168(12),1266–1277. doi: 10.1176/appi.ajp.2011.10111704
Pereira, L., Egan, M., & Stevermer, J. (2010). Screen teens for depression— it’s quicker than you
think. The Journal of Family Practice, 59(11).
https://mospace.umsystem.edu/xmlui/bitstream/handle/10355/9085/ScreenTeensDepressi
on.pdf?sequence=1
Robinson, K., Scharinger, C., Brown, R. C., & Plener, P. L. (2022). Communicating distress:
suicide threats/gestures among clinical and community youth. European Child &
Adolescent Psychiatry, 32(8), 1497–1506. https://doi.org/10.1007/s00787-022-01960-5
Rosal, M. L. (2016). Cognitive-behavioral art therapy revisited. In D. E. Gussak & M. L. Rosal
(Eds.), The Wiley Handbook of Art Therapy (First Edition, pp. 68–75). John Wiley &
Sons, Ltd.
Schorr, M. (2022). DBT and Art for Youth Suicide Prevention: When Art Saves Lives. Jessica
Kingsley Publishers.
Sedillo-Hamann, D. (2021). Building adolescent self-efficacy and resilience through social
action. Child and Adolescent Social Work Journal, 40(3), 409–417.
https://doi.org/10.1007/s10560-021-00788-3

Art Therapy for Adolescent Self-Harm and Suicidality

37

Sheftall, A. H., Asti, L., Horowitz, L. M., Felts, A., Fontanella, C. A., Campo, J. V., & Bridge, J.
A. (2016). Suicide in Elementary School-Aged children and early adolescents. Pediatrics,
138(4). https://doi.org/10.1542/peds.2016-0436
Silva, C., & Van Orden, K. A. (2018). Suicide among Hispanics in the United States. Current
Opinion in Psychology, 22, 44–49. https://doi.org/10.1016/j.copsyc.2017.07.013
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,
266, 686–694. https://doi.org/10.1016/j.jad.2020.01.178
Snir, A., Apter, A., Barzilay, S., Feldman, D., Rafaeli, E., Caril, V., Wasserman, C., Ha
dlaczky, G., Hoven, C. W., Sarchiapone, M., & Wasserman, D. (2018). Explicit m
otives, antecedents and consequences of direct self-injurious behaviours: A
longitudinal study in a community sample of adolescents. Crisis,39(4), 255–266.
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
Stone, Deborah M. et al. (2017). Preventing suicide: a technical package of policies, programs,
and practice.
The Trevor Project. (2024, March 20). Facts about suicide among LGBTQ+ young people | The
Trevor Project. https://www.thetrevorproject.org/resources/article/facts-about-lgbtqyouth-suicide/

Art Therapy for Adolescent Self-Harm and Suicidality

38

Suicide: Pediatric Mental Health Minute Series. (n.d.). https://www.aap.org/en/patientcare/mental-health-minute/suicide/
Van Meter, A. R., Paksarian, D., & Merikangas, K. R. (2019). Social functioning and suicide risk
in a community sample of adolescents. Journal of Clinical Child and Adolescent
Psychology, 48(2), 273–287. https://doi.org/10.1080/15374416.2018.1528549
Wasserman D, Hoven CW, Wasserman C, Wall M, Eisenberg R, Hadlaczky G, et al. (2015).
School-based suicide prevention programmes: the SEYLE cluster-randomised, controlled
trial. The Lancet, 385 (9977), 1536-1544.
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
Wood, A. (2009). Self-harm in adolescents. Advances in Psychiatric Treatment,15, 434–441.
Young, K. S., Sandman, C. F., & Craske, M. G. (2019). Positive and negative emotion regulation
in Adolescence: Links to anxiety and depression. Brain Sciences, 9(4), 76.
https://doi.org/10.3390/brainsci9040076
Zakaria, W. P. N. I., & Ahmad, N. (2023). Expressive art therapy approach in reducing self-harm
among adolescents. International Journal of Education, Psychology and Counseling,
8(52), 189–200. https://doi.org/10.35631/ijepc.852016
Zuckerbrot RA, Maxon L, Pagar D, et al. Adolescent depression screening in primary care:
feasibility and acceptability. Pediatrics. 2007; 119:101-108.

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Appendix A

39

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Table of Contents
Curricular Outline ................................................................................................................... 42
Session Format (Excluding Intake Session) ....................................................................................... 42

Session One – Intake ................................................................................................................ 43
Session Two – Establishing Safety and Building Rapport Using Protective Containers .................. 44
Session Three – Setting Boundaries and Expectations in Therapy................................................ 45
Assignment Handout – SMART Goals ............................................................................................... 46

Session Four – Setting Goals with a Vision Board ....................................................................... 47
Assignment Handout: Distress Tolerance – TIPP Skills ........................................................................ 48

Session Five – Visualizing Triggers of Self-Harm ......................................................................... 49
Session Six– Creating a Safe Environment and Finding Alternatives to Self-Harm ........................ 51
Session Seven – Emotion Identification and Acceptance Using a Self-Made Emotion Scale ......... 52
Session Eight- Learning Distress Tolerance Techniques .............................................................. 53
Session Nine – Urge Surfing/” Riding the Wave” ........................................................................ 54
Session Ten – Creating and Using a Worry Stone for Mindfulness and Relaxation ......................... 55
Session Eleven - Exploring and defining the di\erent DBT States of Mind using states of mind
mandalas ................................................................................................................................ 56
Assignment Handout: Accepts Skill ................................................................................................. 57

Session Twelve – Using Metaphor for Identifying Emotions and Problem-solving Coping Skills ..... 58
Session Thirteen - Cognitive Restructuring Using Collage........................................................... 59
CBT Cognitive Restructuring Session Handout .................................................................................. 60
Assignment Handout: Black & White Thinking ................................................................................... 61

Session Fourteen – Identifying and Reducing Black-and-White Thinking through Opposites ......... 62
Session Fifteen – Write a Postcard to Your Future Self – A Summary of Therapy ........................... 63

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Curricular Outline
The curriculum was created for adolescents struggling with suicidality and non-suicidal self-harm (NSSI),
incorporating interventions aimed at reducing suicidal thoughts and self-harm behaviors. It was specifically
designed for one-on-one use with adolescents aged 10 to 19 in a therapeutic outpatient setting. These
adolescents participated in a school-based Partial Hospitalization Program (PHP), attending Monday through
Friday and engaging in 3 to 4 hours of daily mental health treatment, including both individual and group
therapy sessions. The curriculum consists of fifteen individual therapy sessions, each lasting one hour,
conducted with an art therapist.
The arts-based interventions incorporated both Cognitive Behavioral Therapy (CBT) and Dialectical Behavior
Therapy for Adolescents (DBT-A), two evidence-based approaches shown to reduce suicidal ideation and nonsuicidal self-harm (NSSI) in adolescents. Both therapies emphasize psychoeducation and skill-building,
making them effective in addressing these issues. CBT is a goal-oriented method that teaches skills such as
creating safety plans and developing emotion regulation strategies, like relaxation and mindfulness techniques
(Sinyor et al., 2020; Bryan & Rudd, 2018). DBT-A focuses on addressing risk factors for suicidal ideation and
NSSI by targeting mood instability, impulsivity, relationship difficulties, and identity confusion (Hiller &
Hughes, 2023; Miller et al., 2007).

Session Format (Excluding Intake Session)
•

Check-in: Go over the homework assignment and learning new DBT-A or CBT skill
(10 minutes).
• Psychoeducation and Intro to topic (10 minutes).
• Art therapy Intervention (30 minutes).
• Verbal Processing and discussion of homework for the next session (10 minutes).

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Session One – Intake
Goals:
1. Complete biopsychosocial, determining the needs of the clients.
2. Creating a treatment plan.
3. Creating a safety plan.
Objectives:
1.
To determine if there is an increased suicide risk that requires inpatient hospitalization to ensure the
client's safety.
2.
To get an idea of the client’s access to means, support systems, and internal coping skills.
3.
To give the client a sketchbook for use in completing weekly homework assignments.
4.
To gather information on the client’s experience with the Partial Program they are participating in.
Procedure:
The art therapist is to use the intake to complete a Suicide Risk and Self-Harm Assessment to ensure the client
is not at risk of harming themselves or others. The Suicide Risk and Self-Harm Assessment will also inform
the therapist that the client is in the appropriate treatment setting. The intake is where the creation of the safety
plan will take place. The safety plan needs to be completed in collaboration with the client to increase the
likelihood of the client using the plan when having thoughts of suicide or the urge to self-harm. The safety plan
includes internal and external coping strategies: personal coping skills like distractors and possible supports,
such as personal and professional individuals the client can reach out to during a crisis.
After the completion of the risk assessment and the safety plan, the art therapist is to gather information on the
client’s experience with the Partial Program, including what they have found to be useful or not useful and
what they have learned so far. The information gathered from this will assist the therapist with conducting the
curriculum in a way that is most beneficial for the client and their needs. Lastly, the intake will be where the
therapist provides the client with a sketchbook. The sketchbook is to be used by the client for completing
homework assignments. The art therapist will need to explain to the client that the sketchbook is to be used for
assignments, which will include visual and verbal processing prompts, and should not be used for anything
else.
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.

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Session Two – Establishing Safety and Building Rapport Using Protective
Containers1
Session two centers around the concept of establishing safety and building rapport. Safety and rapport are
important factors in the beginning stages of therapy. For therapy to be effective, there needs to be trust between
the client and the therapist. Due to the topic of suicidality and self-harm being approached in these sessions, it
is important that the adolescent client feels safe and not judged when discussing sensitive topics.
Goals:
1. Establishing safety and rapport.
2. Promoting confidence and empowerment in asking questions and addressing concerns.
Objectives:
1. By the end of this session, the client will have been able to address any questions, concerns, feelings
of fear, or nervousness regarding therapy.
2. The client will develop a sense of safety in therapy with the therapist.
Materials:
- Small cardboard or wooden box
- 9x12 drawing paper
- Acrylic paint brushes
- Drawing and writing materials: crayons, markers, pens, etc.
Procedure:
Session two utilizes the protective container art intervention. 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. The protective container will allow the client to either use a box or draw an
image of the box consisting of possible questions, concerns, fears, or nervousness. After the client is complete
with the intervention, the processing questions will involve the therapist gathering information from the client
regarding any trepidation about attending therapy. The box or container will act as a way to contain these
concerns in a protected place and will allow the therapist and client to revisit them in future sessions. The
therapist will then leave it up to the client where this container will be stored, giving the client a sense of
control and safety. During the processing, confidentiality and its limits are discussed. This aspect is important
because of the potential concern of stigma and embarrassment being experienced by the client (Radez et al.,
2020).
Discussion:
- When looking at your protective container, what is the significance and purpose of each characteristic
or feature you included?
- What are some of your fears, questions, or concerns regarding therapy?
- Where can you keep this box, so it is in a safe and private place?
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/

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Session Three – Setting Boundaries and Expectations in Therapy
In the beginning of any therapeutic relationship, it is important to establish and implement boundaries. The
client should be made aware that therapy is their space, and they cannot be forced to do anything they are not
okay with. Also, setting boundaries early in the therapeutic relationship is needed due to confidentiality
reasons, being sure to explain confidentiality to the client. For example, “If I see you out in public, I will not
say hi to you, but you can say hi to me if you would like.” This session is a continuation of the previous
session which focused on establishing safety. Setting boundaries and expectations both relate to building a safe
environment.
Goals:
1. Defining boundaries
2. Establishing rapport
Objectives:
1.
By the end of this session, the client will be able to gather what their boundaries and expectations are
in therapy.
2.
The client will be able to continue to describe what safety in therapy means to them.
Materials:
- 9x12 drawing or mixed media paper
- Pens and pencils
- Markers
- Crayons
- Oil or chalk pastels
Procedure:
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. It gives the therapist a better
understanding of the client's view on boundaries and offers a chance to teach the importance of healthy
boundaries in therapy. Setting these boundaries is key to creating a safe and supportive space for the client.
Discussion:
- When looking at your castle, what is the significance and purpose of each characteristic or feature you
included?
- What do you know about boundaries?
- How do you set boundaries in your personal life?
- What are some of your boundaries and expectations regarding therapy?
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.
*Provide the client with a handout visualizing the SMART Goals

Art Therapy for Adolescent Self-Harm and Suicidality

Assignment Handout – SMART Goals

46

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Session Four – Setting Goals with a Vision Board2
Session four involves the use of a vision board for the client to set realistic, reachable goals. Setting goals
collaboratively with the client early in therapy is important as it increases client motivation and will increase
the likelihood of them showing up for the next session. Setting goals with clients allows them to create goals
unique to them and who they are as an individual. The purpose of the vision board is to provide the client with
a tangible object they may refer to when feeling discouraged or unmotivated as a reminder of what their shortterm and long-term goals are.
Goals:
1. Defining and practicing the goal-making process in therapy
Objectives:
1.
By the end of this session the client will establish realistic, reachable short-term and long-term
goals.
2.
By the end of this session, the client will have a tangible object to refer back to when needing a
reminder of their treatment and life goals.
Materials:
- 11x14-inch mixed media paper
- Precut magazine images and words
- Colored paper
- Bits of cloth
- String or yarn
- Beads
Procedure:
Session four centers around the client setting long-term and short-term goals. Such goals can relate specifically
to therapy or the client’s personal life: treatment goals and goals at school, with family, at work, future career
and education, etc. Using open-ended questions, the therapist is to ask the client to create a list of their longterm and short-term goals and to think about imagery relating to these goals and changes the client would like
to make in their life. Some examples of open-ended questions:
- Where do you see yourself in ten years?
- What do you value?
- Where will you live?
- Who would you help?
After the client is completed with their list of goals, the client is then asked to identify precut images and
words that represent their identified goals. The client will then arrange the images and words in a way that is
meaningful to them on the piece of paper. The client may use other materials like yarn, beads, and cloth to
make their vision board more personalized to them.
Discussion:
- What are the goals you identified?
- How will you achieve these goals?
- Are there any barriers that may come up for you when trying to achieve these goals? If yes, how can
you overcome or remove these barriers?
Where will you put your vision board so that you can easily look at it when feeling discouraged or less
motivated?
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.

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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.
*Provide the client with a TIPP Skills handout.

Assignment Handout: Distress Tolerance – TIPP Skills

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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.
Assisting the client with becoming aware of what their triggers are and the physical sensations that occur can
provide them with the ability to know which coping skills need to be used for different situations.
Goals:
1. Develop an increased awareness of certain emotions, events, people, etc. that may trigger an urge for
them to self-harm.
2. Identify coping strategies when having the urge to self-harm.
Objectives:
1. Define the word “trigger.”
2. The client will be able to identify warning signs leading up to self-harm.
3. The client will be able to identify helpful strategies to manage the urge to self-harm whenever
triggered.
Materials:
- 9x12 drawing or mixed media paper
- Pens and pencils
- Markers
- Crayons
- Oil or chalk pastels
Procedure:
Session five begins with the therapist providing the client with information on trigger awareness and the
possible bodily sensations that may occur when triggered, leading to the urge to self-harm. These bodily
sensations can include sweating, shaking, and much more. These bodily sensations are typically ignited by
feelings of stress, anger, sadness, etc. Session five involves having the client use crayons, markers, or colored
pencils to create a simple outline of their body. The client is asked to write or draw the triggers and trigger
signs in and around the body. These triggers can include physical or emotional. Learning to identify the
triggers will allow the client to establish strategies they may use when these triggers occur, allowing the client
to manage the urge.
Discussion:
-

What were you able to identify as your triggers that may lead to the urge to self-harm?
What were you able to learn about the bodily sensations that occur when you are triggered?
What are some of the coping strategies you can use when feeling these body sensations?

Assignment Prompt: When doing this assignment, make sure you are sitting comfortably in a place where
you feel safe. Take a moment to visual in your mind a real or imaginary place where you feel relaxed and safe.
This can be your bedroom, the beach, a forest, etc. Create an image visualizing this space while keeping the
following questions in mind:

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

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What safe place did you choose?
How does this safe place make you feel?
What emotions came up for you as you visualized your safe place?
How can looking back at this visualization of your safe space help you in the future when
experiencing intense emotions?

50

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Session Six– Creating a Safe Environment and Finding Alternatives to SelfHarm
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. This conversation of safety also
gives the therapist the ability to review the safety plan and ask the client if any changes need to be made. It is
important that the safety plan is done in collaboration with the client as this will increase the likelihood of
them using it during crisis events.
Goal:
1. Gaining knowledge on limiting access to means in their living environment.
Objectives:
1. The client will explore and practice alternatives to self-harm that they will be likely to try.
2. The client will review their safety plan created at intake and make any changes as needed.
Materials:
- 9x12 drawing or mixed media paper
- Pens and pencils
- Markers
- Crayons
- Oil or chalk pastels
Procedure:
Session six focuses on identifying a safe environment through the "My Safe Space" art intervention. The client
is asked to create an image of their bedroom or another space they consider safe. Within the image, the client is
encouraged to identify any potential risks or access to harmful means. Then, the client brainstorms and either
draws or writes ways to safely remove or reduce these risks.
Discussion:
- Where did you identify as your safe space? Is it real or imaginary?
- Imagine yourself standing in this safe place. What would you see to the left and right of you, in front
of you, and above and below you?
- Under what circumstances would your safe space be most helpful to you?
- Is there anything unsafe in your space? What are you able to do to make it safe?
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.

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Session Seven – Emotion Identification and Acceptance Using a Self-Made
Emotion Scale or Thermometer
Emotion identification is especially important when working with clients who struggle with suicidal ideation
and self-harm. Sometimes when the emotions get to be too much, the thought of suicide or self-harm occurs as
a solution to relieve these emotions. Working with the client to identify their emotions will allow them to refer
to their safe space when needed which will consist of their coping strategies and safety plan.
Goals:
1. Be able to name their emotions and identify what coping strategy they need in response to each
specific emotion.
Objectives:
1. The client will be able to communicate tough emotions they are experiencing and what their needs are
in the moment of having that emotion.
2. The client will be able to normalize all emotions, even the “negative” ones like anger and sadness.
Materials:
- 9x12 drawing or mixed media paper
- Pens and pencils
- Markers
- Crayons
- Oil or chalk pastels
Procedure:
During session seven, the client is asked to create an image of a scale, thermometer, or any other imagery that
resonates with them for displaying a variety of emotions they may experience on a daily basis. These emotions
can range from joy, excitement, anger, anxiety, etc. The client can be 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. Lastly, somewhere
in or around the thermometer, the client is asked to draw or write potential coping strategies for the emotions
of anger, stress, anxiety, etc.
Discussion:
- How can you use this scale/thermometer in your daily life?
- What are some coping strategies you can use when feeling angry, sad, stressed, etc.?
- What colors did you use to symbolize each emotion? Why?
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.

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Session Eight- Learning Distress Tolerance (Mindfulness, Distracting, and
Self-Soothing Techniques Used to Cope with Uncomfortable Emotions) with
Do-It-Yourself Zen Gardens4
Session eight focuses on the DBT skill of distress tolerance, which is crucial for adolescents dealing with nonsuicidal self-injury (NSSI) and suicidal thoughts. Distress tolerance helps clients pause and use coping
strategies before acting on self-harm or suicidal urges. 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:
1. Establishing various coping skills to use in response to suicidal ideation and non-suicidal self-harm.
Objectives:
1. The client will be able to practice use of the emotion scale/thermometer created last session.
2. The client will be able to define distress tolerance.
3. The client will be able to identify other ways they can use mindfulness, distracting, or self-soothing
skills when experiencing uncomfortable, intense emotions.
Materials:
- Plain, 5x7 photo frame (with glass removed before giving to client)
- Pre-cut 5x7 foam board
- Fine grain craft sand
- Seashells, stones/pebbles, sea glass, etc.
- Small craft sticks/sticks/twigs to create a rake
Procedure:
During session eight, the client is asked to create their own usable, three-dimensional Zen Garden. This is
something that the client will use as a way to practice mindfulness, distraction, and self-soothing whenever
they are experiencing uncomfortable or intense emotions. The client will review their emotion
thermometer/scale image from the previous session and brainstorm the different ways they can use
mindfulness, distraction, or self-soothing skills for more difficult emotions. The client can identify the Zen
Garden and any other effective coping skills that they will likely try.
Discussion:
- How can you use your Zen Garden in your daily life?
- What did you choose to include in your Zen Garden? Why?
- How likely are you to use this as a coping strategy when having tough emotions? Which emotions do
you think this would be useful for?

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.

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Session Nine – Urge Surfing/” Riding the Wave” Art Intervention for
Learning About the Urge to Self-Harm and How to Not Give in to That Urge5
Session nine focuses on urge surfing. Urge surfing involves taking the time to pause, recognize the feeling, and
practicing an alternative rather than immediately giving into the urge to self-harm. This session will continue
to build on the previous sessions in which the therapist is collaborating with the client on identifying more
healthy and effective coping strategies the client can use when feeling intense emotions.
Goal:
1. Establishing various coping skills to use in response to suicidal ideation and non-suicidal self-harm.
2. Normalize urges as a human experience.
3. Remove shame from experiencing urges.
Objectives:
1. The client will be able to define urge surfing.
2. The client will be able to identify potential desirable consequences of not acting on the urge.
Materials:
- Chalk or oil pastels
- Markers
- Crayons
- Pen and/or pencil
Procedure:
In session nine, 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. The purpose of the “wave” is to associate
the characteristics of the self-harm urge such as using color, lines, shapes, etc. to show the emotional, mental,
and/or physical impact of the urge. After this step is complete, the client is asked to create themselves riding or
surfing on that wave. The client is encouraged to include affirmations, images, symbols, etc. that empower the
client, and remind them that they are capable of riding the wave out, and the positive outcomes of riding out
the wave.
Discussion:
- What are some urges or cravings you have had in the past?
- What typically occurs when you give into your urge to self-harm?
- What do you think would happen if you did not give into your urge to self-harm?
- What are some coping strategies you can use when having the urge to self-harm?

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,” “clam,”
“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.

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Session Ten – Creating and Using 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. The worry stone can be used as a simple grounding tool that is also small
enough to fit in the client’s pocket so they can take it everywhere with them and use it inconspicuously out in
public as needed.
Goal:
1. Establishing various coping skills to use in response to suicidal ideation and non-suicidal self-harm.
Objectives:
1. The client will be able to name ways they can utilize mindfulness and relaxation during crises or
periods of experiencing intense emotions.
2. The client will be able to name ways they can use for mindfulness and relaxation that they will
personally utilize on a daily basis.
Materials:
- Various colors of Crayola Model Magic air-dry clay
- Hands, fingers, and thumbs
Procedure:
During session ten, the client creates their own personal worry stone out of different colored air-dry clay. The
client is asked to create “thumb stones,” in which they flatten a ball of clay with their thumb. The client may
use whichever colors resonate with them (colors that are calming, make them feel joy, etc.). and roll them
together to marbleize the stone. The therapist should demonstrate how these are used (rubbing it between your
thumb and index finger). The therapist should educate the client on the purpose of worry stones as a grounding
tool when experiencing upsetting emotions like anger, sadness, anxiety, etc. Lastly, the therapist and client
should work together to brainstorm additional strategies that can be used for mindfulness and relaxation (one
potentially being the Zen Garden if the client finds it to be useful).
Discussion:
- Looking back at your emotion scale/thermometer, what emotions do you think your worry stone
would be helpful for self-soothing?
- What other coping strategies have you learned recently that would be useful for working through
specific tough emotions?
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:
-

6

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

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Session Eleven - Exploring and defining the different DBT States of Mind
using states of mind mandalas7
Session eleven explores and defines the different DBT States of Mind: Emotion Mind, Wise Mind, Reasonable
Mind. Knowing the three states of mind is important because it allows the client to develop self-awareness of
their emotions and reactions to certain situations and triggers. Also, knowing the three states of mind
encourages the client to find a balance of the three states of mind when making decisions.
Goal:
1. Identify and name examples of own personal experiences of the three DBT States of Mind to
encourage mindfulness and self-reflection.
Objectives:
1. By the end of the session, the client will be able to define each of the DBT states of mind: Emotion
Mind, Reasonable Mind, and Wise Mind.
2. The client will be able to identify their own personal examples of the DBT mind states in their life.
3. To client will be able to practice identifying and understanding different emotions.

Figure 1. What is DBT Wise Mind? (Source: Ogle, 2018)

Materials:
- 9x12 drawing or mixed media paper with a pre-drawn circle
- Pens
- Colored pencils
- Oil pastels
- Chalk pastels
- Markers
Procedure:
Session eleven begins with defining the DBT states of mind. The client creates a mandala to visualize each of
the DBT states of mind without the use of common words and symbols (hearts, smiley faces, etc.). The client
will use their own personal visual language using color, shape, and metaphor. Before beginning each mandala,
the client and therapist will participate in meditation in which the client is asked to take deep breaths and think
about the state of mind. As the meditation occurs, the therapist should describe each state of mind in detail.
The client is also encouraged to think of their own personal life experiences with each of the DBT states of
mind.
Discussion:
- What is an example of a state of mind occurring in your everyday life? (What is an example of the
Wise Mind in your life?)
7

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

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What words or symbols did you choose to represent each state of mind? Why?
What was it like for you to participate in meditation before drawing each mandala?

Assignment Prompt: Read and complete the handout on the DBT Skill: ACCEPTS.
*Provide the client with the worksheet on ACCEPTS

Assignment Handout: Accepts Skill

57

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Session Twelve – Using Metaphor for Identifying Emotions and Problemsolving Coping Skills
Session twelve focuses on the use of metaphors to identify emotions and problem-solving coping skills the
client can use when struggling with intense emotions. Metaphor is used in cognitive and dialectical behavioral
therapies because it individualizes complex concepts for the client, helping them understand the meaning and
importance. Also, using metaphors can make discussing emotions less distressing and even more enjoyable
than simply just talking about the emotions.
Goal:
1. To identify emotions and establish effective coping strategies in response to each emotion.
Objectives:
1. By the end of this session, the client will be able to identify tough emotions (anger, sadness, anxiety,
etc.). and use metaphors to describe them in a personal way.
2. By the end of this session, the client will be able to identify current and new coping skills they will be
likely to use when struggling with intense emotions.
Materials:
- 9x12-inch drawing or mixed media paper
- Pens
- Colored pencils
- Markers
Procedure:
During session twelve, the client participates in The Person in the Rain (PITR) art intervention and assessment.
The client uses crayons, markers, and/or colored pencils to draw a person in the rain. 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. These coping strategies may be
represented by items like an umbrella, rainboots, or a jacket. The intensity of the emotions may be symbolized
by the heaviness of the rain, wind, and other weather conditions.
Discussion:
1. If your drawing could tell a story, what would it say?
2. Tell me about the way you drew the rain (clouds, lightning, etc.), in what way does this weather
represent tough emotions?
3. What is your umbrella? What coping skills can you use in the event of these intense emotions?
4. What can you do in a crisis? Have you used your safety plan in the event of a crisis? Why or why not?
Assignment Prompt: Next session we will be talking about cognitive distortions (inaccurate ways we think
about ourselves) and the ways we can restructure these distortions (ways we challenge these thoughts). In your
journal, I want you to answer the following questions:
1.
2.
3.
4.

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?

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Session Thirteen - Cognitive Restructuring Using Collage, Turning Negative
Thoughts into Something New
Session thirteen focuses on cognitive restructuring. Cognitive restructuring is a cognitive-behavioral technique
that focuses on the client identifying unhelpful and inaccurate thoughts (“I am a bad person,” “I am stupid).
Cognitive restructuring involves changing the unhelpful thought into a more helpful or neutral thought (“I
made a bad choice; however, I am not a bad person,” “I made a mistake, I am not stupid.”). This is an
important skill for adolescents with suicidal thoughts and thoughts of self-harm because unhelpful thoughts
can feed the urge to self-harm or die by suicide.
Goal:
1. To learn cognitive and behavioral strategies to reduce or alleviate thoughts of suicide and self-harm.
2. To identify negative thought patterns and replace them with healthier thoughts.
Objectives:
1. After this session, the client will be able to define cognitive restructuring and provide examples.
2. The client will be able to identify their own cognitive distortions.
3. The client will be able to identify ways to reframe cognitive distortions.
4. The client will be able to define and name each part of the CBT triangle.
Materials:
- 9x12-in Mixed Media paper
- Glue or Mod Podge
- Construction paper in various colors.
- Writing and drawing tools: colored pencils, markers, graphite pencil, etc.
Procedure:
Before beginning, take a moment to explain the CBT triangle to the client and how thoughts, feelings, and
behaviors are all connected. Take a moment with the client to close their eyes if they are comfortable and take
a few deep breaths. Ask the client to think about a time they had a tough emotion (anger, sadness, anxiety).
Have the client pick the emotion and think about the physical sensations that this emotion has caused. 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.
with the use of collage, including using drawing utensils to create positive and hopeful images on the collage.
Discussion:
- What was it like for you to express your tough emotions through destroying the paper?
- What did you learn by recreating something new with collage?
- What was it like for you to have control of the paper?
- Can you think of a time when this restructuring skill would be helpful for you in your own life?
Assignment Prompt: Next session we will be discussing black-and-white thinking. Please complete the blackand-white thinking handout so you may get a better understanding of black-and-white thinking.
*Provide client with handout on black-and-white-thinking

Art Therapy for Adolescent Self-Harm and Suicidality

CBT Cognitive Restructuring Session Handout

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Art Therapy for Adolescent Self-Harm and Suicidality

Assignment Handout: Black & White Thinking

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Session Fourteen – Identifying and Reducing Black-and-White Thinking
through Opposites8
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. Black-and-white thinking is a cognitive
distortion that can lead to increased thoughts of suicide and instances of self-harm. Black-and-white thinking
can contribute to poor self-image and emotional distress, which is what increases the risk of self-harm and
suicidality. The following session utilized a line art intervention, allowing the client to see a visual of
opposites.
Goal:
1. To learn cognitive and behavioral strategies to reduce or alleviate thoughts of suicide and self-harm.
Objectives:
1. After this session, the client will be able to define and provide examples of black-and-white
thinking.
2. The client will be able to have increased self-awareness and insight regarding their emotions.
3. The client will be able to find personal balance and acceptance of their strengths and weaknesses.
Materials:
- 9x12-in drawing or mixed media paper
- Graphite pencil
- Pens
- Markers
- Oil pastels or crayons
- Glue or Mod Podge
Procedure:
The client begins by drawing lines that represent their current emotions, followed by creating exaggerated lines
to emphasize these feelings. On a separate sheet of paper, the client focuses on the opposite emotions and
creates a drawing that reflects these contrasting feelings. The client then rips both images, glues the pieces
together, and merges them into one unified artwork, symbolizing the process of integration.
Discussion:
- What was it like working with opposites?
- What was it like integrating both papers into one piece?
- How do you think working with opposites could be helpful for you in your daily life?
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?

8

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

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Session Fifteen – Write a Postcard to Your Future Self – A Summary of
Therapy
Because session fifteen is the final session of the curriculum, 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:
1. To terminate therapy and reflect skills learned and practiced.
Objectives:
1. After this session, the client will be able to summarize and reflect on all the CBT and DBT skills they
learned.
2. The client will be able to utilize their artworks and journal responses as reminders in the future during
crises.
Materials:
- Blank postcard or 4x6-in index card
- Graphite pencil
- Colored pencils
- Markers
- Crayons or oil pastels
Procedure:
On the blank side of the card, the client begins by creating an image that represents their hope for the future.
This could relate to areas such as their mental health, school, family, or work. Once the image is complete, the
client flips the card and writes a note to their future self—five to ten years from now. The client reflects on
what they have learned in therapy, how they plan to use their new skills, and how this knowledge will impact
their life. The client is also encouraged to list their strengths and outline their future goals.
Discussion:
- What skills did you learn in therapy?
- What is the most helpful skill you have learned? Most unhelpful?
- Where do you see yourself, five to ten years from now?
- Was there anything about this program that you really liked? Disliked?