Therapeutic Nursing Interventions to Reduce Self-Injurious Behavior: A Scoping Review

Introduction

Self-Injurious Behavior (SIB) differs from suicidal behavior in that, although it was committed intentionally, it is typically not intended to result in death.¹ SIB is also described as an intentional action to harm or poison oneself regardless of motivation or suicidal intention.² Not only that, SIB is also carried out on individuals who feel emotional stress and intense inner conflict, even though they do not have suicidal intentions, but the consequences can be fatal.³ Types of SIB include actions such as self-cutting, strangulation, self-hitting, excessive use of prescribed-medicine or over-the-counter-drugs.⁴ Although SIB may seem latent, it has the potential for serious consequences in the future.

The proportion of SIB cases has been reported on a global and national scale. In an Adults, the lifetime prevalence of SIB is estimated to be over 4%.⁵ The average age of onset of SIB is 17.25 years, and the average age of cessation of SIB is 26.74 years, with a duration of SIB involvement of 9.3 years.⁶ The risk of recurrence within five years after the initial episode is over 22% for non-fatal cases^7. However, the WHO reports an estimated lifetime prevalence of 18% for a single SIB episode in a community sample and has declared it the fifth most common health risk in adolescence worldwide.³ Another report for the lifetime prevalence of SIB among adolescents is 19%, and females are 1.57 times more likely to engage in SIB than males.⁸ Meanwhile, based on region, as many as 4.8% of adolescents were found in Asia compared to other continents.⁹ It has been reported that the prevalence of SIB occurs in the general population in South Asia is approximately more than 44%, while it is recorded at more than 16% in clinical population.¹⁰ Meanwhile, the rate of SIB in adolescents in Chinese schools was 28.9%¹¹ and adolescents in Singapore reported a lifetime prevalence of SIB at 25%, with a median age of 14 years as the onset of lifetime SIB.¹² Adolescents in Indonesia tend towards SIB behavior at a rate of 59.6%.¹³ There have been no reports of SIB in people over 40 years of age or older people.¹⁴

The high rate of psychiatric comorbidity and its role as suicidal risk factor, and its role as risk factor of suicide, providing evidence-based treatment becomes highly important.¹⁵ Therefore, intervention that can help to reduce and prevent SIB is required. Generally, interventions are categorized into three main categories: pharmacological, non-pharmacological, and combined.¹⁶ Although there are no clear reports regarding the advantages and disadvantages of specific interventions, several research results report that several methods can be useful in reducing SIB. Recent studies have reported the benefits of mobile-based SIB-specific interventions¹⁷ and school-based interventions, which have proven effective¹⁸ and also the results of psychotherapy conducted by other healthcare professionals can reduce SIB.^19–21 Study of systematic review and meta-analysis of psychotherapy interventions showed high to moderate efficacy.²² This suggests psychotherapy has advantages because it has been shown to have better efficacy, many reviews report on effective interventions and strategies in reducing and preventing SIB. Long-term efficacy and comparative results require further investigation.²³ However, to date, no review has examined this issue from the perspective of therapeutic nursing intervention.

Mental health and psychiatric nurses (MHPn) have three essential roles: providing information, teaching strategies, and delivering holistic care²⁴ The therapeutic relationship is a fundamental component of MHPn.²⁵ Community mental health nurse which relies on therapeutic relationship as a crucial prevention method in handling those with SIB.²⁶ The therapeutic relationship is formed through nursing actions, which begin with a series of healing nursing care interventions. MHPn should be recognized for their therapeutic value, not as an alternative.²⁷ Finally, nurses must be able to demonstrate their comprehensive role in delivered, leading or within the nursing process in case SIB. Effective nursing care, combined with patient compliance, has been shown to help improve the physical and mental well-being of patients with SIB.¹

Nurses currently face challenges in combating SIB. When dealing with SIB patients, nurses need to differentiate whether the patient has attempted SIB or prevented it, guide the patient in psychotherapy, or provide other assistance according to their abilities.²⁸ Recently, many patients with SIB have come to nurses in emergency unit seeking for help, but they need a diagnose model in order to receive a quality treatment.²⁹ Interviews suggest that nurses are uncertain about how to provide adequate care and engage in conversations about SIB and mental well-being with patients who experience SIB.³⁰ Study reported that nurses felt overwhelmed in trying to apply psychological therapy techniques to SIB patients, thus requiring a standard intervention program that could serve as a guide.²⁶ This suggests the need for evidence-based research to guide therapeutic interventions provided by MHPn.

A review is needed to draw appropriate conclusions for SIB prevention delivered therapeutically by nurses. To our knowledge, no study has systematically mapped the existing evidence, clarified key concepts, and identified research fragmentation on this broad and complex topic. Therefore, the scoping review aims at identifying nursing care therapeutic which can be used to reduce SIB. The findings are expected to provide information on future therapeutic interventions that can specifically become part of a nursing care for patients with SIB in both clinical or non-clinical settings.

Material and Method

The scoping review was carried out based on a framework divided into six practical stages: identifying the research question; identifying relevant studies; selecting studies; mapping the data; collecting, summarizing, and reporting the data; and consulting (optional),³¹ and ensuing recommendations five stages.³² To identify the relevant studies, this study used PRISMA-ScR guideline for the scoping review.³³

1. Identifying the research questionResearch question in this study is whether therapeutic nursing can be used to minimize self-injurious behaviour? Accordingly, two sub-research questions were developed to obtain the following scoping review results: a). What types of therapeutic nursing care can nurses use for SIB?; b). What is the outcome of therapy on SIB?
2. Identifying relevant literatureThe review process began with a search for relevant literature in clinical electronic databases subscribed to by the Indonesian National Library service and the University of Padjajaran E-Journal. The description of study selection from four databases, based on the inclusion criteria, identified from PubMed, CINAHL, Scopus, and Garuda. The key words used included operator Boolean and consisted of key words in English, that is (((((((nursing care[MeSH Terms]) OR (therapy[Title/Abstract])) AND (adolescents[MeSH Terms]))) AND (adults, young[MeSH Terms])) AND (non suicidal self injury[MeSH Terms])) OR (self harm[Title/Abstract])) OR (self injurious behavior[Title/Abstract]). While in Indonesian “Intervensi Keperawatan OR Terapi Keperawatan” AND Anak AND Remaja AND Dewasa AND Self-Harm OR non-suicidal self-injury.
3. Study selectionThe Inclusion criteria encompassed: (a) Population including school-age children, adolescents, and young adults with SIB in both clinic and non-clinic settings; (b) Research studies that referred to therapeutic nursing interventions including delivered by nurses or nurse‑led to reducing SIB; (c) Articles published in English and Indonesian; (d) The articles published 2015–2025 (e) Mix/RCT/Quasi-Experiment/Cohort/Descriptive study designs PICO in this study is P: school-age children, adolescents, and young adults with self-harm or self-injurious behavior in both clinic and non-clinic settings. I: Nursing Intervention; Nursing Therapeutics. C: - O: Reduce SIB. We searched from 2 to 9 June 2025 records identified from database PubMed (n = 12105); CINAHL (n = 145807); Scopus (n = 99); Garuda (n = 46). Articles were selected based on their titles and abstracts; 158057 articles were selected. All articles were checked for duplication (n = 151021) articles were found. We exclude exluded non specific SIB (n = 3474), excluded not focus nursing care therapeutic (n = 3536), full text unavailable after extensive search (n = 14). Not in English language and Bahasa Indonesia (n = 2), excluded with qualitative design (n = 6), the final search results were exported into Mendeley Reference Management Software. Ultimately, 4 studies met the criteria because therapeutic interventions in reducing SIB were delivered and led by nurses in the nursing care process. We did not assess the quality of the studies due to the limited number of articles. Given our aims to identifying interventions nurses can implement and to map breadth the overall findings, we did not find any studies using RCTs. This is due to the limited resources nurses have in the context of reducing SIB. The study selection process was shown in Figure 1.
4. Charting the dataBoth reviewers (T.H.P. and S.A.) independently identified articles by screening citations based on titles and abstracts. Full texts versions of all the identified studies by one of the reviewers (T.H.P). Both reviewers then independently assessed the full texts according to the specific inclusion criteria. Any discrepancies in the assessment were resolved through consensus. In addition, articles were chosen based on inclusion criteria, and articles were acquired. The articles were re-selected based on the content and purpose of the study, and four articles were acquired to use in this study. All reviewers (T.H.P.; S.A.; S.S.; K.L.A; F.F.; S.Y.) extracted data from a subset of studies (30%) with 100% inter-reviewer agreement. Two reviewers (T.H.P; F.F.) extracted data from all included study sets. The data were extracted into a Google Form (www.google.com/forms/about), including the authors and publication years, countries, study aims, study designs, populations, settings, sample sizes, ages, and interventions.
5. Collating, summarising and reporting resultsThe next step is to review all articles. The articles obtained are summarized and reported as study findings. The results are reported through the approach. a) Types of therapy that can be used by nurses in patients with SIB. b) Outcome of therapy on SIB. The stakeholder consultation stage is an optional step designed to gather input on research questions and information sources, as well as to provide insight into a topic.³⁴ We did not conduct this stage because consultations can be incorporated into all observation stages and can be conducted through group discussions. According to³⁵ reports of stakeholder consultation processes are often brief and general, and frequently fail to report on the impact of the stakeholder consultation process.

Figure 1 The research selection process using a standard PRISMA flowchart.

Results

Characteristics of Study

The characteristics of this study encompassed a Quasi-Experimental study (n = 3) and a retrospective cohort study (n = 1). The total sample size was 258 respondents with Psychiatry patients (clinical) and adolescents with SIB (non-clinical). The age characteristics involved in this study were 8–40 year. The studies included were conducted in Saudi Arabia (n = 1), Indonesia (n = 2), China (n = 1) (Table 1). The Therapeutic nursing interventions included psychological therapy groups (n = 1), psychoeducation and Mindfullness Based Cognitive Therapy (MBCT) (n = 1), Dialectical Behavior Therapy (DBT) (n = 1), and Dhikr therapy (n = 1) (Table 2).

Table 1 Characteristics of Studies Reporting Therapeutic Nursing Interventions to Reduce SIB (n = 4)

Table 2 The Outcome of Interventions to Reduce SIB in Selected Studies (n = 4)

Therapeutic Nursing Interventions and Outcome

The Comprehensive of Psychological Nursing Groups

Psychological nursing groups can be part of comprehensive nursing planning. The therapy established a group with similar goals and psychological issues by building close relationships within the group. Psychological nursing aims to minimize negative psychological states, correct improper behavior, and promote healthy growth. During its implementation, bonding among individuals facilitates the formation of an effective communication atmosphere that fosters harmony and helps patients gain emotional support from their families.³⁶ The Comprehensive of Psychological nursing groups is effective Reducing SIB severity.

The Combo of Psychoeducation and MBCT

Administering psychoeducation and MBCT can be therapeutic and effective in solving problems among adolescents. The combining both therapy is effective to reduce SIB frequency. This therapy focuses on cognitive restructuring, including affective restructuring, to develop awareness, emotional regulation, and self-control by identifying both positive and negative cognitive and affective patterns. It has an impact on enhancing self-concept and life satisfaction. Adolescents who are able to regulate their emotions tend to develop positive emotions and manage negative ones more effectively. Adolescents tend to more easily develop a rational mindset, and negative thoughts can be replaced with more positive ones.³⁷

Culturally Practice: Dhikr Therapy

Dhikr therapy is becoming a means of minimizing the symptoms and risk of SIB among adolescents. Dhikr is an Islamic meditation technique by reciting astagfirullahaadzim, which means giving yourself the opportunity to reflect on wrong deeds and seeking forgiveness from Allah. Dhikr therapy can be administered to adolescents at risk of SIB, as it is portrayed as a gateway to relaxation and happiness because the final of Dhikr is to achieve inner peace, enabling individuals to find solutions and free themselves from hardship.³⁸ This culturally therapy is effective to reduce SIB frequency.

Module DBT

DBT is an approach used for patients with suicide attempts and SIB, and it is considered an effective therapy with its own advantages. DBT has a positive effect as a patient treatment approach, as identified through emotional reactions and regulation. The patients are instructed to regulate their emotions, then to understand them without judgment, to face unpleasant events, and to explore their social skills, which are useful for developing interpersonal connections and communication.³⁹ DBT skills modules teachable by nurses for reducing SIB frequency and severity.

Scope and Limitation of Evidence

Most of the studies found in this review were from specific populations and socioeconomic contexts, particularly Asian countries. Therefore, findings regarding prevalence, risk factors, and interventions may not be directly generalizable to other cultures, which may have different views on mental health and SIB. In accordance with the methodology of a scoping review, no assessment of the risk of bias or quality of the included studies was conducted. This limits the ability to make robust and generalizable recommendations for practice or policy. Evidence suggests that how SIB is expressed, the underlying motives, and the coping strategies used can vary significantly across cultural groups. This review highlights a significant gap in research centered on providing nursing interventions for SIB in ethnic minority groups or non-Western cultures, which may have different behavioral manifestations. Differences in cultural norms, beliefs, and family dynamics may act as risk or protective factors for SIB. Existing studies may not fully capture these nuances, limiting our understanding of how interventions can be culturally tailored. In conclusion, while this review provides an overview of nursing interventions for SIB, it cautions against generalizing the findings. It acknowledges that cultural context plays a significant role in understanding, experiencing, and managing SIB.

Discussion

This scoping review aims to identify therapeutic nursing interventions that can be used to reduce SIB. The main findings of this study describe four therapeutic nursing care approaches, consisting of psychological therapies, that can be provided to children, adolescents, and adults with SIB in various clinical and non-clinical settings: group psychological therapy, psychoeducation and MBCT, DBT, and Dhikr Therapy.^36–39 Currently, many specific programs and methods for managing SIB have been proven.^19–21 However, the results of this review demonstrate that nurses can lead a therapeutic role in reducing SIB in various clinical and non-clinical healthcare settings.

Our review of findings on the first therapeutic method, the comprehensive of psychological nursing groups.³⁶ Another study, conducted by⁴⁰ suggests that the application of psychological nursing in pediatric clinical nursing can improve pediatric care compliance, reduce the incidence of adverse events, increase parental satisfaction, and have both promotional and clinical application value. The advantage of this therapy is that it involves guardians in group psychotherapy, making it easier for guardians and patients to establish a harmonious communication atmosphere that helps patients receive emotional support. Group psychological interventions involve subjective family support activities designed to build patient confidence in overcoming the illness.⁴¹ The limitations of this therapy can lead to other psychological problems. According to previous research by Visagie, patients attending group therapy for the first time may experience anxiety or fear of being judged by other group members and the psychiatric nurse facilitating the group session.⁴²

The combining of psychoeducation and MBCT is second therapeutic intervention by nurse.³⁷ A study conducted⁴³ examining the impact of a positive psychoeducational group program showed that it can reduce stress and fatigue and increase post-traumatic growth, self-reflection and insight, self-compassion, psychological empowerment, and compassion satisfaction. Likewise, the efficacy of MBCT is highly promising for both prevention and treatment.⁴⁴ The advantage of this method is that it can provide mutual reinforcement between therapies, allowing for a more comprehensive approach. Studies comparing psychoeducation and MBCT report that both therapies reduce anxiety severity equally and complement each other, although MBCT is more effective⁴⁵ and both combining can be implemented in services with more limited resources.⁴⁶ A limitation of this method is the potential for conflict in therapeutic approaches, as some individuals may feel confused by the overlap between the two approaches. There may be differences in the implementation of the interventions, both in terms of duration and the number of sessions, as well as the number of elements included.⁴⁷

Culturally therapeutic interventions by nurse such as Dhikr therapy using Islamic phrases,³⁸ this is a cultural approach. A study on Dhikr therapy, as a form of religious activity in Islam, has a positive role in the mental health of the elderly⁴⁸ and is also effective in reducing anxiety in patients with chronic kidney failure.⁴⁹ The advantage of this method is that it is very easy to practice and saves time, as it is purely verbal and can be done before going to sleep. Dhikr therapy is a simple, inexpensive, and holistic treatment for healing.⁵⁰ However, this therapy is not a single solution, but rather a cultural practice. It should be combined with other therapies, as its effectiveness has not been established for SIB patients, and this therapy will only be used among Muslims. Dhikr therapy can only be given to Muslims and therefore cannot be used generally.⁵¹ Last, Module DBT skills modules teachable by nurses.³⁹ This shows that DBT is a practical, beneficial, and superior approach for patients with suicidal tendencies and SIB compared to conventional care. The advantages of this method have been proven to be effective. Recent studies have reported DBT to be a better choice than pharmacotherapy,¹⁶ and it is the preferred option for reducing SIB.¹⁵ The disadvantages of DBT adolescent participants include a high dropout rate, making it difficult to interpret the results, and may indicate problems with the delivery or intensity of the intervention.⁵²

Therapeutic nursing care is realized in the nursing care process. This can take the form of crisis management carried out by nurses aimed at effectively managing critical situations in patients with SIB. First, through screening, nurses can perform independently using validated screening tools. Other aims include reducing the frequency of SIB behavior by screening high-risk individuals.¹ Second, nurses must immediately create a safety plan. Planning stage is a pivotal part of the purpose and result that influence the patients based on the evidence base practice guideline.⁵³ The Nursing Diagnosis (NANDA) and the Nursing Intervention Classification (NIC) are effective therapeutic tools to prevent and treat behavioral issues related to SIB and suicide.⁵⁴ Nurses can consider these findings from four therapy from these evidence-based studies in planning nursing interventions with referral to primary nursing resources. Third, Therapeutic Communication aims to reduce uncertainty and increase adherence to the care plan. Nurses must enhance the human aspect of nursing care to encourage effective communication with patients.¹ Furthermore, during the implementation process, nurses should focus therapeutic interactions on managing psychological distress and reducing further SIB behaviors and the risk of suicide.⁵⁵ Finally, Referral Pathways by referring patients to other services or professionals ensure that individuals receive appropriate and ongoing levels of care, both within and outside their current medical facility. Nursing care for SIB patients should be an integration of multidisciplinary, multifaceted, and multilevel issues.¹

The novelty of our study lies in demonstrating that all four methods are effective in reducing SIB in both clinical and non-clinical settings. It may provide valuable references for both clinical and non-clinical applications in children, adolescents, and adults. By adopting a comprehensive, patient-centered approach, MHPn can contribute significantly to reducing SIB, as this review provides evidence for MHPn to support decision-making in providing effective nursing care to manage SIB. All four methods have advantages and disadvantages, although all methods reported statistically significant results. The recommended therapeutic nursing intervention in groups is group psychological nursing. Meanwhile, in hospital settings, DBT is the recommended method, and in communities, a combination of psychoeducation and MBCT is recommended. Dhikr is recommended as a culturally practice.

Strength and Limitations

This scoping review identifies studies from Saudi Arabia, China, and Indonesia that can be used as information to create a guideline and program regarding SIB in various populations, especially conducted by nurses. This review has limitations, firstly it did not assess the quality of the studies due to the limited number of articles may increase cultural/geographic risk of bias. Future research should explicitly address cultural specificities to address this knowledge gap. Second, the findings cannot summarize/percentage the benefits of all four methods; a meta-analysis is necessary. Nurses can consider the setting of therapy. Despite its limitations, several advantages of this study are also worth highlighting. First, to our knowledge, there is no study to identify therapeutic nursing interventions to reduce SIB. Second, this study identified several positive outcomes from the interventions, which can serve as a basis for MHPn interventions in both hospital and community settings, including both clinical and non-clinical settings.

Conclusion

The findings of this review can be used as a guideline and primary source of information for nurses implementing therapeutic care in various settings and populations. MHPn as professional profession need to assume a therapeutic role as delivered and leaders in providing effective nursing care to manage SIB. This can take the form of crisis management carried out by nurses aimed at effectively managing critical situations in patients with SIB, with screening, safety planning, therapeutic Communication and Referral Pathways. The recommended therapeutic nursing intervention in groups is group psychological nursing. Meanwhile, in hospital settings, DBT is the recommended method, and in community settings, a combination of psychoeducation and MBCT is recommended. Dhikr is recommended as a culturally practice. Nurses need training in managing SIB effectively in health care settings. However, more research conducted by nurses is needed to observe the effectiveness of additional therapeutic interventions using RCT methods. Furthermore, to obtain a summary and conclusions from all studies, additional research, such as systematic reviews and meta-analyses is necessary.