Unfortunately, not all alternative explanations were considered by Tyrer and colleagues (2003a) when the findings of the POPMACT study were published

To the Editor : Unfortunately, not all alternative explanations were considered by Tyrer and colleagues (2003a) when the findings of the POPMACT study were published. The study consisted of a randomized controlled trial, comparing a brief cognitive behaviour therapy with treatment as usual in a sample of deliberate self-harm (DSH) patients. In our opinion, the study has raised unnecessary concern among those working with DSH patients using interventions based on a cognitive behaviour approach, which has become apparent from the considerable number of reactions we received from clinicians in the past months. An important advantage of the RCT by Tyrer et al., compared to most previous RCTs in this area (Hawton et al. 1998; Hawton & Sinclair, 2003) is that this is the first multi-centre trial, enabling them to include a large sample and to reach sufficient power to test the efficacy of the experimental treatment intervention: A brief Manual Assisted Cognitive Behaviour Therapy (MACT). However, taking into consideration the inclusion criteria that were applied, as well as the eventual profile of the DSH patients, the outcomes are not surprising. First of all, the criterion to only include DSH patients who were repeaters at the time of the index episode of DSH in combination with the fact that nearly half (42%) of the sample had a personality disorder (Tyrer et al. 2003a, b), is usually an indication for a long-term rather than a short-term treatment (Bornstein et al. 1988; Linehan et al. 1991; Johnson et al. 1999). Compared to firstever DSH patients, those who repeatedly harm themselves appear to be more strongly sensitized for suicide-related thoughts and behaviours under the influence of previous suicidal experiences. Consequently, repeated episodes of DSH appear to be primarily elicited by a wide range of intra-psychic and external stimuli, and not by specific negative events. In contrast, first-ever DSH patients more often report specific negative events to be primarily associated with the intensity of the suicidal crisis at the time of the first episode (Joiner & Rudd, 2000). Considering the fact that this sensitization process is associated with persistent states of distress and lack of responsiveness to external events (Joiner & Rudd, 2000), efforts to change this process are likely to involve more time and effort from a therapist than a maximum number of five-plustwo booster sessions, including reading a treatment manual (Tyrer et al. 2003a, b). Although the active treatment MACT was intended to combine bibliotherapy and treatment sessions of cognitive–behavioural therapy, more than one third (38%, n=90) attended no treatment sessions, and their treatment involved the treatment booklet alone, while an additional five patients had no record of receiving the booklet. The authors compared repetition rates of the non-attenders with those who received a minimum of one session of therapy. This would probably underestimate the effect of the therapy sessions. Therefore, it would have been worthwhile if the authors had compared the repetition rates of those who attended a maximum of only two therapy sessions with those who attended three or more sessions. The treatment rationale behind the use of a 70-page self-help manual for DSH patients with repeated episodes is questionable given that this patient population’s problem-solving approach has been associated with passivity and an inability to actively solve problems (McAuliffe et al. 2002), which has also been underlined by Hawton & Sinclair (2003). Pollock & Williams (2001) further demonstrated that DSH patients who were more over-general in memory, have difficulties in remembering and analysing specific situations, making them less able to perform manual-based self-assessments. From our experience with ongoing randomized treatment trials including cognitive behavioural interventions, a consistent observation is Psychological Medicine, 2004, 34, 1143–1146. f 2004 Cambridge University Press Printed in the United Kingdom