Self-harm is common among young people, and is linked with increased risk for many other mental health issues such as depression and suicide. The findings from the recent Mental Health of Children and Young People in England survey (2018) found that a quarter of 11-16 year olds with a mental disorder had self-harmed or attempted suicide, (compared to 3% without a disorder), and this figure rises to 46.2% in 17-19 year olds.

The act of self-harm is complex and involves many thoughts, emotions, behaviours, and events (Townsend et al, 2016). Self-harm is often hidden, done in isolation when a person is on their own, and research tells us that many people don’t access formal support (Ysygaard et al, 2009) so self-management may be a more accessible option.

Young people talk of feeling urges to engage in self-harm, which can be fleeting or long in duration and intensity (Turner et al, 2018). In one small study, Klonsky & Glenn (2008) report that young people do actively try to resist these urges through a number of coping methods, such as keeping busy or writing about their feelings. Having access to a tool that could help young people during this time may help them in ‘slowing down’ or preventing the self-harm process.

In collaboration with young people with lived experience of self-harm, Paul Stallard and colleagues have developed BlueIce, a mobile app for young people with the intention to help them manage their emotions and prevent self-harm. BlueIce is currently in its early testing phase in a Phase 1 trial (Stallard et al, 2016). This qualitative study represents one aspect of the mixed-methods analysis of the trial. Unlike many other apps designed for mental health, BlueIce is only available on ‘prescription’ from a clinician working in CAMHS (child and adolescent mental health services).

Methods

The authors recruited young people (aged between 12-17 years) who were either currently self-harming or had a history of self-harm and felt they would self-harm again. Participants received face-to-face care from CAMHS for the whole of the study, and could choose to discuss their BlueIce use in their appointments with clinicians. Clinicians at CAMHS within one NHS Trust identified young people on their case-load who met this criteria and provided them with the study information.

In total, 44 young people (90% girls, average age 15.98 yrs) took part: just over two-thirds had self-harmed in the month prior to entering the study. There were several steps involved in using the app:

• An initial meeting (‘baseline’ meeting)
• A two-week period of familiarisation with the app, followed by a second ‘post-familiarisation’ meeting
• 10 weeks of app use, followed by one final ‘post-use’ meeting.

The semi-structured interviews were done at the post-familiarisation (40/44 participants) and post-use (33/40 participants) meetings: these were held either at the participant’s home or at the CAMHS clinic where they were receiving care.

Data were analysed through Thematic Analysis (Braun & Clarke, 2006): this is a frequently-used approach used to identify patterns (known as ‘themes’) across participants. During this six-stage analysis process, two of the authors met to discuss codes/themes and to resolve any discrepancies between them.

Results

The findings of the interviews focus around six aspects of the BlueIce app:

Appraisal

• The app was felt to be helpful in offering privacy and providing several different techniques that young people could use to help them manage their urge to self-harm
• The majority (including those who didn’t personally benefit from BlueIce) would recommend it to others, and felt that it might also have uses outside of helping to prevent self-harm.

Usability

• BlueIce was simple and straightforward to navigate
• Several participants had been loaned an Android phone for the study (as it wasn’t available on iOS for Apple phones), which hindered engagement
• Physical environments sometimes hindered engagement: using the app may have drawn attention from others, or young people were unable to use the techniques described in the app in their current environment
• The type of CAMHS therapy participants were receiving may have influenced their opinions about BlueIce, e.g. being able to understand that specific features of the app were linked to certain psychotherapies
• Participants tended to use BlueIce more at the beginning of the study – their use tapered off: many said this was because their self-harm thoughts had reduced. A few participants were regular users as they had frequent self-harm thoughts and liked using the ‘mood diary’ function.

Safety

• No withdrawals from the study were due to increased risk as a result of using the app
• BlueIce was primarily opened and used when the young person was having thoughts of self-harming, or to prevent further self-harm after an episode. Young people reported it was reassuring, helped them feel safer, and gave access to instant support
• Two participants who benefited from using the ‘mood diary’ said that there might be risk that this feature could trigger negative feelings.

Benefits

• The ‘mood diary’ and ‘mood lifter’ elements were viewed positively to help participants to monitor and change their cognitions and behaviours
• Using the app also helped them to start conversations with other people about their feelings, but they could also use BlueIce to note down their thoughts
• The ‘mood lifter’ feature allowed participants to develop new ways to manage their thoughts of self-harm, and this element helped remind them that they did have strategies they could use.

Agency and control

• Some participants described the fluctuation in their desire to receiving support for stopping self-harming. Sometimes their urge to self-harm was highly intense, and BlueIce would not help with this: there are points where they feel out-of-control with self-harm.

Less helpful

• Seven participants did not find BlueIce helpful for their self-harm: they felt hesitant about the app’s helpfulness and didn’t use it much. Through interviews, a pattern that was found for these participants was that they weren’t ready to stop self-harming and so didn’t see the rationale in using an app to help
• Four participants experienced crises during the study, for which increased CAMHS contact was needed. This took priority over using BlueIce.

Conclusions

From their analysis, the authors suggest:

BlueIce promoted positive changes for a number of adolescents, including helping to slow down or reframe their thinking, distraction from thoughts of self-harming, and identifying triggers of negative moods. Overall, BlueIce was deemed to be helpful, easy to use, and safe.

One of the Top 10 questions from the recently published Research Priorities for Children and Young People’s Mental Health (McPin, 2018) is about needing research about effective self-help resources for this population. Many freely-available mHealth apps for young people do not undergo formal evaluation (Grist R et al., 2017) and so it is good to see that a great effort is being made here to review BlueIce’s acceptability and perception by its target users, as part of a Phase I trial. This is a neat study to consider as part of the overall evaluation of the BlueIce app, and shows how qualitative approaches can provide insights into what specific aspects of an app are helpful to young people in helping to minimise their self-harming behaviours, as well as thinking about areas in which there might be discrepancy between the app’s intentions and lived experience of self-harm (for example, for those who might not be wanting to change their self-harm).The themes were fairly broad, with the authors clearly showing what findings were grouped in each theme.

Although the participants were a self-selected sample who volunteered to use BlueIce (and so might have more positive attitudes about mHealth), a strength here is that the authors did manage to interview some young people who did not use the app (under the ‘Less Helpful’ theme) and gauged some understanding as to why this was. This is useful in giving an idea as to who the app might not be useful for and understand that it does have some limitations, and so might be able to assist clinicians in helping decide whether or not they might want to recommend/prescribe BlueIce to their patients.

Noticeably, participants reported their use of BlueIce declined in the study, due to decreased thoughts and intentions about self-harm. BlueIce was used in conjunction with receiving CAMHS treatment, and so it’s difficult to decipher what particularly led to this therapeutic change: was it in the face-to-face sessions with their clinician, the app itself, or a combination? Participants did say that the app helped in several different ways, and it was their choice to discuss their use of BlueIce in their clinical sessions. It might be worth exploring whether disclosure and discussion with a clinician added additional benefits.

Conflicts of interest

Bethan Davies (BD) knows two of the researchers involved in the study (RG and PS) and has worked with them on another project evaluating virtual reality software in CAMHS. BD was also involved in ‘Framework for the effectiveness evaluation of mobile (mental) health tools’ project, which BlueIce was involved in.

Thanks to Jo Lockwood for her assistance with this blog.

Links

Primary paper

Grist R, Porter J & Stallard P. (2018) Acceptability, Use, and Safety of a Mobile Phone App (BlueIce) for Young People Who Self-Harm: Qualitative Study of Service Users’ Experience. JMIR Mental Health, 5 (1), e16. https://mental.jmir.org/2018/1/e16/

Other references

Grist R, Porter J & Stallard P. (2017). Mental Health Mobile Apps for Preadolescents and Adolescents: A Systematic Review. Journal of Medical Internet Research, 19 (5), e176. https://www.jmir.org/2017/5/e176/

Klonsky ED & Glenn CR. (2008). Resisting Urges to Self-Injure. Behav Cogn Psychother, 36 (2), 211–220. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5841247/

McPin Foundation (2018). Research Priorities for Children and Young People’s Mental Health: Interventions and Services. London: McPin Foundation. http://mcpin.org/get-involved/youngpeoplemhq/

NHS Digital. (2018). Mental Health of Children and Young People in England, 2017: https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-of-children-and-young-people-in-england/2017/2017

Stallard P, Porter J & Grist R. (2016). Safety, Acceptability, and Use of a Smartphone App, BlueIce, for Young People Who Self-Harm: Protocol for an Open Phase I Trial. JMIR Research Protocols, 5 (4), Oct-Dec. http://www.researchprotocols.org/2016/4/e217/

Townsend E, Wadman R, Sayal K, Armstrong M, Harroe C, Majumder P, Vostanis P & Clarke D. (2016). Uncovering key patterns in self-harm in adolescents: Sequence analysis using the Card Sort Task for Self-harm (CaTS). Journal of Affective Disorders, 206, 161-168. https://www.sciencedirect.com/science/article/pii/S0165032716303585

Turner BJ, Baglole JS, Chapman AL & Gratz KL (2018). Experiencing and Resisting Nonsuicidal Self-injury Thoughts and Urges in Everyday Life. Suicide and Life-Threatening Behaviour [ePub ahead of print]. https://onlinelibrary.wiley.com/doi/full/10.1111/sltb.12510

Ystgaard M, Arensman E, Hawton K, Madge N, van Heeringen K, Hewitt A, de Wilde EJ, De Leo D & Fekete S. (2009). Deliberate self-harm in adolescents: Comparison between those who receive help following self-harm and those who do not. Journal of Adolescence, 32, 875-891. https://www.sciencedirect.com/science/article/pii/S0140197108001176?via%3Dihub

Photo credits

• Photo by Justin Main on Unsplash
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• Photo by David Kennedy on Unsplash