In 1841, the British epidemiologist William Farr called for an end to reporting of “dramatic tales of suicide” (Gunnell & Biddle, 2020), a guideline echoed by today’s recommendations for responsible reporting of suicide from the World Health Organization (WHO, 2008). These guidelines are supported by evidence that certain types of reporting about suicide have been linked to an increase in suicide deaths (WHO, 2017) thought to be the result of the imitation of suicidal behaviour by others.

Young people are suggested to be particularly affected (Gould, Jamieson, & Romer, 2003) and globally, suicide is the second leading cause of death in young people aged 10-24 (WHO, 2014). However, despite the use of social media platforms by young people to talk about suicide, until the development of the #chatsafe guidelines there were no specific guidelines for talking about suicide safely on social media for young people.

The #chatsafe guidelines were developed through a Delphi method in a previous study by the authors (Robinson, et al., 2018). The current study outlines in more detail how young people were involved in the co-design of a campaign using the #chatsafe guidelines.

Originally developed in Australian, the #chatsafe guidelines have now been adapted for use in the UK (see the UK #chatsafe guidelines) and in a number of other international countries.

Methods

The #chatsafe campaign content and delivery methods were informed by a set of 11 co-design workshops that took place across 4 Australian states between December 2017 – May 2019.

In total, 134 young people aged 16 – 25 years were involved in the workshops. Experience of suicidal ideation or behaviour was not an inclusion or exclusion criteria, however 78.6% of young people reported suicidal ideation and 85.5% reported supporting a friend experience suicidal ideation.

The workshops followed the same general but flexible procedure: warm-up, co-design activities, evaluation and cool-down. The warm-up section included a basic introduction activity, warm-up activity and collaborative development of ‘ground rules’. The co-design actives themselves varied depending on the focal element of the workshop (defined below) but through the process of co-design learnings from one workshop iteratively informed the schedule of the next. Small group work and creative tools to facilitate design activities such as the scenes storytelling software were used, with feedback obtained using score cards. The sessions closed with an unrelated activity and time was given to allow an informal opportunity for young people to “share their experiences, ask questions, and provide feedback” with facilitators remaining in the room to allow sharing in private.

Different elements of the co-design workshops

• Define – To map the ways in which young people used social media platforms to talk about suicide and to determine how young people wanted to see the #chatsafe guidelines implemented via the campaign
• Design – To develop a social media campaign strategy that incorporated young people’s perspectives and addressed their wants and needs. This included identifying campaign directions, themes and messages, and selecting content types for message delivery.
• User-testing – To test and obtain feedback on design prototypes for inclusion in the final campaign.

Importantly, to ensure safety during each workshop collaborative, ‘Wellness Plans’ were developed for each young person including key contact and medical details as well as bespoke coping strategies for each young person. The plans could be enacted if a young person became distressed during a workshop. In addition, support from a psychologist was available during and after each workshop.

At the end of each workshop, young people were asked to complete a 10-minute quantitative survey, focusing on demographics, perceived benefits gained from involvement, and workshop acceptability and safety.

A few days after each workshop, facilitators identified the key recommendations generated from each workshop, the notes from which were later analysed by the research team through a process of thematic analysis (Braun & Clarke, 2006). The analysis findings were then checked by one of the project youth advisors, and by the designers and producers, which the authors say increases the “trustworthiness of the findings”.

Results

Key results from the quantitative survey with young people included that the majority of those involved with the campaign:

• Had experienced a mental health problem (84%), suicidal ideation (78.6%), and had supported a friend experiencing a mental health problem (96.9%) and/or suicidal ideation (85.5%)
• Had been exposed to suicide-related content on social media (88.5%)
• Perceived the workshops as enjoyable (96.2%), helpful (85.5%), and safe (88.5%), gaining new skills (74.8%) whilst improving interpersonal (56.5%) and communication (67.9%) skills
• Felt better equipped to emotionally support (54.2%) and educate (62.6%) peers as a result of attending the workshops
• Felt they had gained somewhat improved suicide literacy skills in understanding how to communicate about suicide generally (57.3%), safely (68.7%) and understand how to identify and support others online who may be at risk of suicide (61.1%).

However, importantly 8 young people did report that the workshops made them feel suicidal and 6 young people were unsure about this.

Campaign content

The key themes emerging from the qualitative analysis shaped the 12-week social media campaign content and delivery. In general, young people wanted the content included to:

• reflect agency and self-care,
• involve stories of recovery and hope,
• encourage active support and self-awareness,
• and include multicultural perspectives/diversity/visibility.

Campaign delivery

In terms of delivery of the campaign young people wanted:

• real people delivering content,
• use of animation to allow cultural protection and prevent over-identification,
• accessible delivery,
• and the campaign to be embedded in existing social media platforms.

The seven campaign directions prioritised in light of the qualitative analysis were:

1. General tips and introduction to #chatsafe
2. Responding to someone who might be suicidal
3. What does a safe post look like?
4. Before you post, pause and reflect
5. Remembering someone who has died by suicide
6. Dealing with harmful content

Conclusions

The authors concluded that:

The adapted co-design process was found to be feasible, safe, and acceptable and highlights the importance of modifying methodology when undertaking co-design with young people in the suicide prevention arena.

Further, workshop attendance increased suicide literacy among young people.

Strengths and limitations

One of the main strengths of this study was the quality of the reporting of involvement, as per the GRIPP2 guidelines. For example, detailed descriptions of how and which young people were involved in addition to discussions on how involvement influenced the study.

Another strength was the elements of good practice for involvement of young people in research. Remuneration, consideration of an appropriate workshop venue, setting of ground rules, debrief sessions, use of varied and interactive workshop activities, and provision of skilled and trained facilitators are key elements of practice outlined by INVOLVE (INVOLVE, 2019).  Furthermore, the workshop was highly tailored to young people from Aboriginal and Torres Strait Islander backgrounds, and the inclusion of ‘wellness plans’ meant that the wellbeing of young people was considered.

Although one young person was involved in reviewing the qualitative data, it would have been even better if more young people could have been supported to be involved in the qualitative data analysis process. It would be interesting to see any differences in qualitative analysis emerge if young people were involved in this process; would they have identified different themes, for example. The richness of the qualitative dataset could be further enhanced by conducting qualitative interviews with the young people involved.

As stated by the authors, another limitation is that the recruitment method, primarily through youth advocacy groups in metropolitan Australia, which may have meant people involved had “higher levels of mental health literacy and access to health services” than the general population. Therefore, the campaign may not be inclusive of the mental health literacy and service needs of all young people.

An evaluation of the co-design process was not conducted, but a trial is underway testing the reach and impact of the social media campaign.

Implications for practice

The #chatsafe research sets the precedent for continued research on using social media to communicate safely about suicide and shows that when involvement is appropriately adapted it can be done safely. Involvement of young people is key to enhancing the relevance and reach of such research studies. In particular, the flexible informal workshop structure and considerations to safely tailor sessions to different groups are important aspects of this study to apply to future involvement work with people in underrepresented groups. The results of the thematic analysis will also be useful starting point for other campaigns in this area, however it is important to conduct specific involvement work for specific campaigns.

Reflecting on my own use of social media to discuss lived experience of mental health problems, I have found looking at reporting guidelines helpful to guide my own posting and consumption of content on social media. Whilst helpful, we need to better capture the nuances of conversations on these dynamic platforms. The difficulty of managing your own mental health whilst wanting to be able to safely support others was strongly emphasised by young people, and is a feeling I know all too well.

Despite our historical understanding of risks of irresponsible reporting it is important now more than ever to consider this knowledge within today’s landscape of social media communication.

Statement of interests

Zoë is part of the coordination team for the UKRI mental health research networks and is based at the McPin Foundation, a mental health research charity that exists to transform mental health research by putting the lived-experience of people affected by mental health problems at the heart of research methods and the research agenda.

Links

Primary paper

Thorn, P., Hill, N.T.M., Lamblin, M., Teh, Z., Battersby-Coulter, R. … Robinson, J. (2020). Co-designing a suicide prevention social media campaign with young people: The #chatsafe project. Journal of Medical Internet Research.

#chatsafe guidelines

The original Australian #chatsafe guidelines have now been made available for people in the UK and a range of other international countries.

Other references

Braun, V. & Clarke, V. (2006). Using thematic analysis in Psychology. Qualitative Research in Psychology.

Gould, M., Jamieson, P. & Romer, D. (2003). Media contagion and suicide among the young. American Behavioural Scientist.

Gunnell, D. & Biddle, L. (2020). Suicide and the media: reporting could cost lives. The British Medical Journal.

Robinson, J., Hill, N.T.M., Thorn, P., Battersby, R., Teh, Z. … Skehan, J. (2018). The #chatsafe project. Developing guidelines to help young people communicate safely about suicide on social media: A Delphi study. Plos One.

Staniszewska, S., Brett, J., Simera, I., Seers, K., Mockford, C. … Tysall, C. (2017). GRIPP2 reporting checklists: tools to improve reporting of patient and public involvement in research. The British Medical Journal.

World Health Organisation (2008). Preventing suicide: A resource for media professionals.

World Health Organisation (2017). Preventing suicide: a resource for media professionals – update 2017.

Photo credits

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