Web-based Interventions

for Young People who

Self-Harm
Bee Team
Isabella Nina Kristine B. Manuel - Philippines
Kyung Hyun Lee - South Korea
Caoimhe McWilliams - UK
Tiara Ti Gittens - Barbados
PICO Question

Among young people aged 12-18 engaging in self-harm behaviours,

does implementing online support groups related to self-harm
reduce frequency and severity of self-harm by 20% and improve
well-being over the course of three months compared to those who
do not access this program?
PICO Question

Young People [12-18]; Who self-harm [self-harm is defined using Hawtons

P:
(2003) definition as intentional self-injurious behaviour regardless of suicidal
motivation];
I: Implementing online support groups

C: Contextually grounded self-harm treatment modality

O: Decrease in frequency and severity of self-harm (by 20%) [Self-Harm

Inventory]; increase in well-being (decrease in depressive symptoms or
improved affect regulation)
 Background & Significance
What is self-harm?
Definition:

Deliberate self-injurious behaviour regardless of motivation or suicidal intent.

(Hawton et al 2003)

Major depressive disorder is the most common disorder, present in 35% of suicides.
(Wilkinson et al 2011)

Klonksy (2011), Mars et al (2014), Bergen et al (2012).

 Background & Significance

What are the risks associated with self-harm? Why is it a concern?

Heightened risk of mental illness, suicide, psychological difficulties, poor

educational and vocational outcomes and premature mortality due to other
causes
Globally: second leading cause of adolescent death in Europe and South-East Asia

WHO (2015)
Background & Significance: Adolescents

Self-injurious behaviour peaks in adolescence, with average onset between

12-14 years of age
Only 33-50% of adolescents who self-harm seek help for this behaviour
Of the small proportion who do seek help, the majority access informal sources,
including online resources as a primary step.
The Internet is a pervasive presence in young peoples lives: 100% of 12-14
year olds in the UK accessed the Internet regularly.
Internet use increased globally by 566.4% between 2000-2012

Rowe et al (2014); WIP (2009); Jacobson & Gould (2007); Internet World Stats (2012)
Background & Significance: Causes?

Biological Cultural Epidemiological

Psychopathology Stigma and taboo More common in
(depression, anxiety, Contagion? females than in males
psychosis) Intercultural Exposure to trauma
Affect regulation stresses and Persistent bullying
Autism (13x more family conflict Family environment -
likely to self harm) more likely in children
Endorphins released of addicts
can lead to addiction Educational attainment
LGBTQIA+
Green et al (2005), Hawton & James (2005), Kerr et al (2010), Aggarwal et al (2017), Liu & Mustanski (2012),
Jacob et al (2014)
Background & Significance: Prevalence

UK: Estimates range from 7-14%; 22% of 15 year-olds in England reported

ever having self-harmed (Hawton & James 2005, Brooks et al 2015).

Korea: 16~35% (published in academic journal 'abnormal psychology')

Philippines: 46% since 2010 are from the youth; 30% are young adults
aged 20 to 35 years old & 16% are teens aged 10 to 19 years old (NPMCC,
2016)
Background & Significance: Prevalence
Barbados: No data

USA: 24% of 12-17 year olds self-harmed at least once in a 12-month

period (Nock et al 2008)

Europe: 11.5% of adolescents across 7 countries reported self-harming at

least once in 12-months(Madge et al 2008)

Why is it so difficult to attain accurate, consistent numbers?

-Self-reporting; stigma; help-seeking attitudes; taboo in cultures
Search strategies
Databases PubMed PsycInfo CINAHL Cochrane

Search terms (MH "Adolescence+") OR (MH "Young Adult") OR young pe# OR teen#
OR adolescen#
(MH "Self-Injurious Behavior") OR (MH "Injuries, Self-Inflicted") OR self
harm# OR self injur# OR self mutilation OR NSSI OR DSH
(MH "Internet+") OR (MH "Online Services") OR (MH "Telepsychiatry")
OR (MH "Support Groups+") OR (MH "Text Messaging") OR (MH
"Instant Messaging") OR (MH "Bulletin Boards") OR forum* OR message
board# OR app# OR online OR website# OR tumblr OR instagram OR
facebook OR social media OR social network

Filtered Results 2 3 2 1
Search results
Inclusion criteria:
Total: 467 Young people aged 12-18
Filters applied (Language, 2012-2017): 247 Active self-harm [regardless of
By title: 47 suicidal thought]
By abstract: 15 Accessing online support
Removing duplicates: 12 Community-based
By full-text article: 8
Exclusion criteria:
General risks of internet activity
Suicide
A systematic review of the relationship
between internet use, self harm and suicidal
behaviour in young people. The good, the
bad and the unknown. (2017) Marchant et al
LEVEL ONE!!

Summary: Forty six independent studies of varying quality were included. Perceived
influences were: positive for 11 studies; negative for 18 studies; and mixed for 17
students. A relationship between internet use and self harm/suicidal behaviour was
particularly associated with internet addiction, and websites with self harm or
suicide content.
Marchant et al (2017)
-There is significant potential for harm
from online behaviour (normalisation,
triggering, competition, contagion)
but also the potential to exploit its
benefits (crisis support, reduction of
social isolation, delivery of therapy,
outreach) .

-Young people appears to be increasingly

using social media to communicate
distress, particularly to peers.
Lewis & Seko (2016) A Double-Edged Sword: A
Review of Benefits and Risks of Online Nonsuicidal
Self-Injury Activities
+ Mitigation of social isolation - most
frequently cited draw and described
as therapeutic in itself.
+ Disclosure - first step - paradoxical?
+ Curbing urges
+ Total number of posts created and
received in the first two months
associated with lower levels of
distress in the third month
- Normalisation
- Downplaying risks or misinformation
- Cyber bullying
- Hopelessness [cause/effect?]
- Negative attitudes toward recovery
reinforced with repeated access to these
messages
- Sharing evidence of self-harm: One study
found one third compared their wounds to
peers leading to increased severity
Lewis & Seko (2016)
Level V: Systematic Review & Meta-Synthesis

Majority of studies were qualitative, and did not include a control group.

Half of the studies included used an indirect, observational approach.

Inherent risk of bias in these studies, as Internet-users are a self-selecting

population. The majority had not been recruited specifically for these studies.

Quantitative studies evaluated were of better quality overall than qualitative, and
found more negative associations.

Negative aspects could be mitigated by using professional moderation.

 Intervention: For whom & By whom?
~Nurse led intervention~

Whos using online support already?

- Predominantly young people (Arora et al 2015, McCarthy 2010).
- Young people who are the most distressed, suicidal and have less offline
support.
- Initial engagement for most is motivated by seeking information about
self-harm (Lewis & Seko 2016).
- Preference for self -management in some cultures as a major obstacle to
help-seeking for self-harm from clinical perspective
- Internet could be utilised as a proximal step in reaching these young people.
Arora et al (2015), McCarthy (2010), Lewis & Seko (2016), Frost & Casey (2016)
Intervention: Aims 2. Encourage
self-disclosure

1. To reduce stigma,
particularly internalized
3. Provide accurate, validated
and anticipated stigma
information and dispel myths
surrounding self-harm

5. Improve mood
and mood stability 4. Reduce frequency and
severity of self-harm
 Intervention: What?
Online discussion forum, professionally moderated and run by nurses

Interactive discussion amongst peers has been the most frequently studied and
endorsed online intervention.

Nurses will moderate discussion

Combatting and preventing cyber-bullying
Removing triggering imagery (given the generally negative influence studies
have found graphic imagery has on participants, we recommend a full ban on
this)

Based on findings and recommendations from Lewis & Seko (2016), Marchant et al (2017), Daine et al (2013),
Duggan et al (2012), Grist et al (2017), Kendal et al (2017)
 Intervention: What?
Online discussion forum, professionally moderated and run by nurses

Nurses will also engage with the young people by posting on the forum
Facilitate discussions: similar to acting as a facilitator in offline support
groups
Impart information: Sticky thread offering static information dispelling
myths around self-harm, information about seeking help and treatment
options.
Encourage help-seeking
Break down barriers to help-seeking by challenging perceived power
imbalance
Based on findings and recommendations from Lewis & Seko (2016), Marchant et al (2017), Daine et al (2013),
Duggan et al (2012), Grist et al (2017), Kendal et al (2017)
 Intervention: What?
Online discussion forum, professionally moderated and run by nurses

Nurses will offer advice where appropriate

In moderating discussion, nurses will be screening for indicators of crisis and
can intervene to offer targeted advice, or signpost to appropriate services
for further investigation
Private 1-1 Messaging
Shifts
Ensures global coverage
Established times where help will be available
Based on findings and recommendations from Lewis & Seko (2016), Marchant et al (2017), Daine et al (2013),
Duggan et al (2012), Grist et al (2017), Kendal et al (2017)
 Intervention: What?
How do we engage professionals to implement and share
this intervention?
Concern amongst professionals about poor quality information
Addressed via moderation and fact-checking by facilitators
Privacy
Using unique usernames chosen by participants to identify themselves
Posts by users will only be visible to other users

Based on findings and recommendations from Sharkey et al (2011), Bauer et al (2017), Gleeson et al (2014)
 Intervention: What?
How do we engage professionals to implement and share
this intervention?
Education
Many professionals have reservations about engaging with technology they are not familiar with
Concerns have been raised about never being off the clock
Education regarding internet-based activities pervasive in young peoples lives is a key part of
understanding their psychosocial context, as well as giving invaluable insight into their needs.
Assessment
If clinicians are aware of the need to assess online activities in young people who self-harm, they
will now have a viable alternative to replace potentially dangerous activities.

Based on findings and recommendations from Sharkey et al (2011), Bauer et al (2017), Gleeson et al (2014)
 Evaluation and Outcomes

Pre- and post-test measurements through e-mail

3 months and 12 months after registration.

Becks Depression Inventory (BDI-II)

Self-Harm Inventory (SHI).
Internalised Stigma of Mental Illness (ISMI) scale.
The Attitudes Toward Seeking Professional Psychological Help Scale
(ATSPPHS)
Based on findings and recommendations from Griffiths et al (2012)
 Intervention: Cultural Applicability

Philippines: psycho-spiritual intervention (e.g. incorporation of

self-reflection; discussion of concepts on religiosity)

Korea : We use korean language. information on website should be

translated into Korean. We will have a foreign language section available.
Many people are worried about stigma. Website should be anonymous.

Based on findings and recommendations from Arcenas (2011)

Intervention: Cultural Applicability

Barbados: this intervention would be applicable to Barbadian society

because Barbados is a small island and there is always concerns about
anonymity especially among the younger generation. This intervention will
make participants feel safe in terms of disclosing information and
maintaining confidentially.
Limitations
The majority of research is conducted in Western Europe and North America.
Barriers to implementation: professionals attitudes and tech-literacy.
Moderation may cause young people to seek out other communities where
destructive behaviour or triggering imagery is not restricted (Daine et al 2013,
Lewis & Seko 2016).
Most research targets active users - unsure what effect this will have on passive
viewers.
For young people without Internet access, this intervention has very limited
benefit.
Not all countries have the same internet speed
Reflection
Having an easy-to-access intervention for at-risk adolescents from different
nations is very beneficial, especially that it is a global concern.

Amount and quality of research in this area has seen a significant increase in the
last 4-5 years: this is indicative of the scale, significance and growth of online
support.

Peer-to-peer support without professional involvement remains the most

common form, with significant risks and negative influences which could be
mitigated (Lewis & Seko 2016, Marchant et al 2017, Daine et al 2013, Duggan et
al 2012).
 References
1. Hawton K., Hall S., Simkin S., Bale E., Bond A., Codd S. & Stewart A. (2003) Deliberate self-harm in adolescents: a study of characteristics and trends in Oxford, 1990-2000. Journal of Child
Psychology and Psychiatry, and Allied Disciplines 44(8), 1191-1198.
2. Mars B, Heron J, Crane C, et al. Clinical and social outcomes of adolescent self harm: population based birth cohort study. (2014) British Medical Journal (BMJ) 349:g5954
3. Bergen H, Hawton K, Waters K, et al. Premature death after self-harm: a multicentre cohort study. (2012) Lancet 380:156874
4. Klonsky E.D. (2011) Non-suicidal self-injury in United States adults: prevalence, sociodemographics, topography and functions. Psychological Medicine 41(9), 1981-1986.
5. Rowe S.L., French R.S., Henderson C., Ougrin D., Slade M. & Moran P. (2014) Help-seeking behaviour and adolescent self-harm: a systematic review. Australian and New Zealand Journal of
Psychiatry 48(12), 1083-1095.
6. Internet World Stats: Usage and population statistics (2012) World internet usage and population statistics June 2012
7. The World Internet Project 2009, USC Annenberg School Center for the Digital Future.
8. Hawton K. & James A. (2005) Suicide and deliberate self harm in young people. British Medical Journal 16330(7496), 891-894.
9. Jacobson C.M. & Gould M. (2007) The epidemiology and phenomology of non-suicidal self-injurious behaviour among adolescents: a critical review of the literature. Archives of Suicide Research
11(2), 129-147.
10. Daine K., Hawton K., Singaravelu V., Stewart A., Simkin S. & Montgomery P. (2013) The Power of the Web: A Systematic Review of Studies of the Influence of the Internet on Self-Harm and
Suicide in Young People. PLoS One 8(10), e
11. Arcenas, F. (2011). A Psycho-Spiritual Intervention to Deal with Aggression of Adolescents Who Self-Harm. ADDU-SAS Graduate School Research Journal, 8(64-72).
12. Kerr P.L., Muehlenkamp J.J. & Turner J.M. (2010) Nonsuicidal self-injury: a review of current research for family medicine and primary care physicians. Journal of American Board of Family
Medicine 23(2), 240-259.
13. Aggarwal S., Patton G., Reavley N., Sreenivasan S.A. & Berk M. (2017) Youth self-harm in low- and middle-income countries: Systematic review of the risk and protective factors. International
Journal of Social Psychiatry 63(4), 359-375.
14. Liu R.T. & Mustanski B. (2012) Suicidal ideation and self-harm in lesbian, gay, bisexual, and transgender youth. American Journal of Preventative Medicine 42(3), 221-228.
15. Frost M. & Casey L. (2016) Who seeks help online for self-injury? Archives of Suicide Research 20(1), 69-79.
16. Arora V.S., Stuckler D. & McKee M. (2015) Tracking search engine queries for suicide in the United Kingdom, 2004-2013. Public Health 137(), 147-153.
17. McCarthy M.J. (2010) Internet monitoring of suicide risk in the population. Journal of Affective Disorders 122(3), 277-9.
18. Lewis S.P. & Seko Y. (2016) A Double-Edged Sword: A Review of Benefits and Risks of Online Nonsuicidal Self-Injury Activities. Journal of Clinical Psychology 72(3), 249-262
19. Duggan J.M., Heath N.L., Lewis S.P., Baxter A.L. (2012) An Examination of the Scope and Nature of Non-Suicidal Self-Injury Online Activities: Implications for School Mental Health
Professionals. School Mental Health 4(1), 56-67.
20. Kendal S., Kirk S., Elvey R., Catchpole R. & Pryjmachuk S. (2017) How a moderated online discussion forum facilitates support for young people with eating disorders. Health Expectations 20(1),
98-111.
21. Gleeson J.F., Lederman R., Wadley G., Bendall S., McGorry P.D. & Alvarez-Jimenez M. (2014) Safety and privacy outcomes from a moderated online social therapy for young people with
first-episode psychosis. Psychiatry Services 65(4), 546-560.
22. Bauer M., Glenn T., Monteith S., Bauer R., Whybrow P.C., Geddes J. (2017) Ethical perspectives on recommending digital technology for patients with mental illness. International Journal of
Bipolar Disorder 5(1), 6-10.
23. Sharkey S., Jones R., Smithson J., Hewis E., Emmens T., Ford T. & Owens C. (2011) Ethical practice in internet research involving vulnerable people: lessons from a self-harm discussion forum
study (SharpTalk) Journal of Medical Ethics 37(12), 752-758.
24.
Q&A
Thank you!