Digital Interventions and Self-harm Prevention

In this In Conversation podcast, we are joined by Dr. Bethany Cliffe, a research fellow at the University of Westminster. Beth’s research interests include self-harm, suicide prevention, and digital health.

The focus of this podcast will be on self-harm and technology.

Discussion points include:

• The prevalence of self-harm in children and young people and which groups are more at risk than others.
• The kind of support that is typically accessed by children and young people who self-harm.
• What the evidence tells us about interventions for self-harm.
• Insight into the BlueIce app – a prescribed evidence-based app – including how it was developed.
• The effectiveness of BlueIce and how it is being assessed.

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Dr. Bethany Cliffe is a research fellow at the University of Westminster. She is a qualitative researcher with an interest in self-harm, suicide prevention and digital interventions.

Transcript

[00:00:10.000] Jo Carlowe: Hello, welcome to the In Conversation podcast series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Jo Carlowe, a Freelance Journalist with a specialism in psychology. Today, I’m interviewing Dr. Bethany Cliffe, Research Fellow at the University of Westminster. Bethany has an interest in self-harm and suicide prevention and digital health. Self-harm and technology will be the focus of today’s podcast.

If you’re a fan of our In Conversation series, please subscribe on your preferred streaming platform, let us know how we did, with a rating or review, and do share with friends and colleagues.

Beth, welcome. Thanks for joining me. Can you start with a brief introduction about who you are and what you do?

[00:00:52.392] Dr. Bethany Cliffe: Of course. So, firstly, thank you so much for speaking with me today. So, it’s a real pleasure. But as you said, I am Dr. Bethany Cliffe, but it’s a bit of a mouthful, so Beth is fine, and I’m currently a Research Fellow at the University of Westminster, working on a project, evaluating the use of surveillance technologies for suicide prevention in public places.

I started working in research in around 2017. My first role was working with Professor Paul Stallard over at the University of Bath, and we were looking at a digital intervention called ‘Sleepio’, for insomnia in young people and that, sort of, kickstarted my interest in how tech can fit in with mental health. And I realised quickly there’s lots of mental health apps available, but the evidence base was quite thin and so, I got quite passionate about thinking about if young people are wanting to access these mental health apps, then we at least need to make sure there’s ones out there that they can trust. So, I then went straight from that into my PhD, which was looking at self-harm in university students and how tech can fit in with that. I’ve done a few other, kind of, tech in mental health roles since and now, here I am.

[00:01:54.378] Jo Carlowe: Brilliant, thank you. We’ll focus more specifically on tech and mental health in a moment, but just to provide some context, Beth, how prevalent is self-harm in children and young people and are some groups more at risk than others?

[00:02:10.652] Dr. Bethany Cliffe: A huge issue with self-harm is it’s quite a hidden problem. A lot of data around prevalence comes from things like hospital admissions or people presenting to primary care, but often, young people don’t actually present to these places. So, it’s quite tricky to get accurate statistics about prevalence. So, it’s quite underreported, but bearing that in mind, I think around 20% of young people are likely to self-harm, but yeah, I would say take that with a pinch of salt.

And yeah, some people are definitely more at risk than others. There’s a whole range of risk factors that could mean someone’s more vulnerable to self-harm and that could be things like having experienced abuse as a child, having a difficult home life, difficult family life, lots of conflict. Things like experiencing greater adversity through being part of a minoritised group, having other mental health difficulties, like depression or eating disorders, for example, and being bullied or socially isolated. I mean, there’s lots of different factors that can increase someone’s morbidity, and thinking about intersectionality and things like that, as well.

It’s really important to challenge the stereotypes around self-harm. I think there’s this idea that self-harm is something that happens exclusively to young white women, when in reality, it can affect people of any background. So, we’ve got to not make assumptions about who may or may not be self-harming, whilst also, kind of, bearing in mind that there are certain risk factors that are worth looking out for.

[00:03:29.588] Jo Carlowe: Yeah, great, that’s very helpful. What kind of support will a young person who is self-harming typically access?

[00:03:36.829] Dr. Bethany Cliffe: It varies, really. I mean, self-harm varies so much from person-to-person in terms of what it looks like, how self-harm is understood, as well as the, kind of, help-seeking behaviours they would have, as well. And lots of young people who self-harm would prefer to speak to a friend or a family member, that, kind of, more close contact, whereas others wouldn’t want to confide in them what they feel is guilt or shame around their self-harm, so they prefer to talk to a professional, whose, kind of, job it is to deal with it, I suppose, and they can go through CAMHS.

There’s also a lot of pressure and responsibility on schools when it comes to self-harm, ‘cause young people spend a lot of their time there and schools, of course, do the very, very best with what they have, but with know they’re quite under-resourced, so that can be quite challenging. There’s also the more informal types of support, so things like peer support, which a lot of young people who struggle to access those, kind of, professional services, or if they’ve had a bad experience with seeking support, then, yeah, they can access those more, kind of, informal peer spaces. And I think they can find this quite validating, being part of those communities where people know how they feel and they can, kind of, understand what that person’s going thorough. But there are, of course, also risks of peer support, like being triggered and hearing other people’s stories, learning new ways of self-harm. So, it’s important to be mindful of that.

It’s also important to acknowledge that whilst there are different types of support available, young people can face quite a few barriers in accessing them, with, you know, self-harm being quite stigmatised and being quite hard to talk about and, you know, that, kind of, guilt and shame. So, whilst there is lots of support available, we need to make it easier for people to access it and we need to make it easier for people to disclose self-harm and will get a really supportive response when they do.

[00:05:07.468] Jo Carlowe: What does the evidence tell us about interventions for self-harm? What works and what doesn’t work?

[00:05:14.053] Dr. Bethany Cliffe: Unfortunately, with self-harm, the evidence base is quite shaky. There was a Cochrane Review done a couple of years ago and they looked at a variety of different interventions, like cognitive behavioural therapy, dialectical behaviour therapy, family therapy, etc. And quite surprisingly, and disappointingly, as well, they didn’t really find much evidence of effect of any of the interventions they looked at, which was, yeah, very surprising. I think DBT came out on top, if you will, in terms of there was some evidence of that, but the research they were drawn from, they said was quite poor quality, so it was hard to draw any firm conclusions, really.

But things that typically work well with interventions are things like helping to develop coping skills, helping develop strategies for regulating emotions without leading to self-harm. Things like problem solving, communication skills, thought challenging, that sort of thing. One that works really well is taking a strength-based approach. I think so often with young people who self-harm, there’s a lot of emphasis on their deficits and what they’re lacking, but I think what works really well is working with that young person to think about what strengths they have. And we know self-harm is a difficult thing to live with, so they do have strength. I think helping them to realise that and acknowledge that is a really helpful place to start.

But I think, as well, one of the key issues that I’m interested in at the moment, that’s a bit of a new body of work, I suppose, is that – is starting to, kind of, question this idea of what an intervention that is effective looks like or how we define or measure that. And I think typically, there’s this focus on an intervention being effective if it stops self-harm or reduces self-harm, which is, of course, important. We don’t want people to be self-harming. But when we speak to young people about what improvement or recovery looks like for them, they don’t often mention self-harm. Instead, they’ll say things like, “I want to be able to spend time with my friends.” “I want to do things that I enjoy.” “I want to be able to look after myself and practice self-care.” “I want to live a fulfilled and meaningful life.”

And I think that it’s really important to acknowledge that what’s important for a young person might not be stopping or reducing self-harm just yet, but instead helping them cope with the distress that’s causing the self-harm in the first place. And so, when we’re thinking about what interventions work and doesn’t – and don’t work, I think it’s important to maybe take a broader approach and not just think about whether that person has stopped self-harming, but if they’re feeling better and if they’re living a more fulfilled life.

[00:07:29.976] Jo Carlowe: Let’s dig a bit into the use of technology and health, and specifically, we’re going to look at BlueIce. So, this is a prescribed evidence-based app. Can you describe the app? Who is it for, what does it look like and what does it do?

[00:07:46.138] Dr. Bethany Cliffe: BlueIce is now actually freely available for anybody to download on Apple on Android app stores, and it’s, essentially, a digital toolbox that was developed with and for young people. So, it starts off with a mood diary, where you can say if you’re feeling – if you’re having a good day, if you’re having a bad day, and you can add notes as to why you’re feeling that way. And that, kind of, maps onto a calendar. So, you can track your mood over time. You can try and identify possible triggers and things that mean that you’re having a better day, yeah, to try and help understand your mood better and, also, to try and get some perspective of I do actually have some good days. And then, from that, if the person puts that they’re having a bad day, it then routes them through to the ‘Mood Lifting’ section, which has lots of different suggestions in it of things to try and pick you back up when you’re having a bad day.

And so, it comes preloaded with some suggestions, but it’s personalisable, so you can delete those and add your own. And there’s different sections, like ‘Getting Active’, so, kind of, physical activities or hobbies, that kind of thing. There’s a ‘Music’ section, so you can have playlists or particular songs. There’s a ‘Good Time’ section, so you can upload photos or memes, inspirational quotes, things like that. There’s ‘Guided Meditation’, there’s ‘Thought Challenging’. So, there’s lots going on in there, and then, once they’re, kind of, going through that section, if the person is still feeling down or feeling like they might self-harm, the app then routes them through to a ‘Contact’ section, where they can import contacts of friends or family members they feel they’d be able to call in a difficult moment. And it also comes preloaded with Childline and 111, as well.

So, it’s quite a comprehensive app that’s got lots in there and as I said, it’s – it was initially developed for adolescents, but my PhD was looking at it with university students, as well. So, I think it is – you know, it does have a broader application than just young people.

[00:09:38.858] Jo Carlowe: Hmmm hmm. So, starting from what kind of age would it be appropriate, as young as 11 or…?

[00:09:43.397] Dr. Bethany Cliffe: Yeah, so what’s interesting with BlueIce is there’s nothing in the app that explicitly mentions self-harm. So, it’s quite suitable for any age, really, as long as, you know, parents are happy for children to be using it. So, yeah, around 11 or 12.

[00:09:57.200] Jo Carlowe: Hmmm hmm, and how did it come about and how was it developed and why is it called BlueIce?

[00:10:04.448] Dr. Bethany Cliffe: Hmmm. So, it was developed with young people and Clinicians, and it came about through a series of workshops with young people. It was quite an iterative process. They had lots of ideas about what to include in the app and they also came up with the name. So, ‘Blue’ is, you know, feeling blue, feeling down, and ‘Ice’ stands for in case of emergency. So, that was their idea.

[00:10:25.622] Jo Carlowe: Yeah, makes perfect sense. And you said it’s downloadable. Can everybody access it?

[00:10:33.231] Dr. Bethany Cliffe: Yeah, yeah. So, it’s completely free to access. It’s available on Apple and Android. So, yeah, anybody can download it if they wish to.

[00:10:40.310] Jo Carlowe: And how effective is BlueIce in terms of – well, it’s interesting, my question to you was going to be in terms of self-harm reduction, but you’ve actually said that isn’t always a primary focus for young people. It’s about improving mood, quality of life and so on. But how effective is it and how is it being assessed?

[00:11:03.457] Dr. Bethany Cliffe: So, there was an initial evaluation done of BlueIce back in 2018 and the findings for that were really positive. So, at the end of, I think it was a 12-week study period, around three quarters of the participants had either stopped self-harming or had reduced self-harming, and there were also significant improvements in wellbeing. So, scores on things like anxiety and depression scales were much, much better, and there’s also good acceptability, as well. So, I think it was around 90% of participants wanted to keep using the app after the study.

So, that was really positive, and there’s been a more recent RCT done now as well, and the paper for that has literally just been accepted. So, hopefully, that will be out soon. But that RCT also found that using that app reduced the need for hospital admissions, which was great, and overall, they’ve, basically, shown that the app is safe. You know, there’s no detrimental effects of it. So, even for the people who don’t necessarily find it helpful, it’s not going to cause any harm.

And then, my PhD was looking at it with university students and yeah, I didn’t focus so much on reducing self-harm. I looked at, kind of, urges to self-harm and I did find that using the app has significantly reduced those thoughts of self-harm. So, people were feeling the need to self-harm less. I also found significant improvements in anxiety and depression, but I also looked at coping, which was one of my key things I wanted to focus on, because that’s what students I’ve spoken to had said what they really wanted out of an intervention was feeling like they could cope better. And so, I found that after using the app, they did have an increasing coping self-efficacy. So, they were more confident in their abilities to cope.

And what was really interesting is we also saw a shift from the more negative coping styles, like avoidant coping, towards more positive ones, like reappraisal. So, yeah, there was really positive, kind of, quantitative results, and the qualitative feedback that we get from the app, typically, is things like “It helps to re-shift my focus away from self-harm whilst doing something that I enjoy, which helps to, kind of, regulate emotions.” And it’s a good way of learning coping strategies that can then be used outside of the app. So, one participant said, for example, that they were in a situation where they didn’t have their phone on them and they were feeling like they had the urge to self-harm, and then they were able to remember the strategies that they’d identified within the app and use those, which was really nice to hear.

So, yeah, lots of positive feedback, but of course, you know, it’s not for everybody. For some people an app isn’t enough and they prefer that, kind of, professional support to get to the root of the problem. So, it’s not for everybody, but it’s helpful to offer for some. And also, what was really interesting was that they said participants feedback typically was that whilst it’s helpful for self-harm, yes, they also said that because there’s nothing within the app that explicitly references self-harm, they also thought it could be helpful for people who just want to check in with their mood, or people who are maybe struggling with exam stress or a mood disorder, for example. So, it seems that there’s quite a broad application of it, really. So, I’d be interested to see how it gets used in the future.

[00:14:03.232] Jo Carlowe: Yeah, and presumably, it could be used in a complementary way with professional uses. It’s not one or the other, presumably?

[00:14:10.939] Dr. Bethany Cliffe: Yeah, absolutely and we did have that feedback, as well. So, people said that it was helpful to keep track of how they’ve been feeling throughout the week, so when they had their next session, they could look back and say, “Oh, actually,” you know, “this happened last week and now I’m feeling this way.” Because they said that often, when they got to their session, all they could think about was how they were feeling that day, whereas it had helped them look at the whole week and have that greater, kind of, reflection on how their mood had been fluctuating and what caused that. So, yeah, they said it worked quite well as a, kind of, adjunct to that counselling, as well.

[00:14:41.674] Jo Carlowe: And is it well-known? I mean, is – and how – is it widely used, is it?

[00:14:45.977] Dr. Bethany Cliffe: Not yet, no, because up until this RCT, it had only been available on a prescription basis through certain CAMHS. But now that the RCT findings are out, or nearly out, and we can say with, you know, quite a lot of certainty, that it is safe [inaudible – 15:28] has made it widely available and so, yeah, now anybody can download it, but it’s still early days. It was only released a couple of weeks ago, I think, so…

[00:15:08.111] Jo Carlowe: Hmmm hmm. Okay, that’s great. It’s a really helpful overview. Beth, what else is in the pipeline for you that you would like to share with us?

[00:15:16.350] Dr. Bethany Cliffe: At the moment, I’m working on a really interesting project with wonderful colleagues at University of Westminster, Middlesex, Glasgow, Canterbury Christ Church, on a three-year NIHR funded project. And we’re essentially looking at surveillance technologies that are used in public places for suicide prevention, so things like smart CCTV or motion activated technology, things like that. And we’re looking at whether they can be effective for identifying somebody at risk of suicide and then getting that response initiated.

And then, I’m also looking – with the qualitative work, we’re looking at whether they’re also, kind of, acceptable and what the ethics are around them, which is really interesting. And we’re hoping to put some guidance together for people who might be considering implementing these technologies. So, if people are going to be using them, then we’re going to try and say how to use them in a way that’s more helpful than harmful. So, hopefully, we’ll have some real practical implications from this, but it’s early days.

[00:16:13.768] Jo Carlowe: Hmmm, it sounds fascinating. Finally, Beth, what is your take home message for our listeners?

[00:16:20.362] Dr. Bethany Cliffe: So, I think the key thing that I really always am quite enthusiastic to get across is that a big responsibility if somebody has disclosed self-harm to us and how we manage that. And I think there’s so much emphasis around, you know, if you’re struggling, you need to speak up, you need to ask for help. But one of the key things that prevents that is people being scared of what the response might be and people having these horror stories of having spoken up and it not having gone very well.

And so, I think there’s that responsibility on us to make sure that if somebody does disclose to us, then we’re managing that well, and making sure that we’re, you know, not being judgmental, we’re not making any assumptions about why that person’s self-harming or what their self-harm might look like. But instead, giving them the time and space to really tell their story and just being really supportive of that. And I think what’s really important is working with that young person to find out what they need, or as I said earlier, you know, helping them realise they have strengths and building on those. Building on the skills they already have. Helping them to get whatever it is that they need, really. It’s all so crucial for helping young people on their path to managing self-harm, which is no easy thing to do.

[00:17:25.952] Jo Carlowe: Excellent. Beth, thank you ever so much. For more details on Dr. Bethany Cliffe, please visit the ACAMH website, www.acamh.org, and Twitter @ACAMH. ACAMH is spelt A-C-A-M-H, and don’t forget to follow us on your preferred streaming platform, let us know if you enjoy the podcast, with a rating or review, and do share with friends and colleagues.