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Digital resources have the potential to bridge the gaps in mental health services for young people who self-injure. Most research on digital resources for this population has involved observational studies of content in web-based communities or formative studies focused on the design and early evaluation of new interventions. Far less research has sought to understand young people’s experiences with publicly available digital resources or to identify specific components of these resources that are perceived to be of value in their recovery.
This study aimed to understand young people’s experiences with 2 publicly available digital resources for self-injury—a peer support app and web-based factsheets—and to disentangle potential explanatory mechanisms associated with perceived benefits and harms.
Participants were 96 individuals (aged 16-25 years) with nonsuicidal self-injury behavior in the past month, who recently completed a pilot randomized controlled trial designed to assess the efficacy of a peer support app as compared with web-based factsheets to reduce self-injury behavior. The trial showed that participants using the peer support app reported less self-injury behavior relative to those receiving the web-based factsheets over 8 weeks. In this study, we used a conventional approach to content analysis of responses to 2 open-ended questions delivered at the end of the trial with the aims of exploring participants’ overall experiences with these resources and identifying the qualities of these resources that were perceived to be beneficial to or harmful for participants’ recovery.
Overall, participants were more likely to report benefits than harms. Participants who used the peer support app reported more harms than those who received the web-based factsheets. In the open coding phase, clear benefits were also derived from repeated weekly surveys about self-injury. Key benefits across digital resources included enhanced self-knowledge, reduction in self-injury activity, increased outreach or informal conversations, improved attitudes toward therapy, improved mood, and feeling supported and less alone. Key challenges included worsened or unchanged self-injury activity, diminished mood, and increased barriers to outreach. The most prominent benefit derived from the web-based factsheets and weekly surveys was improved self-understanding. However, the way this manifested differed, with factsheets providing insight on why participants engage in self-injury and the function it serves them and surveys making the frequency and severity of participants’ behaviors more apparent. The benefits perceived from using the peer support app were general improvements in mood and feeling less alone.
Findings contribute a nuanced understanding of young people’s experiences with these digital resources and have implications for the optimization of existing platforms and the design of novel resources to support individuals who self-injure.
Nonsuicidal self-injury affects approximately 13% of young adults [
Web-based and mobile digital interventions offer accessible, low-cost, and potentially efficacious ways of bridging the gaps in services for individuals who self-injure and who are not in treatment [
Psychoeducation—an evidence-based intervention focused on increasing a person’s understanding of, and ability to cope with, a condition—is a core component of self-injury prevention and intervention [
In contrast, web-based communities (eg, forums, social media, and message boards) are a category of digital resources that has received a lot of attention. Studies have shown that people share details about their mental health status and symptoms with peers in web-based communities to obtain support, advice, and validation [
A study upon which this paper draws aimed to address these gaps in the literature through a small-scale randomized controlled trial of web-based psychoeducation (in the form of factsheets) and an app-based peer support community [
This study aimed to understand the relationship between unique intervention components and self-injury behaviors, through the analysis of participants’ experiences with, and perceptions of, these 2 publicly available digital resources for self-injury. We asked the following research questions (RQs):
RQ1—What are the perceived benefits and harms of engaging with the peer support app and web-based factsheets?
RQ2—Which features or interactions are perceived to be central to users’ experiences and the benefits and harms derived from use?
In this study, we analyzed open-ended feedback from adolescents and young adults (aged 16-25 years) regarding their experiences with using the peer support app or receiving web-based factsheets following a 2-month, 2-arm, pilot randomized controlled trial. A detailed description of trial procedures is published elsewhere [
The first group of participants was invited to use TalkLife (the
The second group of participants received a series of self-injury
Participants were recruited via the web through self-injury information websites, professional networks, social media outlets (such as Facebook or Twitter), listservs, and the university recruitment system. Potential participants completed a web-based survey to determine eligibility based on the following criteria: individuals aged between 16 and 25 years, with current (within 3 months) and chronic (>6 episodes in the past year) self-injury history were eligible to participate. Exclusion criteria included the following: recent history of psychosis (>2 weeks of institutionalization in the past year) or current suicidality (operationalized as suicidal thoughts or plans). All individuals who completed the eligibility survey received contact information for the National Suicide Prevention Lifeline (NSPL) call center and chat line. Participants who were screened as ineligible were provided with a message thanking them for their willingness to get involved, letting them know that they were ineligible based on their responses, and containing a link to resources on the Cornell Research Program for Self-Injury website and NSPL contact information. Participants who reported elevated suicidal ideation or plan received an additional pop-up message encouraging them to reach out to someone for support, with hyperlinks to the NSPL embedded within the message for easy access. Eligible participants received an email from the research team, providing them with key information about their participation. Those who provided consent via the web were randomly assigned to engage with the peer support app or the web-based factsheets for the study duration. During onboarding, participants received a welcome email containing several videos explaining the expectations per week, how to register on the platform (where applicable), and details about how and when they would receive compensation. In total, participants were eligible to receive US $90 in the form of Amazon gift cards for completion of weekly surveys throughout the 8-week trial and were compensated based on the number of weekly surveys submitted. Participants received US $10 for the week-8 survey, which was the data set used in the present analysis. More details on the trial methodology are published elsewhere [
This study was approved by Cornell University’s institutional review board (approval number 1807008133), with a waiver of parental consent approved for individuals aged 16 to 17 years. All participants provided informed assent or consent before participating in the study activities. Additional questions were built into the web-based assent procedure to ensure that adolescents understood who they could reach out to if they experienced distress (including contact information for the study’s principal investigator [PI] and national crisis resources), what types of activities they would be asked to engage in, and that they had the right to discontinue the study.
The types of data collected as part of this study were also described in detail in the assent and consent form. This included data from activity on the peer support app and survey responses at baseline, during the trial, and at follow-up (which we used in this study). Participants’ privacy and confidentiality were priorities in our study design. As part of the large study, only the research PI and research coordinator had access to information linking participants to their contact information and unique identifier. All identifying information was kept separate from survey and use data in a password-secured computer that was accessible only to the PI and study coordinator. All data presented in this paper were deidentified before analysis. Participant safety was also a priority. All potential participants were provided with a list of mental health resources (mentioned previously) during the eligibility screening. Enrolled participants were provided with these resources at the beginning and end of the study and after each weekly survey.
We used a mixed methods analytical approach in this study. We present quantitative analyses mainly to provide a descriptive overview of our participant sample and a general distribution of our codes. We report on participants’ demographics, mental health history, and previous experiences with mental health–focused apps. Qualitative methods were then used to analyze responses to 2 open-ended prompts aimed at eliciting overall impressions about and experiences with the digital resources after 2 months of engagement. As mentioned previously, although there were 131 participants in the original trial, our sample for the present analysis was limited to participants who responded to at least one of the open-ended questions on the week-8 survey. Complete responses were provided by 73.3% (96/131) of the participants (45/96, 47% of the participants who engaged with the peer support app and 51/96, 53% of the participants who engaged with the factsheets). As the open-ended responses to these questions were meant to solicit general comments about user experience, they were merged at the participant level during open coding.
We used a conventional approach for qualitative content analysis, as described by Hsieh and Shannon [
In total, 96 participants aged between 16 and 25 (mean 20.26, SD 2.51) years provided feedback on their experiences with the peer support app or web-based factsheets after 8 weeks of use. Of the 96 participants, most (n=64, 67%) identified as women, whereas 21 (22%) participants identified as men, 8 (8%) identified as nonbinary, and 3 (3%) identified with other gender identities (transmasculine, 2-spirit, and questioning). Of the 96 participants, most were from North America (n=66, 68%), 13 (14%) were from the United Kingdom, and 17 (18%) were from the European Union.
Participants reported diverse mental health histories. As self-injury commonly co-occurs with other mental health conditions, we assessed for common diagnoses, indicators of lifetime self-injury severity, and traumatic life events through a survey at the beginning of the trial. Of the 96 participants, 70 (73%) reported injuring themselves >50 times in their lifetime, whereas 19 (20%) reported injuring between 21 and 50 times and 7 (7%) reported injuring ≤20 times. Of the 96 participants, 90 (94%) reported having another mental health condition. The 2 most prevalent comorbidities were depression (85/96, 89%) and anxiety (69/96, 72%). Finally, 95% (91/96) of the participants reported at least one other distressing or traumatic life experience (eg, emotional abuse, sexual abuse, physical abuse, death of loved one, or familial divorce).
Participants were asked whether they had engaged with any other digital resources for mental health including apps, web-based communities, or seeking information through other web-based channels. More than half (61/96, 64%) of our sample reported having used other digital resources. Of the 96 participants, 61 (64%) participants reported using web-based communities and 53 (55%) reported using mobile apps for mental health or well-being, when they entered the trial. Of those reporting use, 48% (46/96) and 22% (21/96) of the participants reported sharing or exchanging information about self-injury, respectively. While interacting through these platforms, approximately one-third of the participants reported some degree of anonymity (eg, not using real name or photo; 38/96, 40% for web-based communities and 30/96, 31% for apps). Commonly reported web-based communities were Reddit (25/96, 26%), Discord (8/96, 8%), Facebook Groups (10/96, 10%), and Tumblr (6/96, 6%). Commonly reported apps were Mood path (7/96, 7%), Calm Harm (11/96, 11%), and 7 Cups of Tea (7/96, 7%). On a scale of 1 to 100, participants rated the overall satisfaction with web-based communities (mean score 21.37, SD 26.24) and apps (mean score 20.49, SD 28.61) as quite low.
To understand participants’ experiences with these digital resources, we first examined codes and their general distribution across groups. It became evident in our early open coding that the weekly surveys on self-injury activity, which were received by all participants throughout the trial period, were also perceived to be beneficial in fostering reflection. As self-monitoring is a common feature of digital mental health interventions, we chose to include surveys in our coding of benefits and challenges. Findings are organized in two key sections corresponding to our RQs: (1) perceived benefits and challenges associated with the use of digital resources and (2) specific factors or features influencing experience and acceptability.
Participants identified several ways in which the digital resources affected them and their self-injury behavior over the 2-month period. Benefits included references to how the digital resources were perceived to be helpful in their self-injury self-management and included (1) enhanced self-knowledge, (2) reduction in self-injury activity, (3) increased outreach or informal conversations, (4) improved attitudes toward therapy, (5) improved mood, and (6) feeling supported and less alone. Challenges referred to ways in which the digital resources were less helpful or even harmful to participants’ self-injury self-management. These included experiences of (1) worsened or unchanged self-injury activity, (2) diminished mood, and (3) increased barriers to outreach.
To provide a high-level overview of the distribution of codes within our sample, we performed chi-square analyses comparing the benefits and challenges across participants interacting with the peer support app and factsheets. We found that participants who used the peer support app were less likely to mention benefits (odds ratio 0.41, 95% CI 0.17-0.97;
The most mentioned benefits identified among participants who used the peer support app were improved mood and feeling less alone. Regarding improved mood, participants described that being able to connect with others through the app helped them to better self-regulate and improve their mood. For example, a participant noted the following:
It was really helpful to be able to talk to people online when I was feeling down.
This participant described that in-the-moment use of the app was helpful in managing difficult moods, whereas other participants noted that using the app helped them to get a better sense of how their emotional state shifted over long periods. A participant described that the app helped them “get a better image of my emotions over the last few weeks” (Participant 11). Both in-the-moment mood boosts and developing a deep awareness of emotional patterns were reflected upon as key benefits across participant experiences.
Another commonly mentioned benefit among participants using the app was feeling less alone in their struggles. A sense of connection was derived from interactions with peers on the app and through reading content from peers with shared experiences or characteristics. For example, a participant described the following:
I’ve met some nice people on [the app] and they make me feel less alone.
Many participants attributed feelings of validation and relief to know that they are not alone to their experience on the app. For example, another participant noted the following:
It really helped me to understand there are people who relate to my struggles.
However, not all participants described that their experiences with peers on the app were beneficial. The most common challenges attributed to the use of the peer support app were its impact on participants’ self-injury behavior and worsened mood. Regarding the impact on self-injury behaviors, a participant described that they felt “like my recovery was less likely after spending any significant portion of time on the app” (Participant 14). This participant, and others, described that being exposed to harmful content and peers’ distress made them feel less inclined toward or hopeful about their ability to recover. Other participants described a more agnostic experience with the app and the impact it had on their self-injury. A participant noted the following:
It didn’t feel like [the app] actively hurt anything, but I’ve relapsed during the course of this survey, so I don’t think it helped either.
In addition, despite some participants describing improved mood owing to engaging with the peer support app, a comparable proportion of users commented on how experiences within the app had harmful effects on their mood. Most of these comments were related to the effects of community negativity. For example, a participant wrote the following:
Most times I felt worse after using the app.
Another participant elaborated upon the following idea:
The toxic community on the app had a very negative effect on my time management and mental health.
Although the fact that there are both benefits and harms perceived from app use is consistent with the existing literature on web-based peer support for self-injury, it is interesting to note how nuanced these effects are, with some participants reporting both benefits and harms after a relatively short period of use.
The most common perceived benefits of the web-based factsheets were enhanced self-knowledge, reduction in self-injury behaviors, increased outreach, and improved attitudes toward therapy. When participants described improvements in self-knowledge, they commonly referenced factsheets that helped them to explain why they injured themselves or the way self-injury was related to coping. For example, a participant wrote the following:
Learning about why people self-injure helped me gain focus on my coping methods and how compulsive it has become for me when I’m upset.
Similarly, another participant wrote the following:
I liked understanding why self-harm made me feel better and how to change.
This participant also went on to describe how factsheets about the recovery process and readiness to change self-injury behaviors helped to change their perspective on their existing coping strategies:
I feel a lot more normal in coping with urges and understand my thought process in the precontemplation stage in a new light.
Participants also commented on the relationship between the factsheets and their self-injury behavior. Mostly, these comments were regarding the use of new coping skills during the study and how this helped them to reduce their weekly self-injury frequency. For example, a participant wrote the following:
Some of those tips helped me not to injure myself.
Other participants described how simply having new resources made them feel more capable of stopping injury over time and that this was a catalyst for change. Regarding this aspect, a participant wrote the following:
It’s definitely helped me to take the steps towards stopping self harm for good, as I have new coping mechanisms.
Although most comments on the benefits of the factsheets focused on the materials referencing new coping skills, there were also comments on information about help seeking. Several participants noted that the help-seeking materials focused on how to seek help and improved their attitudes and receptivity toward formal treatment. A participant described the following:
I think the pushes for therapy in this study were well placed, because truly, professionals can help those who are troubled better than they can themselves. I’m looking for therapy at the moment.
Another participant similarly noted that materials motivated them to try treatment:
They’ve also helped me be open to begin online therapy, which I will start tomorrow.
In terms of challenges, only 1 participant described how the psychoeducational factsheets did not support their efforts toward recovery from self-injury. In particular, they wrote that a factsheet describing “how to disclose to others” made them feel discouraged about engaging in further outreach, writing that it “made me feel like I was a burden to the only friend I tell about myself injury” (Participant 55). Although most participants described positive experiences with factsheets, this finding underscores the potential harms that come from delivering even well-intentioned materials through a format that lacks context and does not easily facilitate direct paths for follow-up and clarification.
Although we did not set out to explore the survey as a catalyst for benefits and challenges, many participants made explicit reference to the role the weekly survey played in their experience with digital resources. Given the extensive literature on the value of self-monitoring [
I liked [the] survey because it gave me an idea of where I was at by the end of every week and allowed me to reflect on my behavior.
Another participant described that the surveys made some of their behavioral patterns more salient:
I liked this survey because it opened my own eyes to some behaviors I hadn’t originally recognized.
In some cases, this enhanced self-awareness motivated participants to make changes to stop or reduce their self-injury behavior. Some participants described a mental shift in how they thought about their self-injury frequency or severity. For example, a participant wrote the following:
The survey helped me pinpoint what could be holding me back from letting go of my addiction to cutting. I felt like I didn’t need to cut as much as normal during this study.
Other participants described that the surveys made them realize that change was needed. For example, a participant wrote the following:
Answering the “how often have you been self harming this week” was very helpful in getting me to realize that I needed to cut back on self harming and/or stop altogether.
Similarly, participants felt empowered to make changes by this newfound awareness. A participant described the following:
The questionnaire is very insightful. I found myself asking questions that get me out of complacency. I gotta start making moves for myself.
Participant 20 wrote that the survey helped them “to reflect on my behaviours and seek active steps and resources to challenge and positively change my behaviours over time.”
Several participants also mentioned improved attitudes toward therapy because of the continuous reflection on the frequency of their self-injury behavior that these surveys provided. For example, a participant wrote the following:
It definitely opened my eyes to see how much I probably need to be in counseling. Having the same questions repeated helped me see how I was growing as well as how I am being held back.
Similar sentiments were evident in another participant’s reflection:
I have never tried therapy, but have contemplated it for a while. These surveys have made me feel, more so than ever, that I should at least try to take the first step.
Although most comments related to the survey were focused on benefits, several participants noted that the survey may have worsened their mood. A participant wrote the following:
I felt somewhat depressed when I answered your questions, but I was okay. It just reminded me of all the things that happened.
Notably, this participant reported that they had seen improvements in their self-injury leading up to the study; therefore, the weekly reflections on self-injury activity may not have been as helpful for them at this point in their recovery.
In the next section, we delve more deeply into the specific features or interactions that contributed to the benefits and challenges described previously. We present participant quotes in tables and elaborate on particularly novel findings in text.
Features associated with peer support benefits.
Features | Quotes |
Interactions with supportive peers | “I felt fairly supported by responses to any posts or comments I made. I liked the feature where you could react in several different ways alongside commenting, as this was more accessible and the combination helped more people to show support to each other.” [Participant 20] |
Sense of shared experience | “Some of the people would comment on my posts and tell me their stories similar to what I would be talking about. Knowing that there are people older than me that understand what I’m going thru really helps and then knowing how their life changed even with the same past also made me feel supported.” [Participant 32] |
Space for venting | “Shouting into the void is therapeutic in itself.” [Participant 34] |
Immediacy of support | “The fact that there’s almost always a quick response to a post and the responses in general being kind and wholesome added to that feeling of being supported.” [Participant 78] |
Anonymity | “It was nice to vent anonymously.” [Participant 36] |
Reduced stigma | “Being able to interact with a community of fellow self-harmers without fear of being judged proved itself beneficial to be.” [Participant 40] |
Provision of support | “I liked being able to help other people with their problems.” [Participant 39] |
Features associated with peer support challenges.
Features | Quotes |
Community negativity | “It made me uncomfortable and felt like an echo chamber of negativity along with people giving instructions on how to cut the ‘right’ way.” [Participant 44] |
Interactions with unsupportive peers | “Many of the users on the app made the experience less enjoyable.” [Participant 74] |
Perceived inauthenticity of other posters | “Everything feels completely impersonal, and the times I was in crisis and needed help I only really got platitudes in response.” [Participant 63] |
Exposure to triggering content | “It can be a very triggering app, yes there are nice people on it that just want to talk but it upset me reading all these upsetting posts.” [Participant 58] |
Preference for therapy or in-person support | “I feel like in person connection is more effective than anything online can be.” [Participant 33] |
Perceived difficulty in intervening | “It did make me feel less alone but it was not worth having to read through all the other stuff people have going on, I don’t know these people so it makes me sad that they feel like that and there’s not a lot I can do.” [Participant 58] |
References to specific factsheets.
Features | Quotes |
Coping strategies | “Learning about why people self injure helped me gain focus on my coping methods and how compulsive it has become for me when I’m upset.” [Participant 16] |
Pain offset relief | “Understanding that it is a pain offset not onset that actually helps me feel better.” [Participant 35] |
Disclosure | “I liked the guide to self-disclosing about one’s self-injury and I think this is something that will inform future interactions.” [Participant 17] |
Science and statistics | “I liked getting science backed info to make it more real.” [Participant 31] |
Stages of change | “The last materials in week 8 regarding the different stages and the guide to coping with urges were without doubt the most helpful. I found it helpful for my own identification of struggles with where I’m at now and learned what I could do about it.” [Participant 23] |
When reflecting on the benefits of using the peer support app, participants generally commented on design features that made the sharing of support possible and qualities inherent in the community of peers. Factors that contributed to benefits included (1) interactions with supportive peers, (2) sense of shared experience, and (3) space for catharsis or venting. Participants also made explicit reference to (1) immediacy of support, (2) anonymity, (3) lack of stigma, and (4) being able to provide support to others to a lesser degree.
Consistent with the findings on benefits and challenges related to experiences with the peer support app, participants commonly described characteristics of peers that made them feel accepted and less alone (eg, shared experiences and lack of stigma). Participants similarly appreciated being able to show and receive support in a variety of ways through 1-click responses (eg, likes and hearts) and through commenting on peer posts openly via the main feed and privately via direct messaging. As mentioned previously, participants commonly used the app to obtain feedback or support in moments of distress and thus appreciated being able to receive feedback from peers quickly during these times.
Interestingly, participants described mixed feelings about both venting and provision of support. Although several participants described an intellectual understanding of the benefits of venting, they also expressed dissatisfaction with the experience as a whole. For example, a participant wrote the following:
It is a well-intentioned but likely ineffective app. It’s a good place to vent and send something off into space for the sake of being seen, but often the interactions with others leave much to be desired.
Another participant described the following:
It can be cool I guess if you just wanna vent or talk to people who are going through similar things as you, but there’s way too much negativity there for it to be useful to actually get better.
These participants seemed to feel as if there was a benefit inherent in being able to express themselves openly, but that this may not outweigh exposure to negativity. Similarly, although several participants referred to the benefits of providing support, the balance between support provision and receipt was not always equal. A participant noted the following:
I felt like I supported more people than who supported me.
As is clear in these participants’ experiences, there appears to be a personal
Participants also described the elements that contributed to challenges or harmful interactions on the app. These elements included (1) community negativity, (2) interactions with unsupportive peers, and (3) perceived poster inauthenticity. Participants also mentioned (1) exposure to triggering content, (2) preference for therapy or in-person support, and (3) perceived difficulty in intervening. Quotes corresponding to these subthemes are presented in
In contrast to factors that were helpful, many comments about negative or potentially harmful experiences were related to content, rather than design features, and how participants perceived peers (eg, authentic vs inauthentic). Comments falling under interactions with unsupportive peers or community negativity were differentiated by their reference to isolated incidents resulting in negative interactions with individuals versus a general sense of negativity at the community level. In addition to the quotes in
Whenever I would post I would have people privately message me and try to hit on me. It seems completely inappropriate for this type of app.
Participants also described a perceived inability to effectively intervene while navigating the app, and this led to a sense of helplessness when reading distressing comments from peers. Although many of these comments referred to limitations that participants perceived in their ability to help, there were also comments on the perceived lack of moderation. For example, a participant noted the following:
I understand that everyone should be able to express their feelings, but I feel like if the app itself could somehow catch and delete inappropriate or triggering responses that are meant to be mean to the person, that would be really nice.
Though the app has several layers of moderation, including the ability for users to flag or block harmful peers and administrative moderators that can remove harmful content, this reflects the imperfect nature of top-down and automated moderation efforts on peer support platforms—particularly those devoted to sensitive topics such as self-injury.
Participants who received weekly web-based factsheets described specific topic areas that they found to be particularly helpful. Materials related to coping strategies (including distraction techniques) were the most referenced, followed by information on pain offset relief, information on how to disclose, and resources addressing the science behind self-injury and statistics. Quotes corresponding to these content areas are presented in
Many participants saw value in factsheets related to coping strategies; however, as in other studies, participants expressed doubt about their ability to use coping strategies when experiencing intense urges [
The alternative coping skills have been helpful. However, I still struggle to implement them in moments of very intense frustration, and I still don’t quite know what to do about that.
Factsheets that focused on scientific evidence such as pain offset relief and those including statistics were particularly compelling and appreciated largely because they increased self-understanding and made participants feel as if they were less alone in their struggles.
In addition to the utility of learning about how to disclose, several participants described the factsheets as being catalysts to conversations with others. Overall, 10% (5/51) of the participants described sharing factsheets with family or friends. A participant noted that sharing the factsheets made them feel further supported by their significant other:
My boyfriend has been helping me through a lot of my mental health problems. I discussed some of the articles with him and that made me feel heard and supported.
Another participant described that they opened up to their sister about their self-injury:
I spoke with my sister about what I was learning regarding [self-injury]. I was surprised to find little judgment from her and that alone made me feel better about myself.
In these cases, the materials led to valued offline conversations.
Overall, our findings suggest that there were elements of value in both digital resources, but that they were characterized by different effects and experiences. Several factors were identified as contributing to positive experiences with the peer support app; however, there was also significant variability in the perceived value of features across participant experiences. Individual differences in the types of psychoeducational factsheets that were most valued and useful were also apparent—despite the relative agreement on the importance of learning coping skills. These findings reflect the high level of nuance that individuals perceive when describing their experiences with digital resources and the multifaceted nature of the effects derived.
Many of the previous studies on digital resources for self-injury have focused on whether the use of digital interventions leads to more or less of the behavior, with less attention on other types of effects that may be relevant to individuals’ experiences of self-injury and recovery. This study explored the benefits and challenges perceived by young people who engaged with 2 publicly available digital resources for self-injury. Although many of our findings align with the existing literature on the risks and benefits of web-based activities [
In general, participants were more likely to mention benefits than challenges; however, these varied according to digital resource. Our findings suggest the highest and most consistent satisfaction with the web-based factsheets containing psychoeducation on self-injury and treatment. This finding is not without precedent, as psychoeducation is a core component of self-injury prevention and intervention [
Participants articulated several direct benefits from their experience with the web-based factsheets, with the dominant benefits focused on improved self-understanding, increased motivation to use other coping techniques, and improved attitudes toward additional support. Interestingly, similar benefits were supported through experiences with the survey. However, participants’ reflections on how the survey improved self-knowledge differed from their reflections on the factsheets. Benefits derived from the survey focused on how weekly reflections or
Both the benefits from the survey and factsheets on self-knowledge resonate with principles of behavioral approaches to self-injury treatment, which emphasize a functional understanding of self-injury and involves tracking antecedents (or triggers) and consequences of the behavior over time. This appreciation of features that allow users to monitor patterns is also consistent with findings from design work on self-injury self-management [
Another possible benefit from the weekly surveys may have been the perceived presence of an empathetic listener. We must acknowledge that the weekly surveys were sent by the study research assistant, and although the emails were meant to be simple reminders, participants may have benefited from regular contact with someone who was responsive and expressed interest in their experience. The potential benefit of having someone bear witness to personal experience was clearly present in comments about the peer support app, and it may have similarly played a role in the surveys. Empathy through repeated contact with someone invested in patient wellness is a critical component of the caring contacts program for suicide prevention. For example, in caring contacts, a clinician sends a series of repeated asynchronous messages to patients following acute care, and this simple intervention has been associated with reduction in suicidal ideation and attempts [
The main benefits of the peer support app differed from those of the factsheets and weekly surveys and were instead focused on general improvements in mood and feeling less alone. Experiences of interacting with peers seemed to increase the salience of mood and mood shifts for some participants. Other participants mentioned using the app when their mood was particularly low. This finding is consistent with other studies on peer support for self-injury, in that it is common for people to navigate to these apps or communities in moments of distress for just-in-time support [
Participants described negative effects on mood and interactions or exposure to content that increased or did not help their self-injury behavior. There was significant variability in references to app features, such that some features were identified as being both positive and negative across participants. Examples include anonymity—a feature that was identified as allowing for positive supportive exchanges, while also being a source of negative interaction and perceived inauthenticity of peer exchanges, as in other studies [
Most participants reported previous use of digital resources for mental health (eg, web-based communities and apps), suggesting general receptivity to these resources and digital interventions in this population. However, participants also reported low satisfaction with historical use of these resources, indicating a clear need to improve upon existing spaces where individuals seek information and support. Our study contributes additional insights for designers to consider when working to build and improve digital resources for this population. In this section, we outline several implications for design and future studies.
The overall positive experience participants described with the web-based factsheets was notable because many existing websites include psychoeducational content. However, publicly available web-based communities for self-injury do not often include active or structured psychoeducational components. Our study suggests that the integration of psychoeducational components within web-based communities may increase their perceived value and diversify the benefits gained. Web-based communities that include psychoeducation through existing banks or
A way to increase awareness of and engagement with psychoeducation within web-based peer support communities may be to design these materials as a push feature, which encourages or reminds users to perform beneficial actions (eg, read psychoeducation or watch content). We should underscore that there was likely value in receiving materials directly through a prompt (such as email) and with some regularity in this study versus needing to seek out such resources. This may be especially true for individuals with comorbid conditions that affect motivation (eg, depression). In the self-monitoring literature, push elements are frequently more useful and used, relative to pull elements (where users must seek out content) [
In addition to making high-quality psychoeducation accessible to individuals engaged in web-based communities, we must also ensure that these materials are relevant and resonate with their experiences [
The lack of overlap in benefits perceived across the peer support app, web-based factsheets, and survey suggests the unique ways these resources contribute to recovery. The main benefits of the peer support app appeared to be the sharing of stories, ability to express oneself, and connection to individuals with shared experiences. However, being able to derive benefits was contrasted with harms such as exposure to community negativity that exacerbated mood and self-injury symptoms. This potential for harm may be especially amplified once the novelty of sharing and hearing similar stories wanes. A way to leverage the beneficial qualities of peer support in a different digital context may be to present peer stories alongside psychoeducational programs. Enabling young people to gain exposure to peer experiences in a structured context may circumvent some of the harms inherent in an open (often unmoderated) peer support community, while still providing beneficial qualities to reduce loneliness. Peer narratives are becoming a prominent feature in several brief digital interventions targeting youth mental health [
In addition to using peer stories as part of digital intervention, researchers and designers should also consider new and safe ways for young people to interact with one another to exchange support. An option may be to build peer pairing or referral systems that connect peers based on a set of characteristics. Creating a structured exchange between 2 individuals may allow users to develop deep connections, while also reducing the likelihood of them being exposed to negative or harmful content. For example, similar to the Alcoholics Anonymous [
Finally, one of the most consistent benefits that participants derived from the digital resources was an increased sense of self-knowledge. Although this was most apparent in participants’ reflections on their experiences with the web-based factsheets and the survey, it was also highlighted in comments regarding increased awareness of mood patterns while using the app. Given the importance of tracking self-injury behavior using chain and functional analyses in formal treatments for self-injury, it is important to consider ways of improving self-knowledge and increasing awareness through interactions with digital resources. A way to promote awareness is through simple self-report monitoring, such as check-ins that ask users to reflect on a series of questions over a period. Alternatively, passive monitoring can be used to detect patterns and provide a brief report for users along with suggested strategies or activities to improve mental health and reduce in-the-moment distress. Although passive monitoring can relieve the user burden as it does not require participants to input additional data, more active approaches that require users to input data may increase the salience of patterns and allow for more opportunities for self-reflection. To account for different user needs, an ideal design may allow users to switch back and forth between periods of passive and active monitoring (eg, semiautomatic tracking) depending on their needs (as described elsewhere [
This study should be considered in the context of several limitations. Although participants were encouraged to respond to open-ended responses honestly, it is important to note that we analyzed self-report data in a study examining the efficacy of a digital intervention. Therefore, desirability bias may play a role in participant responses; however, we feel that the range of positive and negative responses we received is reassuring. In addition, participants’ characteristics may make them willing and interested in using digital resources for self-injury. Our participants may have been more likely to use these resources, given their history of using digital resources and their desire to participate in our trial. This may limit the generalizability of our findings to other populations with less experience with or interest in digital resources and in the context of natural use (outside of a trial). In addition, although we believe that sustained use of the digital resources for 8 weeks is a strength of our study, our results may not extend to more naturalistic use of these resources over long periods. Finally, our results should be interpreted with the understanding that we used a specific set of psychoeducational materials developed by researcher advocates and a peer support platform that was developed as a community for mental health.
The potential to leverage web spaces to provide resources to support young people who engage in self-injury is an area of increased research interest and practical importance. The unique nature of our study enabled us to focus on the perceived value of 2 publicly available digital resources. In doing so, we discovered details on what is and is not perceived to be helpful for individuals with self-injury history. The general congruence of our findings with themes from other studies exploring the types of services and design features that are valued by individuals with lived experience of self-injury (eg, distraction and coping) provide a clear direction forward for future research and design. Although there is certainly merit in designing new technologies to support individuals who self-injure, there is also a need to improve and augment existing platforms that are already frequently used by these individuals.
Web-based factsheets on self-injury.
National Suicide Prevention Lifeline
principal investigator
research question
The authors would like to thank the participants for contributing their perspectives to this study. This work was supported by the United States Department of Agriculture's (USDA) National Institute of Food and Agriculture, Hatch project 1004268 and the Cornell Center for Social Sciences. KPK received support from the National Institute of Mental Health (T32 MH115882) while completing final drafts of this manuscript. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
The data sets generated and analyzed during this study are available from the corresponding author upon reasonable request.
None declared.