Out of the lab and into everyday life: Using Experience Sampling Methods to better understand self-harm and suicide

By Olivia Kirtley

The lab and questionnaire-based nature of much self-harm and suicide research means that we often only have access to snapshots of participants’ experiences and behaviours. Furthermore, the chronic lack of prospective and longitudinal research in the field means we know very little about how behaviours and experiences change over time. Most often, we see participants once or twice in the lab or in the clinic, when they take part in our experiments or interviews and like many researchers, I always found myself wondering about the parts of participants’ lives that I never got to see during their brief lab visit: their everyday life experiences.

No two individuals have identical experiences of self-harming or thinking about ending their lives. Suicidal thoughts and behaviours are also dynamic, ebbing and flowing from day to day or even hour to hour and are firmly embedded in individuals’ emotional, physical and social contexts. If we are to move forward in our understanding of these phenomena and to develop better and more individualised support options for people who are struggling, we need to use methods that allow us to capture within- as well as between-person differences. Furthermore, we need to use research techniques that are better able to capture these rapidly changing, dynamic psychological processes and behaviours as they are happening, in context. In other words, we need to move beyond looking at snapshots and trying to extrapolate what happens in between them. We need to start watching the movie.

The Experience Sampling Method (ESM) [1], also referred to as Ecological Momentary Assessment (EMA) [2], is a technique that allows us to collect rich, dynamic data from participants as they go about their day-to-day lives. We ask participants to complete brief questionnaires (around 1-3 minutes in length), multiple times per day for several days. This enables us to gather information about individuals’ experiences, almost in real-time. We also have the potential to passively gather data from participants via wearables, such as Fitbits, or using in-built sensors in their phones.

Currently, we are about to begin recruitment for Wave II of SIGMA, a large-scale, longitudinal study of adolescent mental health and development, using ESM. In Wave I, our fantastic team of PhD students collected data from 1913 adolescents from the general population in Flanders (Northern Belgium), giving us a crucial window into adolescents’ daily lives. Amongst many other questions, we ask participants about their lifetime experiences of self-harm and suicide, but we also asked about their current self-harm thoughts and behaviours ten times per day for six days via a smartphone app. This means that we will be able to investigate not just how often individuals think about or engage in suicidal and non-suicidal self-harm, but what else is happening at the moments where thoughts of self-harm come to mind or when people think of ending their lives. Are people feeling isolated? Who are they with? Are they feeling less positive about the future? These are all questions we are investigating in SIGMA.

ESM brings myriad opportunities for suicide research and prevention (via ecological momentary interventions or EMIs), however, it also comes with numerous challenges, which may account for why it is still an underused methodology in this field [3]. There are important additional ethical considerations regarding privacy and participant safety when conducting ESM research with people who self-harm or who experience suicidal thoughts. As our study is anonymous, we cannot directly intervene if someone indicates they are distressed. We provide all participants with support information at baseline, but we also have a “hot question” as part of the ESM questionnaire, where giving a particular answer triggers a pop-up that provides details for the national suicide prevention helpline.

Another important ethical consideration is measurement reactivity. In other words, will repeatedly asking people about their suicidal or non-suicidal self-harm thoughts and behaviours increase the likelihood that they will engage in those behaviours? There is a growing body of literature [e.g. 4-7] which suggests that sensitively asking about self-harm or suicide is not associated with an increased likelihood of thinking about or engaging in suicidal or non-suicidal thoughts and behaviours. Less is known about the type of repeated questioning that occurs during ESM studies, however Husky and colleagues [8 ] found no evidence of increased suicidal ideation as a function of ESM study duration.

ESM research is also methodologically and statistically challenging, and to a large extent it is still the Wild West; almost none of the items used in ESM have been psychometrically validated and in some cases, we have yet to develop best practices for accomplishing this. Measures are not always publicly available, reporting/conducting power calculations is not commonplace, and there is little routine use of open science practices. These challenges are, however, also opportunities and together with collaborators, I am trying to work on changing some of these things for the better. Earlier this year we launched the Experience Sampling Methodology Item Repository (https://osf.io/kg376/), a multi-phase project where we are working to develop an open-source item bank of ESM measures. We also developed a pre-registration template for ESM studies (project OSF page: https://osf.io/2chmu/; pre-print: https://psyarxiv.com/seyq7/) to try and facilitate the use of open science practices in ESM research.

Leaving the lab and going out into individuals’ daily lives using ESM opens up a whole new world of research and prevention opportunities, which we must seize with both hands if we are to move forward in our understanding of the complex and dynamic nature of suicidal and non-suicidal thoughts and behaviours. The goal of increasing our understanding of self-harm and suicide is to enable us to develop better ways of supporting those who are experiencing extreme emotional pain. To accomplish this, we need to do the best quality and most innovative science that we can, which is why I am so passionate about trying to improve transparency and reproducibility in this field. The theme for this year’s World Suicide Prevention Day is “working together to prevent suicide” and if we do work together, collaboratively as a field, we can overcome the challenges and realise the potential of experience sampling for helping to understand and prevent suicide.

References:

1. Hektner, J.M, Schmidt, J.A, and Csikszentmihalyi, M. (2007). Experience sampling method. Thousand Oaks, California: SAGE Publications Inc.
2. Stone, A.A., & Shiffman, S. (1994). Ecological momentary assessment (EMA) in behavioural medicine. Annals of Behavioral Medicine, 16, 199-202.
3. Davidson, C. L., Anestis, M. D., & Gutierrez, P. M. (2017). Ecological momentary assessment is a neglected methodology in suicidology. Archives of suicide research, 21(1), 1-11.
4. Blades, C. A., Stritzke, W. G. K., Page, A. C., & Brown, J. D. (2018). The benefits and risks of asking research participants about suicide: A meta-analysis of the impact of exposure to suicide-related content. Clinical Psychology Review, 64, 1-12.
5. Blades, C. A., Stritzke, W. G., Page, A. C., & Brown, J. D. (2018). The benefits and risks of asking research participants about suicide: A meta-analysis of the impact of exposure to suicide-related content. Clinical psychology review, 64, 1-12.
6. Cha, C. B., Glenn, J. J., Deming, C. A., D’Angelo, E. J., Hooley, J. M., Teachman, B. A., & Nock, M. K. (2016). Examining potential iatrogenic effects of viewing suicide and self-injury stimuli. Psychological Assessment, 28(11), 1510-1515.
7. DeCou, C. R., & Schumann, M. E. (2018). On the iatrogenic risk of assessing suicidality: a meta‐analysis. Suicide and Life‐Threatening Behavior, 48(5), 531-543.
8. Husky, M., Olié, E., Guillaume, S., Genty, C., Swendsen, J., & Courtet, P. (2014). Feasibility and validity of ecological momentary assessment in the investigation of suicide risk. Psychiatry research, 220(1-2), 564-570.

Olivia Kirtley (@LivveyKirtley) is a postdoctoral research fellow within the Center for Contextual Psychiatry at KU Leuven in Belgium. Olivia leads “SIGMA”, a large-scale longitudinal study of adolescent mental health and development using experience sampling methods/ecological momentary assessment. Her research focuses around investigating factors that cause individuals to move from thinking about self-harm to engaging in the behaviour, within the context of ideation-to-action models of suicide (Olivia.kirtley@kuleuven.be).

*Featuring photo by Daniel Cañibano on Unsplash.