Why smartphone apps can be useful for students who self-harm

By Bethany Cliffe.

It is well-documented that mental health difficulties are highly prevalent among university students, with self-harm in particular being twice as common in this group than in the general population [1]. The transition to university often involves moving to a new environment and leaving support networks behind, with uncertainties around how and where to access mental health support. High levels of demand also mean university mental health services commonly have long waiting lists [2]. Furthermore, students who self-harm may also experience interpersonal barriers; given the sensitive and often taboo nature of self-harm, it can be difficult for individuals to feel comfortable disclosing it. Indeed, the face-to-face nature of traditional talking therapies has been found to make disclosure of self-harm particularly difficult for some [3]. Cumulatively, these factors help to explain why rates of help-seeking behaviour among university students who self-harm is so low; it is estimated that only 19% will seek professional support for self-harm [4]. It is clear that alternative options are therefore necessary to promote help-seeking among students who face barriers to accessing professional support.

Smartphone applications (apps) are one such option that may be of benefit to students who self-harm. Apps can be used in several ways, for example they can be used alongside professional support as a way of ‘practising’ therapeutic techniques, such as breathing exercises, or as a tool to support therapy, such as using an app as a mood diary. They can also be used while on a waiting list for therapy to help introduce students to concepts that may arise, such as mindfulness, and to provide them with self-help resources until they are able to access professional support directly. Apps can also be used as standalone, self-help interventions in themselves, in which therapeutic techniques are distilled into a ‘digital toolbox’ that the individual can access via their smartphone. In this way, the individual is able to access resources that can help them manage difficult emotions and feelings in crisis moments, as well as learning more adaptive ways of coping for longer term management. Using an app without input from a professional is not advisable for those who require more intensive support, so for some this could also be seen as a stepping-stone approach whereby the app helps individuals to acknowledge and understand their relationship with self-harm. In turn, this can increase their abilities and confidence around being able to discuss it with a mental health professional.

There are benefits and drawbacks to using apps to help manage self-harm which should be acknowledged. Importantly, using an app loses the personal qualities of professional support, including non-verbal cues and a sense of connection, understanding and trust. They also may not be able to detect situations in which an individual may be at high risk of significant harm or distress. Apps can also be subject to attrition as, without the input from a professional, the individual may lose motivation to regularly engage with it. Conversely, there are also noteworthy benefits to apps. Primarily, apps are very accessible in that downloads are generally unlimited, meaning no waiting lists. They also aren’t subject to ‘office hours’ and are therefore available 24/7. Given the high rates of sleep difficulties among students [5] and the fact that self-harm typically occurs more frequently at night [6], it is particularly important that students have something that is available out of hours. Fundamentally, apps offer a way of distributing therapeutic techniques and psychoeducation to people who are unable to access it in other ways.

As discussed, help-seeking is very low among university students who self-harm. There are several steps that could be taken to address the barriers to support that they face. For example, greater provision of mental health services that are well-signposted to students would help reduce waiting lists and ensure that students are aware of what support is available and how to access it. Putting things in place to help ease students into university life would also be a positive, preventative step. There also needs to be greater cultural change to help break the taboo around self-harm so that individuals feel more able to disclose it and seek support earlier on. Another solution is diversifying the support that is available by offering things such as smartphone apps for those who may benefit from this. It is important to acknowledge that there is no one size fits all approach with self-harm, as preferences for support are varied across this group [ref?]. However, if offering an app could help a portion of students to access support who otherwise wouldn’t, it is an important and necessary step to take.

While research on smartphone apps for university students who self-harm is incredibly limited, it has been found that students are willing to use apps when experiencing significant distress [7]. Further, apps have been found to be effective in helping students to manage other mental health issues such as anxiety and depression [8]. There are apps available for self-harm that have promising findings with regards to their efficacy and acceptability, but these are yet to be applied to student populations specifically [9]. This is the foundation of my PhD research, where I am seeing if an app (BlueIce) could be helpful for students who self-harm. BlueIce is an app developed with input from young people with lived experience of self-harm, and it is based on principles of Cognitive Behavioural Therapy (CBT) and Dialectical Behaviour Therapy [DBT]. It has been found to be both effective and appealing for adolescents who self-harm [10,11], and I am hoping to extend its application to use with university students also.

References

1. Swannell, S. V., Martin, G. E., Page, A., Hasking, P., & John, N. J. S. (2014). Prevalence of Nonsuicidal Self-Injury in Nonclinical Samples: Systematic Review, Meta-Analysis and Meta-Regression. Suicide and Life-Threatening Behavior, 44(3), 273–303. https://doi.org/10.1111/sltb.12070
2. Thorley, C. (2017). Not by degrees: Improving student mental health in the UK’s universities. https://www.ippr.org/publications/not-by-degrees
3. Franklin, J. C., Fox, K. R., Franklin, C. R., Kleiman, E. M., Ribeiro, J. D., Jaroszewski, A. C., Hooley, J. M., & Nock, M. K. (2016). A brief mobile app reduces nonsuicidal and suicidal self-injury: Evidence from three randomized controlled trials. Journal of Consulting and Clinical Psychology, 84(6), 544–557. https://doi.org/10.1037/ccp0000093
4. Fitzgerald, J., & Curtis, C. (2017). Non-suicidal self-injury in a New Zealand student population: Demographic and self-harm characteristics. New Zealand Journal of Psychology, 46(3), 156–163.
5. Schlarb, A. A., Friedrich, A., & Claßen, M. (2017). Sleep problems in university students – an intervention. Neuropsychiatric Disease and Treatment, 13, 1989–2001. https://doi.org/10.2147/NDT.S142067
6. Hawton, K., Bergen, H., Waters, K., Ness, J., Cooper, J., Steeg, S., & Kapur, N. (2012). Epidemiology and nature of self-harm in children and adolescents: Findings from the multicentre study of self-harm in England. European Child & Adolescent Psychiatry, 21(7), 369–377. https://doi.org/10.1007/s00787-012-0269-6
7. Ryan, M. L., Shochet, I. M., & Stallman, H. M. (2010). Universal online interventions might engage psychologically distressed university students who are unlikely to seek formal help. Advances in Mental Health, 9(1), 73–83. https://doi.org/10.5172/jamh.9.1.73
8. Lattie, E. G., Adkins, E. C., Winquist , N., Stiles-Shields, C., Wafford, Q. E., & Graham, A. K. (2019). Digital Mental Health Interventions for Depression, Anxiety, and Enhancement of Psychological Well-Being Among College Students: Systematic Review. Journal of Medical Internet Research, 21(7). https://doi.org/10.2196/12869
9. Cliffe, B., Tingley, J., Greenhalgh, I., & Stallard, P. (2021). mHealth Interventions for Self-Harm: Scoping Review. Journal of Medical Internet Research, 23(4), e25140. https://doi.org/10.2196/25140
10. Stallard, P., Porter, J., & Grist, R. (2018). A Smartphone App (BlueIce) for Young People Who Self-Harm: Open Phase 1 Pre-Post Trial. JMIR MHealth and UHealth, 6(1), e32. https://doi.org/10.2196/mhealth.8917
11. Grist, R., Porter, J., & Stallard, P. (2018). Acceptability, Use, and Safety of a Mobile Phone App (BlueIce) for Young People Who Self-Harm: Qualitative Study of Service Users’ Experience. JMIR Mental Health, 5(1). https://doi.org/10.2196/mental.8779

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