Self-harm and suicidal content online, harmful or helpful? A systematic review of the recent evidence

An Exploratory Study of the Potential of Online Counseling for University Students by a Human-Operated Avatar Counselor

Recently, the use of digital technologies, such as avatars and virtual reality, has been increasingly explored to address university students' mental health issues. However, there is limited research on the advantages and disadvantages of counselors using avatars in online video counseling. Herein, 25 university students were enrolled in a pilot online counseling session with a human counselor-controlled avatar, and asked about their emotional experiences and impressions of the avatar and to provide qualitative feedback on their communication experience. Positive emotions during the session were associated with impressions of the avatar's intelligence and likeability. The anthropomorphism, animacy, likeability, and intelligent impressions of the avatar were interrelated, indicating that the avatar's smile and the counselor's expertise in empathy and approval may have contributed to these impressions. However, no associations were observed between participant experiences and their prior communication with avatars, or between participant experiences and their gender or the perceived gender of the avatar. Accordingly, recommendations for future practice and research are provided. Accumulating practical and empirical findings on the effectiveness of human-operated avatar counselors is crucial for addressing university students' mental health issues.

Can #chatsafe support parents and carers beyond Australia? A qualitative study

BACKGROUND

Rates of self-harm and suicide are rising for young people globally and many implicate social media in this problem. To address this concern and to increase the confidence of adults to communicate safely about suicide and social media with young people, the #chatsafe Guide for Parents and Carers was developed in Australia. With significant uptake of the resource among Australian adults, the aim of the current study was to update and contextualise the #chatsafe Guide for Parents and Carers for audiences in 15 countries globally. To improve the relevance of this resource for parents and carers in these countries, the present study sought to understand the concerns held by parents, carers and suicide prevention professionals around the world about these topics and to explore the extent to which a resource such as #chatsafe would be helpful within their communities.

METHODS

Seven focus groups were conducted via Zoom with parents, carers and suicide prevention professionals (n = 40) from 15 countries. Transcribed data were coded and thematically analysed using both inductive and deductive processes.

RESULTS

Six themes are reported: (1) Two scary 'S' words; (2) Country and culture impact who talks (or is silent) about self-harm and suicide; (3) The need for a protective social ecosystem; (4) #chatsafe is a tool that can help parents, carers and young people worldwide; (5) #chatsafe should consider local context and end users to improve its relevance for parents and carers worldwide; and (6) A range of marketing and dissemination strategies are needed to reach adults with #chatsafe information. Findings of this study informed the update and contextualisation of the #chatsafe Guide for Parents and Carers for adult audiences in 15 countries.

CONCLUSIONS

The findings from this study underscore a universal need for psychoeducation initiatives that provide adults with the skills and knowledge to support the mental health of young people, both online and offline, and that resources like #chastafe can play an important role in providing reliable information about these topics to adults across a range of cultures and contexts.

What methods are used in research of firsthand experiences with online self-harming and suicidal behavior? A scoping review

BACKGROUND

Online self-harming and suicidal behavior is a novel and rapidly increasing phenomenon warranting comprehensive mapping of used research methods.

AIM

To identify and map how knowledge on online self-harming and suicidal behavior is gathered, including how data are collected e.g. questionnaires and interviews.

METHODS

The review follows the Joanna Briggs Institute Manual for Scoping Reviews in tandem with Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. A keyword search of three electronic databases was conducted on two occasions, yielding 5422 records. Following duplicate removal, the records were screened based on the following inclusion criterions; (1) in English or Nordic language and published between 2011-2022, (2) presenting results for self-harming and/or suicidal behavior on social media and (3) using tools for either interview or questionnaire aiming at assessment of the experience of online self-harming and suicidal behavior from the perspective of the person who engages in the behavior. A total of 64 articles were included.

RESULTS

45 used questionnaires, 17 used interviews, and two studies mixed the two approaches. 17% of the studies had made some effort to ensure validity within the questionnaires and 15.8% gave full access to the interview guide.

CONCLUSION

Research into online self-harming and suicidal behavior is characterized by a lack of validated measurements and methodological transparency. The results emphasize a need for further development, testing, and validation of questionnaires and greater openness and reflexivity in qualitative methodology to enable cross-study comparison and advance knowledge of this complex phenomenon.

The Journey of Engaging With Web-Based Self-Harm and Suicide Content: Longitudinal Qualitative Study

BACKGROUND

Self-harm and suicide are major public health concerns worldwide, with attention focused on the web environment as a helpful or harmful influence. Longitudinal research on self-harm and suicide-related internet use is limited, highlighting a paucity of evidence on long-term patterns and effects of engaging with such content.

OBJECTIVE

This study explores the experiences of people engaging with self-harm or suicide content over a 6-month period.

METHODS

This study used qualitative and digital ethnographic methods longitudinally, including one-to-one interviews at 3 time points to explore individual narratives. A trajectory analysis approach involving 4 steps was used to interpret the data.

RESULTS

The findings from 14 participants established the web-based journey of people who engage with self-harm or suicide content. In total, 5 themes were identified: initial interactions with self-harm or suicide content, changes in what self-harm or suicide content people engage with and where, changes in experiences of self-harm or suicide behaviors associated with web-based self-harm or suicide content engagement, the disengagement-reengagement cycle, and future perspectives on web-based self-harm or suicide content engagement. Initial engagements were driven by participants seeking help, often when offline support had been unavailable. Some participants' exposure to self-harm and suicide content led to their own self-harm and suicide behaviors, with varying patterns of change over time. Notably, disengagement from web-based self-harm and suicide spaces served as a protective measure for all participants, but the pull of familiar content resulted in only brief periods of disconnection. Participants also expressed future intentions to continue returning to these self-harm and suicide web-based spaces, acknowledging the nonlinear nature of their own recovery journey and aiming to support others in the community. Within the themes identified in this study, narratives revealed that participants' behavior was shaped by cognitive flexibility and rigidity, metacognitive abilities, and digital expertise. Opportunities for behavior change arose during periods of cognitive flexibility prompted by life events, stressors, and shifts in mental health. Participants sought diverse and potentially harmful content during challenging times but moved toward recovery-oriented engagements in positive circumstances. Metacognitive and digital efficacy skills also played a pivotal role in participants' control of web-based interactions, enabling more effective management of content or platforms or sites that posed potential harms.

CONCLUSIONS

This study demonstrated the complexity of web-based interactions, with beneficial and harmful content intertwined. Participants who demonstrated metacognition and digital efficacy had better control over web-based engagements. Some attributed these skills to study processes, including taking part in reflective diaries, showing the potential of upskilling users. This study also highlighted how participants remained vulnerable by engaging with familiar web-based spaces, emphasizing the responsibility of web-based industry leaders to develop tools that empower users to enhance their web-based safety.

Exploring gender differences in risk factors for self-harm in adolescents using data from the Millennium Cohort Study

BACKGROUND

Self-harm is common in young people and girls have consistently higher rates of self-harm than boys. Differences in exposure and reactions to risk and protective factors, adverse events and problematic interpersonal relationships, and levels of wellbeing could contribute to the gender difference. This study aims to explore gender differences in risk factors associated with self-harm, to provide the foundation for developing more gender-sensitive approaches to self-harm management.

METHODS

Data were analysed from 11,196 young people recruited to the Millennium Cohort Study, surveyed around age 14. We examined gender differences in the prevalence of key psychological and social risk factors for self-harm, including family and peer relationships, emotional wellbeing, and bullying and victimisation. We utilised modified Poisson regression to estimate gender-specific risks.

RESULTS

At age 14 self-harm prevalence was 15.4 % with a ratio of 2.6 females to 1 male. Differential exposure to recorded psychosocial risk factors explained a third of the gender difference in risk of self-harm. Intense social media use and not confiding in family members were associated with a greater likelihood of self-harm in girls than boys. Bullying others and same-sex attraction were more strongly associated with self-harm in boys than girls.

LIMITATIONS

Self-harm data were obtained by self-report therefore subject to misclassification. The cross-sectional design does not enable us to establish causation.

CONCLUSIONS

Unhappiness and dissatisfaction are common in adolescence. Our findings suggest the need for further research into young people's experiences to explore why rates differ and inform the development of gender-specific approaches to self-harm management.

#chatsafe 2.0. updated guidelines to support young people to communicate safely online about self-harm and suicide: A Delphi expert consensus study

INTRODUCTION

Young people use social media to communicate about self-harm and suicide and this is associated with both potential risks and protective effects. The #chatsafe guidelines were originally developed in 2018 to equip young people to communicate safely online about suicide. They were shown to be safe, acceptable, and beneficial; however, they do not provide guidance on self-harm, and social media is constantly evolving. This study aimed to update the #chatsafe guidelines to reflect new evidence and current social media affordances, and to include guidance on self-harm.

METHODS

A Delphi expert consensus study was conducted, comprising six stages: 1) A systematic search of peer-reviewed and grey literature; 2) A series of roundtables with key stakeholders including social media companies, policymakers, and young people; 3) Questionnaire development; 4) Expert panel formation; 5) Data collection and analysis; and 6) Guideline development.

RESULTS

A total of 191 items were included in the new #chatsafe guidelines. These were organised into eight themes, which became the overarching sections of the guidelines: 1) General tips; 2) Creating self-harm and suicide content; 3) Consuming self-harm and suicide content; 4) Livestreams of self-harm and suicide acts; 4) Self-harm and suicide games, pacts, and hoaxes; 6) Self-harm and suicide communities; 7) Bereavement and communicating about someone who has died by suicide; and 8) Guidance for influencers.

DISCUSSION

The new guidelines include updated and new information on online communication about self-harm, livestreams, games, pacts, and hoaxes, as well as guidance for influencers. They will be disseminated via a national social media campaign and supported by a series of adult-facing resources. Given the acceptability of the original guidelines and the ubiquitous use of social media by young people, it is hoped that the new guidelines will be a useful resource for young people and adults alike, both in Australia and worldwide.

Research Review: Viewing self-harm images on the internet and social media platforms: systematic review of the impact and associated psychological mechanisms

BACKGROUND

Viewing self-harm and suicide-related images online can precede these behaviours. We reviewed studies of potential impacts and mechanisms associated with viewing self-harm-related images on the internet and social media.

METHOD

CINAHL, Cochrane Library, EMBASE, HMIC, MEDLINE, PsycArticles, PsycINFO, PubMed, Scopus, Sociological Abstracts and Web of Science Core Collection databases were searched for relevant studies from inception to 22 January 2022. Inclusion criteria were English language, peer-reviewed, empirical studies with data related to impacts of viewing self-harm images or videos on the internet or social media. Quality and risk of bias were assessed using Critical Appraisal Skills Programme tools. A narrative synthesis approach was used.

RESULTS

Of the 15 identified studies, all found harmful effects of viewing self-harm-related images online. These included escalation of self-harm, reinforcement of engagement behaviours (e.g. commenting and sharing images), encouragement of social comparison (comparing own self-harm with others), development of a self-harm identity, social connection perpetuating or escalating self-harm, and emotional, cognitive, and physiological impacts triggering self-harm urges and acts. Nine studies found protective effects, including self-harm mitigation or reduction, promotion of self-harm recovery, encouraging social connection and help-giving, and emotional, cognitive and physiological impacts mitigating or reducing self-harm urges and acts. Causality of impact was not determined in any study. Most of the studies did not explicitly evaluate or discuss potential mechanisms.

CONCLUSIONS

Viewing self-harm images online may have both harmful and protective effects, but harmful effects predominated in the studies. Clinically, it is important to assess individual's access to images relating to self-harm and suicide, and the associated impacts, alongside pre-existing vulnerabilities and contextual factors. Higher quality longitudinal research with less reliance on retrospective self-report is needed, as well as studies that test potential mechanisms. We have developed a conceptual model of the impact of viewing self-harm images online to inform future research.

Testing the Impact of the #chatsafe Intervention on Young People's Ability to Communicate Safely About Suicide on Social Media: Protocol for a Randomized Controlled Trial

BACKGROUND

Suicide is the leading cause of death among Australians. One commonly cited explanation is the impact of social media, in particular, the ways in which young people use social media to communicate about their own experiences and their exposure to suicide-related content posted by others. Guidelines designed to assist mainstream media to safely report about suicide are widespread. Until recently, no guidelines existed that targeted social media or young people. In response, we developed the #chatsafe guidelines and a supporting social media campaign, which together make up the #chatsafe intervention. The intervention was tested in a pilot study with positive results. However, the study was limited by the lack of a control group.

OBJECTIVE

The aim of this study is to assess the impact of the #chatsafe social media intervention on young people's safety and confidence when communicating on the web about suicide.

METHODS

The study employs a pragmatic, parallel, superiority randomized controlled design. It will be conducted in accordance with the Consolidated Standards of Reporting Trials statement over 18 months. Participants will be 400 young people aged 16-25 years (200 per arm). Participants will be recruited via social media advertising and assessed at 3 time points: time 1-baseline; time 2-8-week postintervention commencement; and time 3-4-week postintervention. They will be asked to complete a weekly survey to monitor safety and evaluate each piece of social media content. The intervention comprises an 8-week social media campaign including social media posts shared on public Instagram profiles. The intervention group will receive the #chatsafe suicide prevention content and the control group will receive sexual health content. Both groups will receive 24 pieces of content delivered to their mobile phones via text message. The primary outcome is safety when communicating on the web about suicide, as measured via the purpose-designed #chatsafe online safety questionnaire. Additional outcomes include willingness to intervene against suicide, internet self-efficacy, safety, and acceptability.

RESULTS

The study was funded in November 2020, approved by the University of Melbourne Human Research Ethics Committee on October 7, 2022, and prospectively registered with the Australian New Zealand Clinical Trials registry. Trial recruitment began in November 2022 and study completion is anticipated by June 2024.

CONCLUSIONS

This will be the first randomized controlled trial internationally to test the impact of a social media intervention designed to equip young people to communicate safely on the web about suicide. Given the rising rates of youth suicide in Australia and the acceptability of social media among young people, incorporating social media-based interventions into the suicide prevention landscape is an obvious next step. This intervention, if effective, could also be extended internationally, thereby improving web-based safety for young people not just in Australia but globally.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12622001397707; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=384318.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/44300.

Investigating How People Who Self-harm Evaluate Web-Based Lived Experience Stories: Focus Group Study

BACKGROUND

The positive and negative effects of interacting with web-based content on mental health, and especially self-harm, are well documented. Lived experience stories are one such type of static web-based content, frequently published on health care or third-sector organization websites, as well as social media and blogs, as a form of support for those seeking help via the web.

OBJECTIVE

This study aimed to increase understanding about how people who self-harm engage with and evaluate web-based lived experience stories.

METHODS

Overall, 4 web-based focus groups were conducted with 13 people with recent self-harm experience (aged 16-40 years). In total, 3 example lived experience stories were read aloud to participants, who were then asked to share their reactions to the stories. Participants were also encouraged to reflect on stories previously encountered on the web. Data were analyzed thematically.

RESULTS

Overall, 5 themes were generated: stories of recovery from self-harm and their emotional impact, impact on self-help and help-seeking behaviors, identifying with the narrator, authenticity, and language and stereotyping.

CONCLUSIONS

Lived experience stories published on the web can provide a valuable form of support for those experiencing self-harm. They can be motivating and empowering for the reader, and they have the potential to distract readers from urges to self-harm. However, these effects may be moderated by age, and narratives of recovery may demoralize older readers. Our findings have implications for organizations publishing lived experience content and for community guidelines and moderators of web-based forums in which users share their stories. These include the need to consider the narrator's age and the relatability and authenticity of their journey and the need to avoid using stigmatizing language.

Motivations and perceived harms and benefits of online communication about self-harm: An interview study with young people

Background

Self-harm behaviour is prevalent among young people and online communication about self-harm is frequent. These online communications are associated with potential harms and potential benefits. To date, few studies have explored the motivations and mechanisms involved in youth online communication about self-harm.

Objective

This study aimed to explore why young people communicate online about self-harm and the perceived benefits and harms of these communications.

Methods

Twenty young people aged between 18 and 25 years completed an online interview. Interviews were audio recorded and transcribed verbatim. Thematic analysis was used to identify themes.

Results

Four main themes are reported: (1) crossing from offline to online-the double-edged affordances of social media: young people engaged in online communication about self-harm because they were unable or unwilling to speak about their experiences in offline contexts. Online spaces afforded anonymity and peer support, which were associated with benefits and harms; (2) user-generated is not quite the same as user-resonated: perceptions were influenced by whether the young person created or viewed or responded to the content. Written and visual content had pros and cons; (3) it's not just you, it's mostly me-individual characteristics influence perceptions: age and mental state influenced perceptions and behavior; and (4) beyond individuals-parameters are protective: leadership and platform policies and procedures aided safety.

Conclusions

Online communication about self-harm is neither entirely helpful nor harmful. Perceptions are influenced by individual, social, and systematic factors. Evidence-based guidelines are needed to increase young people's online self-harm literacy and help them build effective communication skills to buffer psychological and potentially physical harm.

Online suicidal thoughts and/or behaviours talk: A scoping review protocol

The anonymity that the internet and social media affords users means that suicidal thoughts and/or behaviours can be talked about with a sense of freedom and disinhibition that is often not possible in face-to-face contexts. Better understanding online suicidal thoughts and/or behaviour talk is critical as more people turn to online spaces for support. Without this the potentiality of such spaces as sites for suicide prevention and intervention is likely to remain unrealised. Currently there are no scoping or systematic review syntheses focusing on internet and/or on social media suicidal thoughts and/or behaviour talk. This lack of synthesis is problematic as it makes it more difficult for online suicide prevention and intervention practices, policies, and our understanding of suicide to advance in a coherent and evidence-based manner. A scoping review protocol following Arksey and O'Malley's six-step modified framework has been developed to address this synthesis gap. It aims to systematically map the empirical literature that has investigated online suicidal thoughts and/or behaviours talk. It is anticipated that review outcomes could inform the training of health practitioners and peer/professional online moderators in how to best talk with people experiencing suicidal thoughts and/or behaviours. Outcomes could also form an evidence-base for developing policies and practices that focus on online places as safe spaces to talk about suicidal thoughts and/or behaviours. Developers of safe language guidelines could also use the outcomes to audit how well current guidelines reflect empirical evidence. Outcomes could enable researchers to design future online suicidal thoughts and/behaviours talk studies that extend our understandings of suicide leading to potential refinements of contemporary suicide theories/models.

Online suicidal thoughts and/or behaviours talk: A scoping review protocol

The anonymity that the internet and social media affords users means that suicidal thoughts and/or behaviours can be talked about with a sense of freedom and disinhibition that is often not possible in face-to-face contexts. Better understanding online suicidal thoughts and/or behaviour talk is critical as more people turn to online spaces for support. Without this the potentiality of such spaces as sites for suicide prevention and intervention is likely to remain unrealised. Currently there are no scoping or systematic review syntheses focusing on internet and/or on social media suicidal thoughts and/or behaviour talk. This lack of synthesis is problematic as it makes it more difficult for online suicide prevention and intervention practices, policies, and our understanding of suicide to advance in a coherent and evidence-based manner. A scoping review protocol following Arksey and O'Malley's six-step modified framework has been developed to address this synthesis gap. It aims to systematically map the empirical literature that has investigated online suicidal thoughts and/or behaviours talk. It is anticipated that review outcomes could inform the training of health practitioners and peer/professional online moderators in how to best talk with people experiencing suicidal thoughts and/or behaviours. Outcomes could also form an evidence-base for developing policies and practices that focus on online places as safe spaces to talk about suicidal thoughts and/or behaviours. Developers of safe language guidelines could also use the outcomes to audit how well current guidelines reflect empirical evidence. Outcomes could enable researchers to design future online suicidal thoughts and/behaviours talk studies that extend our understandings of suicide leading to potential refinements of contemporary suicide theories/models.