Research portfolio examining the role of imagery and safety planning for self-harm and suicide prevention in young people and adults: a mixed-methods approach

Potential impact and psychological mechanisms associated with viewing self-harm imagery on the internet and social media platforms: a critical systematic review
Background: Concerns regarding the harmful effects of the internet and social media have led to changes to online harms policy. This systematic review critically evaluated the potential impact of, and mechanisms associated with, viewing self-harm imagery on the internet and social media.
Method: A literature search was conducing using CINAHL, Cochrane Library, EMBASE, HMIC, MEDLINE, PsycArticles, PsycINFO, PubMed, Scopus, Sociological Abstracts and Web of Science Core Collection databases. Titles and abstracts were screened, and potentially eligible articles were reviewed in full.
Results: Across the fifteen included studies, ten areas of potentially harmful and helpful impact were identified, relating to self-harm behaviour, sharing and commenting, help-seeking, help-giving, emotional (dys)regulation, self-harm cognitions, physiological responses, social connection, comparison, and personal identity. All studies showed potentially harmful effects, including an escalation of self-harm and being emotionally triggered, and could lead to individuals sharing or commenting on content, thus reinforcing self-harm behaviour. Helpful effects included peer support and social connection. Most studies did not explicitly test or discuss potential mechanisms beyond contagion, and causality and directionality of impact could not be determined in any study.
Conclusions: Viewing self-harm imagery online can lead to both helpful and harmful effects via several mechanisms. A Model of Online Self-Harm Imagery Impact was developed to direct future research exploring the factors that may contribute to these effects, and elucidate the mechanisms involved. Implications for clinical practice and policy are discussed.
Service Improvement Project
Improving Safety Planning in an NHS Adult Inpatient and aligned Community Mental Health Team Evidence suggests safety planning interventions (SPIs) are effective in reducing self-harm and suicide risk. As part of one NHS Trust’s suicide prevention strategy, this project used quality improvement methodology to improve SPIs across an adult inpatient and outpatient mental health team. The study examined whether SPI training, co-designed and co-delivered by Experts by Experience, would improve staffs’ knowledge and confidence, the perceived usefulness and likelihood of SPIs, and increase the frequency and quality of SPIs being completed with patients. Knowledge, confidence and likelihood of using SPIs significantly improved following training. An improvement in SPI frequency was observed for both teams, but was not statistically significant, suggesting further measures, beyond training, are required. Reviewing the quality of SPIs against competency criteria, training feedback and informal discussions with staff, helped to identify recommendations for further training and practice. As the project was undertaken in only one NHS Trust, these recommendations may have limited generalisability; however, the outcomes provide insight into SPIs in clinical settings and highlight some of the possible challenges and solutions when implementing SPIs and training.
Theoretically Driven Research
A Preliminary Investigation of Visual Self-Harm-Related Mental Imagery in Young People: A Mixed-Methods Approach
Background: Growing evidence suggests that self-harm-related mental imagery (SH-MI) is involved in self-harm ideation-to-enactment. However, there has been little research in adolescent populations.
Method: A mixed-method study, using both a questionnaire (Study 1: n=55) and qualitative interviews (Study 2: n=16), explored the role of SH-MI in a transdiagnostic clinical population of young people who had recently self-harmed (Study 1 & 2), and whether negative affect (NA) and future-oriented SH-MI could predict self-harm frequency (Study 1).
Results: Study 1 found that SH-MI was highly prevalent with 96% of young people reporting future-oriented and past imagery. A hierarchical multiple regression found future-oriented imagery was a significant predictor of self-harm frequency, after accounting for depression, anxiety, age and NA. NA was inversely related to self-harm frequency, which may reflect divergent affect regulation functions of self-harm or lower thresholds. Study 2 identified three themes relating to SH-MI: 1) origins and context, 2) impact, and 3) the factors that affect the impact of imagery. Imagery could trigger self-harm but also be protective.
Conclusion: SH-MI is likely to play a role in ideation-to-enactment in young people. However, further research with less reliance on retrospective self-report is required. Clinical implications are discussed.

Keywords: Safety planning
systematic review
suicide
internet
mixed-methods
mental imagery
qualitative
young people
quality improvement
regression
social media
self-harm
Advisor: Knowles Bevis, R
Stewart, D
Hawton, K
Lascelles, K
Steel, C