Imaginator: A pilot study for a brief technology-based intervention to reduce self-harm in young people, harnessing mental imagery
Background & Strength of Scientific Evidence:
Self-harm (up to 10% of 15-16 year old in UK) has substantial personal impacts and costs on the NHS. In Cambridgeshire self-harm is a significant issue with number of hospital admissions for self-harm higher than UK average. Treating underlying mental illness leads to small reductions in self-harm but these are long treatments for complex disorders. There is a need for effective short-term therapy for self-harm , with a specific focus on young people. Mental imagery is the process of ‘seeing through the mind’s eye’. Intrusive mental images carrying intense negative emotions are central to several mental disorders (Holmes & Matthews, 2010).
Addressing distressing mental images and promoting positive imagery has been used for trauma, depression and self-harm in personality disorders and there have been successes in treating people with self-harm behaviour using a short course of imagery-focused therapy for Bipolar Disorder.
The Imaginator app will make use of imagery-focused interventions for people who self-harm as imagining something makes it more likely for action to follow. The intervention will train individuals to imagine more adaptive behaviours, rather than to self-harm when distressed (functional imagery) and reduce the likelihood of self-harm. Imagery focus on visual techniques makes it easily amenable for a smartphone app. Smartphone usage by young people is high and so the app-based intervention can help to overcome barriers to accessing treatment.
- Can a new technology-based intervention (smartphone app ‘Imaginator’) reduce self-harm behaviour and associated distress in young people over 3 and 6 months after intervention?
A feasibility study comparing individuals randomly assigned to one of two groups: Standard Care (SC)+Immediate Functional Imagery Training (FIT) vs SC plus 3-month Delayed FIT; assessments at Baseline, 3 and 6 months.
The app was developed in collaboration with young people with lived experience of self-harm.
Thirty-eight young people were recruited in the study (31 female, mean age 19.5 years old). Twenty self-referred from social media and advertisement in the community. Eighteen were referred by mental health services from Cambridgeshire and Peterborough NHS Foundation Trust (in particular the First Response Service and Liaison Psychiatry Services), GPs or school counsellors, of which seven were already under the care of a mental health team. Participants were randomised to receive two sessions of functional imagery training + Imaginator app immediately (Immediate intervention) or after 3 months waiting (Delayed Intervention arm) in addition to any other mental health support offered by local NHS services or other agencies.
Expected Output of Research and Impact:
Results.The study received 84 contacts over 7 months and Imaginator was able to reach out to young people who were not accessing mental health services support (20/38 participants). 5 participants didn’t want the intervention anymore after the waiting list period, and 2 were ex-cluded after assessment. Of those who started therapy, 19 participants (61.2%) completed the face to face sessions and at least one phone follow-up session. Over six months, self-harm behaviour frequency reduced across the whole sample. Functional Imagery Training supported by the Imaginator app reduced the number of self-harm episodes occurring over three months with some effect maintained after six months. The intervention appeared most beneficial for those individuals who still wanted therapy after waiting for three months (De-layed intervention arm). Reduction in self-harm behaviour was greater in those participants who were more motivated to do so at baseline. The intervention also improved perceived self-efficacy (i.e. the belief that one is able to control one’s behaviour given increasing levels of distress) in young people. Effects appeared stronger in those who completed at least three follow-up phone calls. These results suggest that while self-harm behaviour can reduce spontaneously or in the context of general mental health support, a brief imagery-based intervention with a digital app might be a useful additional targeted intervention; in particular in those young people who continue presenting with self-harm over longer periods
Potential output and added value (future RCT). Self-harm behaviour is common in young people. Although it can be a transient experience, for those who continue to self-harm, it is associated with increased severity and with suicidal risk. Imaginator is a brief and easily deliverable intervention supported by a self-help app that is well received and appealing to most young people, including those who currently struggle to access traditional health services. Imaginator can reduce the frequency of self-harm behaviour and increase the perceived ability to self-control in young people whose feelings of distress and self-harm has been enduring for over three months. This has the potential to impact on severity, functional outcomes and suicidal risk, which is more likely in those who continue to self-harm. Reducing A&E access and psychiatric assessments; wide implementation across trusts at low cost (e.g. via brief training); adaptation to other clinical groups who may benefit, e.g. intellectual (learning) disabilities.
BITE: For a ‘BITE’ sized summary of the research, please see: Imaginator BITE sized summary
This is a small proof of concept study, with promising results, however all impact statements are hypothetical. For more information, please contact Martina Di Simplicio firstname.lastname@example.org