Self-Injurious Behavior Clinical Trial
Official title:
Imaginator: a Pilot of a Brief Functional Imagery Training Intervention for Self-harm in Young People, Supported by a Smart-phone 'App'
Self-harm has substantial personal impacts as well as costs on the National Health Service
(NHS). Around 13-17% of young people report experiences of self-harm. In Cambridgeshire,
this is a significant issue with the number of admissions to hospital for self-harm in young
people being higher than the United Kingdom (UK) average. Treating underlying mental illness
can lead to a reduction in self-harm, but these are long interventions for complex disorders
and many people who self-harm are not under treatment for mental illness. Moreover, young
people struggle to access traditional mental health services where these therapies are
delivered. No short interventions specifically tailored for young people have been developed
so far.
The Imaginator project aims to address the urgent need for an effective and innovative
short-term therapy for self-harm in young people. The investigators will pilot a new
imagery-based psychological intervention for young people aged 16-25 who experience
repetitive self-harm. Mental imagery (the experience of "seeing through the mind's eye") can
carry intense emotions (positive and negative), and imagining something can facilitate
behaviour. Imagery-based therapies have proven useful (i) for problems that feature intense,
hard to manage emotions such as those associated with self-harm, and (ii) for promoting
healthy behaviour. Our new intervention called Functional Imagery Training will support
young people to imagine more adaptive behaviours to cope with the emotional distress that
triggers self-harm, and motivate them to reduce self-harm. Imaginator will comprise of just
two sessions followed by phone support over three months.
Moreover, the investigators will address the challenge of young people accessing and staying
in therapy by using a smartphone app to support the therapy, as apps are widely used and
favoured by this age group. The app will enable participants to continue with the strategies
they have learnt in therapy by themselves, thus ensuring a potential longer-term benefit and
self-empowerment.
The problem of self-harm and the need short interventions for young people.
Self-harm, an "act of self-poisoning or self-injury, irrespective of the apparent purpose of
the act" is a behaviour used to cope with intense emotions and psychological distress. It
can occur in a variety of mental health diagnoses as well as individuals with no diagnosis.
Of concern is that almost one in five young adults report self-harm behaviour. A United
Kingdom (UK) survey in schools described 13% 15-16 years old had self-harmed during their
life and 8% in the last year. Factors associated with self-harm include a disadvantaged
socio-economic background, social isolation and lack of support, negative life events
including childhood emotional, physical or sexual abuse. Although self-harm is different
from suicidality, people who self-harm carry a fourfold risk of suicidal thoughts and
behaviours within one year, a risk over and above risk conferred by mental health problems
and psychosocial risk factors.
Self-harm has substantial personal impacts and costs on the National Health Service (NHS).
In Cambridgeshire, the number of hospital admissions for self-harm has been higher than the
UK average, making addressing self-harm a significant issue for local primary and secondary
health care National Institute for Clinical Excellence (NICE) guidelines recommend offering
a "psychological intervention that is specifically structured for people who self-harm, with
the aim of reducing self-harm. In addition: (i) the intervention should be tailored to
individual need, and could include cognitive-behavioural, psychodynamic or problem-solving
elements; (ii) therapists should be trained and supervised in the therapy they are offering
to people who self-harm; (iii) therapists should also be able to work collaboratively with
the person to identify the problems causing distress or leading to self-harm." A number of
interventions have been developed and have shown some efficacy at reducing self-harm in
adolescents and adults. However these therapies vary between 4 sessions and much longer
duration, and currently are mostly available only to individuals under mental health care
after variable periods of waiting time. Moreover, almost half of young people referred
recommended treatment will not attend any follow-up sessions. There is a lack of short
interventions for self-harm specifically targeted at young people. Short interventions that
engage young people are urgently needed to allow young people to better manage and reduce
self-harm also outside secondary mental health care, and alongside / while waiting for more
longterm problems to be addressed (psychiatric disorders, housing and employment
difficulties etc.).
Developing new treatments for self-harm using imagery-based interventions.
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. For example,
individuals with social anxiety will experience intrusive images of them sweating and
blushing intensely while they try to speak to someone, these images will fuel their anxiety
about being judged by others and possibly stop them from attending further social
situations. Mental imagery associated with self-harm also appears to be a common phenomenon
and individuals describe that images associated with self-harm can carry many different
emotional meanings (e.g. evoking a sense of relief, or increasing the urge to self-harm), in
line with what drives self-harm in every individual. The characteristics of mental images
are related to the intensity of emotions and this applies to positive emotions too. For
example, more vivid positive imagery has been related to greater excitement during positive
mood.
Overall, this suggests that mental imagery is a common phenomenon, which many individuals
are likely to experience in the context of high emotions, and that mental images could be
used to generate helpful emotions. In fact, addressing distressing mental images and
promoting positive imagery has been used for trauma, depression and self-harm in personality
disorders. The investigators have successfully treated cases with self-harm behaviour using
a short course of imagery-focused therapy for Bipolar Disorder.
Moreover, mental images can promote behaviour. Imagining something makes it more likely to
act, because it simulating the actual event in the mind and it allows individuals to
''pre-experience'' all aspects the event. Hence, via imagining future scenarios individuals
may feel more ready to engage in the action successfully. For example, in sports adding
mental imagery training (visualising an exercise) to physical practice of an exercise
improves performance. Moreover, imagining an action also involves anticipating how
emotionally rewarding it is likely to be. This may enhance motivation to act. The more vivid
and real-like the mental image of completing a desired action is, the stronger the positive
emotion and motivation to actually do it. This type of imagery of healthy behaviour and
desired actions has been developed into a therapy called Functional Imagery Training (FIT).
FIT encourages individuals to imagine the benefits of working towards their goals,
especially the benefits that are expected to happen right away (e.g. feeling good about
oneself).
So far, FIT has been shown to be a successful approach for interventions to reduce snacking
and in addictive behaviours.
Based on this, the investigators propose that FIT can train individuals to imagine more
helpful behaviours rather than self-harm when distressed. FIT will train vivid and real-like
imagery of alternative goals to self-harm, which is likely to produce rewarding and positive
emotions. Our FIT protocol will aim to support individuals who self-harm at:
(i) identifying helpful behaviours as an alternative goal when they feel like self-harming
(e.g. going for a run, listening to music); (ii) by practising mental imagery of the
alternative behaviour, boosting the desire to achieve this goal; (iii) succeeding in
engaging in alternative behaviours to self-harm.
Importantly, FIT will consist of two face-to-face sessions plus five brief telephone support
sessions. Therefore it has the potential of offering immediate support for all those young
people who are either excluded from or waiting for more complex interventions.
The challenge of engaging young people.
Imagery-based interventions focus on visual techniques and are easily amenable to be
supported by a smartphone app. Smartphone usage by young people is high. Therefore,
enhancing a psychological intervention via a smartphone app could be a successful strategy
to ensure that young people keep practising the therapy techniques and engaging with what
was learned in therapy once the sessions are over and without the need of face to face
follow-up. The support of a smartphone app following the FIT sessions can aid overcome
barriers to engagement reported in young people.
Therefore, the Imaginator study will tailor FIT to young people by adding a smartphone app
support, which can make the intervention more interesting and approachable to this age
group. The investigators have developed a bespoke app called Imaginator. This app was
created collectively via six meetings of a Young People Advisory Group (YPAG: 4 members, 1
male, aged 19 to 22 years old, with a lived experience of self-harm), together with the
research team and John Harper, from App Shine Development company.
In summary, self-harm behaviour is a highly prevalent problem among young people in the UK
(and worldwide), and of particular urgency in Cambridgeshire. It represents a major social
and healthcare problem for the community. Currently, there is a lack of short and easily
accessible interventions to specifically help young people reduce self-harming behaviour. As
mental imagery-based techniques have been used to reduce unwanted emotions and support
motivation and helpful behaviour, The investigators propose that Functional Imagery Training
(FIT) could represent a successful strategy to reduce self-harm behaviour. FIT is intended
as a brief and focused intervention for young people aged 16-25 (regardless of any
diagnosis) that can be added to any other pharmacological or psychological therapy. To
improve access to and engagement with the intervention by young people, the investigators
will deliver FIT supported by a smartphone app developed together with a Young People
Advisory Group.
;
Allocation: Randomized, Intervention Model: Parallel Assignment, Masking: Single Blind (Outcomes Assessor), Primary Purpose: Treatment
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