stem4 is a teenage mental health charity aimed at improving teenage mental health by stemming commonly occurring mental health issues at an early stage.
Highly Commended - National CYPMH Awards 2019
Calm Harm website: www.calmharm.org.uk
Calm Harm video: https://www.youtube.com/watch?v=JDgdXjEoB2Q&t=24s
stem4 is a teenage mental health charity aimed at improving teenage mental health by stemming commonly occurring mental health issues at an early stage.1 in 12 young people in Britain self-harm (Hawton, 2012), the highest rate in Europe. Within schools, management of self-harm in particular has been highlighted as a major area of concern. GPs have also voiced their concerns, given that specialist services are scarce. In a stem4report, 83% of GPs said that services for young people who self-harm are either inadequate or extremely inadequate, and 86% had concerns about patients coming to harm while waiting for treatment (‘A Time Bomb
Waiting to Explode’, stem42016).
In response to this, Dr Krause, Consultant Clinical Psychologist and expert in self-harm,created the Calm Harm app. Calm Harm is the first clinician-developed app enabling young people to manage the urge to self-harm using evidence-based principles. Using ideas from the evidence-based therapy DBT, the app helps through the use of a range of targeted activities to help alter thoughts, emotions and behaviours, enabling them to ‘ride the wave’ of emotion they experience.
Calm Harm is based on the notion that ‘the urge to self-harm is like a wave – it feels most powerful when you start wanting to do it. Once you surf the wave, the urge will fade.’
Users can learn to ‘surf the wave’ by doing five or fifteen minute activities in these categories:
Distracthelps to combat the urge by learning self-control;
Comforthelps to care rather than harm;
Express Yourselfgets those feelings out in a different way;
Releaseprovides safe alternatives to self-injury.
There is also a breathing technique to help reduce symptoms of stress and anxiety.
Calm Harm can be password-protected, allows users to track their progress and signposts other support channels. It gives some immediate techniques to help break the cycle of self-harm and explore underlying trigger factors.
Self-harm is an impulsive behaviour and immediate access to support is needed to regulate an impulse. It is a key risk factor in suicide and is habit forming. DBT is a therapy that is evidence based for impulse control and emotional regulation. Apps on handheld devices are available immediately and can be used in private to help urge reduction and to reduce frequent behaviour. Calm Harm provides a sense of control to deal with problems, helps self-reflection and increases motivation to ask for help. It is also an economical and widespread way to make evidence based treatment available to all. The tasks are targeted for different ages, the app can be personalised, accessible to marginalised groups where self-harm is high and the tasks and creative development involved user involvement and are updated regularly using user feedback.
stem4has addressed a pressing need to provide support to young people who self-harm, and who are having to wait long periods for treatment, may not meet the CAMHS services acceptance criteria, or who are reticent to seek help. The app is free making it accessible to all, available worldwide and 24/7 so accessible when a young person may be in crisis.
Capitalising on the widespread use of mobile phones means they can be used as catalysts for change, addressing disparities and inequities in health service access and delivery, geographic barriers, shortage of expert providers, increased risk and high costs. Calm Harm helps avoid embarrassment since it can be used in the privacy of home, increases CYPs knowledge and control, shared function enhances patient-provider communication and in the long term helps break habitual behaviour and prevent risk.
Calm Harm statistics:
Feedback on Calm Harm:
‘I came across your app one day, and I can gratefully say that it has been really helpful in every area of fighting the battle against self-harm, including stopping things before they happen as well as keeping up the fight.
I’m writing this e-mail just to thank you, and to recognize in my small way, all of the work that you do and the positive impact that it has had on others. Your app is wonderfully set up, thorough, and extremely helpful. I can tell how much detail must have been put in to every aspect of the app, from the activities themselves, to the words chosen, to the colours and shapes used.
I really can’t stress enough just how important and effective the work that you do is, and I’d just like once again to thank you for your commitment to helping people like me, who no longer need to feel as though they fight alone.’
‘My name is Tiffany and I got this app from someone posting about it on Facebook. I was an avid self-harmer in the past but recently my urges and thoughts have been coming back. I’ve only downloaded this app this morning and I “rode the wave” for about a minute or so. I have to say that this is an amazing app that you’ve created for people like myself. It’s good that someone finally has made something to help cope and distract from the thoughts and actions of self-harming. I think this app has the power to save people’s lives, if that’s not being too much to say. But i think it really can, self-harming is like an addiction to some people and the options and layout you give people is incredible. Hats off to you for making the most important app to help young people with mental illness. Thank you for creating an extraordinary app.’
‘Hello! I use your app and just wanted to say thank you. I am going through a rough patch in life and self-harming was a way to feel better, but not the right way. The app has changed my life for the better, and I just wanted to say thank you very much.’
‘I just wanted to thank you all. You’ve saved my life so many times.’
Calm Harm provides an example of how technology can be used to engage young people and help support their mental health. The app is widely used across the world to support young people, some of who have also recognised the benefits of using the app to help manage other harmful behaviour such as anxiety, bingeing and smoking.
stem4has forged links with the NHS and other organisations that will help ensure further apps can be developed and brought to market efficiently.mHabitat – in 2017 stem4 took part in an NHS England-funded ‘Digital Development Lab’ to accelerate the adoption of digital technologies in mental health. HMA – a digital agency specialising in Health, Science and Tech. NHS England – approval of the app for the NHS Apps Library. The app is listed on NHS Digital Apps library for which it underwent a rigorous analysis. Leeds Health – we have licensed a Leeds version of Calm Harm and will be trialling the effectiveness of a localised app. RCGP – The Royal College of GPs supports stem4 on their RCGP toolkit and GPs have responded very well to recommending Calm Harm as have school and practice nurses. Schools – stem4 have worked with over 250 schools and the app has been recommended by a number of schools.
Dr Krause used her clinical knowledge and experience together with data from several secondary school children who attended stem4 workshops who indicated that there was a need for an evidence-based, self-help tool to help manage their urge to self-harm. One student said ‘The first thing I do is to search the Internet but there are many different sources, I don’t know what is right or wrong.’ Dr Krause trialled the app tasks and the timer with a small group of eight young people who self-harmed to obtain feedback on acceptability and safety.
A co-creation process was key in designing and developing Calm Harm. A group of teenagers was brought together in a series of user engagement sessions to look at desired outputs, user journeys, visual concepts and security/privacy considerations. Users wanted an app with a small digital footprint that was private. A great deal of time and thought has gone into the design to ensure it is of high quality and engaging to teenagers. This has been achieved by making it very interactive, giving the user choice, and making it colourful and restful. It has a good balance of text and images – the images are very appealing and the text is clear and friendly, so may help increase motivation by enhancing personal attachment.
As well as being visually appealing, Calm Harm is safe and customisable. The app can be password-protected, so private. The app allows user anonymity, whilst delivering statistics to evidence effectiveness and inform decisions about future development. Developed by a charity and by a clinician, it is trustworthy and approaches an emotive topic sensitively. The app has a clear focus and is holistic in its approach so that it can appeal to a range of individuals. The app doesn’t feel like treatment, yet it is providing young people with the ability to recognise their emotions, regulate them, and alter them with positive effect.
We continue to support user experience. The app has met the clinical risk requirements to be on the NHS App Library and we continue to consistently monitor user feedback to ensure the app is meeting their needs and release regular updates based on this, keeping clinical safety always in mind. New Calm Harm activities can be suggested within the app by young people and are added each release. In addition, another group of young people have fed back that some of the tasks that are helpful for some (e.g. use of ice) is triggering for others. We have therefore provided the option to customise the app by hiding tasks that are triggering. In addition, the app does not require Wifi for use which minimises the need to use up data and provides safety in terms of being available where there is no phone signal.
Inbuilt app analytics enable us to monitor usage and trends. Recent changes have included making the password optional again based on user feedback, allowing users to add their personal contacts to help screens, and the addition of helplines for US/Canadian and Australian users.
One of our learning processes has been to find the right technical partner. We initially build a beta version of Calm Harm with a tech partner who had a very high profile for app building but was not familiar with health tech and especially NHS requirements. We learned a huge amount by being selected to work with an NHS innovation hub – it would have been good to have had this knowledge in advance in order to save an initial financial outlay. However, the positive was that the version we had permitted us to work co-collaboratively as a user ready tool and make the relevant changes.
stem4’s greatest challenge is having a steady funding stream to both create and maintain our apps. We have a proven track record in our work but to fully meet growing need, we need to expand our offers. Clinical services for young people are overstretched and young people are often hard to reach, making the need for more accessible digitally delivered early intervention tools essential. However, developing these is costly, requiring expert digital skills, investment and an on-going maintenance strategy. We originally fund-raised to both create, deliver and maintain the app. Being on the NHS App library has enabled us to link with other NHS services and we have a much better model of grants we can apply for and licenses we can develop to help maintain the app.
The app is fully functioning and we have input from both clinical psychology, our tech partner and our digital lead in maintaining the working of it. Given the large user base, many of the updates are based on user feedback. Should those leading the service move on, our business model permits for recruiting a clinician, work with another tech partner or a new digital lead
Our business plan has inbuilt a sustainability model. This includes the possibility of developing in app purchases or a parent version of the app. We are exploring interest we have had from Councils and CCGs to license the app for localisation and have already set up a three year contract with Leeds Council on this basis.
We would like to explore the option of using the app data for research and are engaging with the NHS to understand whether Calm Harm can be a vanguard for mental health research. Based on requests from secure units for young people and schools that do not permit the use of mobile phones, we are producing sets of Calm Harm cards for settings where mobile phones and tablets are not accessible but where there are young people who require it. We are fairly positive that we will be able to secure a grant to fund this and have got a clear grant application process under way to fund this.
stem4 listens to and monitors feedback from app users and this information, along with that from inbuilt app analytics, has led us to explore potential options of extending the app to link with suicide prevention. The majority of Calm Harm users are female and aged between 16-19. This need is confirmed by NHS data. We would also like to tailor the app further to increase male use. stem4 is investigating localising the app for different countries after numerous requests. This would dramatically extend the reach. In order to do this we are exploring the option of international grants and have just submitted an application to a large European bank that funds such projects.
Our business plan is to approach various grant making companies and tech companies as well as fund raise to generate the income needed to support these projects which we will develop one at a time based on feedback from focus groups. Based on user feedback from Calm Harm that they were using the app to help manage anxiety, we applied and were successful in obtaining a Comic Relief/Paul Hamlyn Foundation tech for good grant in 2018 and have created ‘Clear Fear’ an app to help children and young people manage anxiety. This app was downloaded over 10,000 in the first month of release and we have applied and been successful for a third app.
The model of the app was developed according to Dialectic Behaviour Therapy principles by an experienced consultant clinical psychologist and a group of 8 young patients who self-harmed provided feedback and tasks. This group then was expanded to 14 young people aged between 15-17. At baseline the severity and frequency of self-harm behaviour was noted and the Moods and Feelings Questionnaire and the Strengths and Difficulties Questionnaire completed. They were given Calm Harm to use in-between weekly treatment meetings with a clinical psychologist. Familiarisation (did they want to use the app) and safety (triggers, crashes) was assessed at two weeks and measures were repeated at 4 weeks. Statistically significant results on depression were noted post use. Free answers indicated a 84% reduction in self-harm in between appointments. Acceptability was high at 99% and safety was also high 99%. The most popular category was comfort and the most common reason for self-harm was ‘I was sad’.
Data is currently collected from the app as outlined in outcomes below. We are hoping to set up a research study using the app and are currently in talks with a possible research partner.
Outcomes
To date, there has been 900,717 downloads globally across both iOS and Android platforms.The number of returning users to the app at 63.7% shows that 712,605 users have used the app more than once to manage their urges. 93%** of users have reported a reduction in the urge to self-harm after completing an exercise and so we can estimate, based on these figures that the newly designed app has supported at least 576,723 people to resist or manage the urge to self-harm since launch. 25% of the user base is located in the UK which demonstrates we have supported at least 225,042 individuals with their urge to self-harm in this country. Of these, based on the trends around anonymised data capture, we estimate that the highest proportion of these are teenagers (168,787).
** This 93% efficacy rating is much higher than anticipated especially when reviewing internationally renowned health apps such as Sleepio who claim a 75% efficacy.
We share our work in a number of different ways. We write about our product and our outcomes for newspaper publications, journals, present at conferences, awards and on our website. We present information at our conferences which are for several different audiences – students, teachers, parents, GPs, school nurses. We also present at other conferences nationally. We inform professional bodies such as the RCGP, RCN, BPS. We have our information on the NHS App library.
We ask young people who co-collaborate to inform us on how we should share our information and also work with them in supporting them spread the word. This is done through school assemblies, peer to peer mentoring. We promote information digitally through our Head-Ed mental literacy programme. We offer lectures at various academic institutions such as the medical students at Imperial, teachers at Roehampton University. We are often visited by researchers, other charities, social enterprises, the media and will share our ideas with them.
We worked with a number of other organisations including the NHS, charities, corporates when we were part of the Tech for Good Programme with Comic Relief and with the NHS Innovation Hub and shared our progress and development as well as successes and failures.
