We have developed an app called Calm Harm to help young people manage the urge to self-harm and we are currently piloting 11 educational videos we have filmed that fit into the secondary school PHSE curriculum on self-harm, anxiety, depression, stress, eating disorders, addiction, internet addiction and resilience.
We have developed an app called Calm Harm to help young people manage the urge to self-harm and we are currently piloting 11 educational videos we have filmed that fit into the secondary school PHSE curriculum on self-harm, anxiety, depression, stress, eating disorders, addiction, internet addiction and resilience.
stem4 is a charity focusing on teenage mental health by targeting early identification of commonly occurring mental health issues in teenagers; raising awareness and enhancing detection, education and motivation. Our work covers four areas – self-harm, eating disorders, anxiety and depression, and addiction, and we target young people, their friends, parents, teaching and healthcare professionals. stem4 has worked with over 200 different schools, providing workshops to over 9,000 students, staff and parents, and in addition has run conferences for students, parents, school nurses, school leaders, and GPs.
The need to develop a psychologically sound resource, which was easily accessible to young people emerged as a result of feedback from these workshops and conferences since many young people informed us that they usually consulted the Internet for information, often being confused about what they read and also because they had found that help and support was not easily available. Many school nurses also asked us if we could provide them with a resource they could provide to students.
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 recent stem4 report, 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’, stem4 2016).
In response to this, and requests as outlined above from the many students stem4 has worked with, Dr Krause, Consultant Clinical Psychologist and expert in self-harm, developed the first clinician- developed smartphone app ‘Calm Harm’ for stem4, a free app designed to help young people manage the urge to self-harm.
Calm Harm provides tasks that help resist or manage urges to self-harm and uses ideas from an evidence-based theory called Dialectic Behaviour Therapy (DBT). The app gets young people to start to manage impulsiveness and to explore underlying trigger factors, and was refined using feedback from a pilot study of young people who self-harm. The app is not intended to replace treatment, but can support young people at risk of self-harm, either as part of an on-going treatment programme or as an interim measure while they decide to seek help or wait to receive treatment.
Calm Harm provides four categories of tasks that target the main reasons for why people self-harm. Distract helps to combat the urge by learning self-control; Comfort helps to care rather than harm; Express gets those feelings out in a different way and Release provides safe alternatives to self-injury. There is also a breathing technique to help reduce the symptoms of stress and anxiety and to stay in the moment. Calm Harm allows users to track their progress, and is password-protected to remain private.
The app targets the digitally-minded young people of today, and is free to download so accessible to all. It gives a young person some immediate techniques to help them break the cycle of self-harm, particularly if they are waiting professional help, or do not meet the criteria for acceptance to CAMHS services. Many young people who self-harm are reticent to talk about it or seek professional help – Calm Harm offers them an easily accessible, private way to get support, as well as signposting other support channels. It is also available 24/7 so accessible when a young person may be in crisis.
Launched in April 2015, the app has been downloaded over 38,000 times to date, mainly through word of mouth, as the app has had minimal marketing. It has a current rating of 4.08/5 on the Google Play store along with a number of highly positive reviews such as:
“Wow, to be honest, I didn’t think this’d help all that much but…Just wow. This is the first time ever that I’ve managed to evade the urge to cut. It was really effective and did the job for me, gave me a few good ideas and all. I’m really happy I came across it, I thank the creators from the bottom of my heart. You did me a huge favor today. “
“Awesome. It’s a great way to help yourself if you can’t speak to anyone. I find the countdown especially helpful :)”
Calm Harm regularly receives positive feedback from young people, and also those working with them, for example:
“A year ago, I was diagnosed with major depression and I went into therapy. During the past year I had to deal with suicidal thoughts, panic attacks and sadness every day. I started cutting myself and it became an addiction: I couldn’t stop. I cut myself every day. But then I discovered the app of Stem4: Calm Harm. This was the solution for my self- harm! Every time I felt the urge to cut myself, I opened the app and I did some activities. The urge faded! I am clean for a month now and I am very proud of that. But it’s because of the app I can stay clean, so that’s why I want to thank stem4 so much for this fantastic invention!”
“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 had a young person who was referred to the service, who said that her reduction in self- harm was due to using your app. Whenever she felt the urge to self-harm she would open the app and use the distraction techniques provided. I have had a look at your app and downloaded it to have a look myself, it would be great to tell the young people who are referred to the programme about it, and if they wish they can download it.”
Project Coordinator for Breaking Silence
– a programme for young people and their families affected by self-harm.
“Just wanted to connect and say I’ve been experimenting with Calm Harm and really love it/will be recommending. I have a long history of self-harm and would have really benefited from something like this when I was younger.”
Nadia Mendoza, Self Esteem Team
In addition, some students have recognised the benefits for using it to help manage other harmful behaviour such as bingeing and smoking.
An enhanced version of the app was released in April 2017 with a re-designed user interface, personalised user experience, and built-in analytics to evidence effectiveness. The re-design process involved co-creation sessions with young people. The enhanced version introduces a variety of characters to personalise the user experience if they wish as well as choose colour backgrounds they wish to have. New tasks have been added based on user feedback. The strength of the urges is graphed for feedback. Since we have a much broader age range of users than the tasks were originally designed for we have also added tasks for younger users and tasks for young adults which will present once an age is added.
Our videos have been developed as a response to the demand for our workshops. We are a small London based charity and we have had requests from all over the UK including Scotland, Wales and Ireland to run our workshops, which we are unable to do. All our workshops are offered by mental health professionals and this is also not sustainable from a cost perspective. The videos will offer any school who would like to the opportunity to experience one of our workshops. The videos have information provided by Dr Krause, Consultant Clinical Psychologist, access to our educational videos and group exercises for teachers to carry out within the time frame of a PHSE lesson. We are currently piloting the videos in a few schools.
stem4 has a number of partnerships with schools primarily in London and the SE, who, over the past 6 years have consulted us for mental health information, run workshops and conferences, train staff and who ask us to return in following years. We educate on teenage mental health issues, including self- harm, and as part of this promote the Calm Harm app as a useful resource for young people to manage self-harm.
stem4 has worked to help educate local GPs on teenage mental health and ran a highly successful conference in June 2016 that was endorsed by the Royal College of GPs (RCGP) and supported by local Community Provider Education Networks, entitled ‘Children and Young People’s Mental Health for GPs’ which saw 55 GPs from Merton, Wandsworth, Sutton, Croydon and Kingston attend. Information packs including guidance on self-harm and the Calm Harm app were provided to delegates and we have received feedback from several GPs that they value having Calm Harm as a resource for patients. Calm Harm was also mentioned as the main app resource for health professionals at the Primary Care & Public Health Conference 2017 in Birmingham and is included as a resource in the soon to be developed self-harm information app for University students by a GP at Expert Self Care Ltd.
stem4 has produced a variety of Calm Harm promotional materials that are being provided to GPs to give to patients, such as ‘business cards’ and has produced posters entitled ‘Worried about self-harm?’ for A&E departments giving advice on what to do and signposting the Calm Harm app. stem4 has linked with Activate Learning, an education and training group, to provide Calm Harm resources for their many students, and to mark Mental Health Awareness week 2017 sent out Calm Harm promotional pack to 150 school nurses around the country.
We are currently taking part in an NHS England funded ‘Digital Development Lab’ run by mHabitat to accelerate the adoption of digital technologies in mental health and have met clinical safety criteria for Calm Harm and are evaluating the effectiveness of the app.
As a charity we have links with CAMHS to whom we signpost. We have worked with Kingston Public Health who sponsored and promoted our student conference in Kingston schools.
We have a bank of local young volunteers who have helped fundraise within their schools or by taking part in a variety of events. We have been involved in young volunteer projects such as the National Citizen Service (NCS) and the Youth & Philanthropy Initiative (YPI). We collaborate with and include a young people with lived experience of self-harm in our conferences, use case study videos produced by young actors who have contributed to our scripts and obtain the opinion of the school population we work with (students, parents and teachers) in our work such as, for example, the content of our pamphlets, including self-harm.
Nationally we are members of the Children & Young People’s Mental Health Coalition, and feature in the RCGP’s Mental Health Toolkit.
We have a number of local corporates involved in supporting the growth of our charity and in helping us raise funds to develop our digital strategy. Our educational videos have been sponsored by one of our corporate supporters.
Examples of ways in which stem4 involves users are as follows:
-Workshop and conference content is discussed with a school, and our offering tailored to meet any particular needs of the school
-stem4 gathers both quantitative and qualitative feedback from all workshops and conferences we run and feed this back into the development of our education offering
-We developed the Calm Harm app co-collaboratively with young people and will continue to work with young people in updates for the app
-We involve young people in producing our teaching videos, including a group of young actors who generated information from other friends and wrote parts of the scripts on case studies
-We regularly monitor feedback on the Calm Harm app from Google Play/App Store reviews and via emails we receive, and feed this information into further development of the app
-We have Involved users on our website by implementing a stem4 community page, allowing users to share their experiences of mental health with others
-We have involved our target audiences in developing leaflets on mental health conditions. We have held focus groups with students to get their feedback on the leaflet information, and sought feedback from parents/carers, GPs and teaching professionals
-We are currently testing our new mental health videos within a few select schools to gain feedback from students and teachers
-We involve our ambassadors who have lived experience of mental health issues. We provide them with training, support and opportunities to have an input into our educational work
-We ask students to give us ideas on what mental health support and initiatives schools should have. We currently have over 300 student’s feedback for a ‘stem4 mental health toolkit’ for schools
-We are hoping to develop a second self-help app and have obtained the views of students on what they think would most help them and will involve them in design and tasks ideas together with clinicians
-We involve service users or parents concerned/affected by their children’s mental health issues in our media messages
-We have regular team meetings at which staff are openly encouraged to put forward ideas for initiatives that will benefit the charity and drive it forward
In retrospect we should have budgeted for a larger amount to incorporate app modifications and maintenance, for design costs, a larger pilot study, and for marketing the product. We continue to manage this by having a business plan that is reviewed, a corporate team who are working on generating a stable income stream, applying to grants and charities and working towards employing a business development manager who can support us in generating new business.
Developing partnerships with statutory organisations such as the NHS has been a challenge, we are pleased to be overcoming this through our involvement with mHabitat’s Digital Development Lab who are able to assist us in maintain the quality standards required such as clinical safety and data protection.
To ensure sustainability, stem4 has developed a five year Business Plan, along with a Business Plan specific to the Calm Harm app. In addition we are looking to recruit a Business Development Manager, and other members to our team who have marketing, design, and research skills.
We have formed a corporate team whose sole task is to help explore funding opportunities. We are also moving towards digital platforms for our services, which makes us less reliant on individuals to deliver the service, thereby maintaining reliability, quality and consistency and reducing costs.
A review in ‘the Psychologist’ May 2017, the journal for the British Psychological Society quoted ‘A particularly useful feature is the My Log component of the app. Every time you ‘ride the wave’ you are asked how strong the experienced urge was, whether your chosen activity helped, and why you got the urge. Your answers, as well as the date and time the distraction activity was taken, will appear in the activity log. You can also see at what time of day on average you appear to be using the tasks and how high your urge to self-harm has been recently. Some cute additional features can be found in the preferences section, where you can change the colour scheme of the app or change the app’s mascots (a tough choice between fun cartoon characters or adorable cartoon animals). Comparing it to another app to help manage self harm it concluded ‘I found both apps user-friendly, however Calm Harm was the favourite for me. It allows the individual’s experience to be personalised and the tracking feature is useful.’
The Black Dog Institute eMHPrac review 2017 in Australia by Psychiatrist Dr Orman who uses a patient review states ‘the timer is great as it gives you two options, 5 minutes and 15 minutes, however when distressed even 30 seconds seems like too much so what is great about the timer on Calm Harm is it breaks it up in 60 second intervals and asks you at the end of each 30 seconds whether or not the urge has passed, or if you require more time and suggestions. When I first used the app, the initial 60 seconds seemed like forever and the urge didn’t pass so I started the timer again and each time I did the time passed quicker and my urges decreased’.
Calm Harm was a finalist at the AXA PPP Health Tech and You Awards 2017 and we were featured at the Design Museum in Kensington. Calm Harm was featured in the Evening Standard on the 12th April, on SKY News on the 25th April 2017. Dr Krause was interviewed on BBC Facebook Live on the 28th April 2017. Self-Harm.co.uk called Calm Harm a ‘helpful tool that can be used with confidence’ and Pharma Focus May 2017 featured Calm Harm as ‘time for a new kind of therapy’. Dr Krause spoke about Calm Harm at UK e-Health Tech Week 2017 at London Olympia for the 2020 Health Challenge and also presented Calm Harm as part of the NHS Digital talks.
We measure the effectiveness of the Calm Harm app by the number of downloads, which is over 38,000 since it’s launch in 2015, the app rating (4.08/5 on Google Play) and also the app reviews and feedback via emails we receive. We encourage feedback from app users, which we use in the update process. We have installed new analytics in the new update of the app which shows that for the month of April we had 4,391 downloads with 2,882 saying that the app helped manage their urge to self-harm that’s 66% positive answers. We receive a lot of positive feedback via Google Play/App Store reviews and emails, for example:
“Just wanted to connect and say I’ve been experimenting with Calm Harm and really love it/will be recommending. I have a long history of self-harm and would have really benefited from something like this when I was younger.”
Nadia Mendoza, Self Esteem Team
“A year ago, I was diagnosed with major depression and I went into therapy. During the past year I had to deal with suicidal thoughts, panic attacks and sadness every day. I started cutting myself and it became an addiction: I couldn’t stop. I cut myself every day. But then I discovered the app of Stem4: Calm Harm. This was the solution for my self-harm! Every time I felt the urge to cut myself, I opened the app and I did some activities. The urge faded! I am clean for a month now and I am very proud of that. But it’s because of the app I can stay clean, so that’s why I want to thank stem4 so much for this fantastic invention!”
Calm Harm user, name withheld
Our current evaluation study is measuring demographics, retention, what tasks are being used and how, time taken for symptoms to reduce, and whether the users are accessing other services. We are also exploring the option to evaluate the use of Calm Harm in a school setting.
Calm Harm has been downloaded over 38,000 times, with early evaluation showing that 66% of users are reporting that the urge to self-harm has passed after completing an activity within the app.
stem4’s website provides evidence-based health education, giving detailed information for young people, friends, parents and schools. It includes templates of policies and procedures for schools, adopted by a number of schools, and practical steps friends and parents can take to support early stages of a mental health problem, as well as support themselves. We provide a number of resources such as how to talk to a teenager, sample eating plans, and tips for managing difficult behaviours, all free to download from our website www.stem4.org.uk.
At each conference we run we produce a bespoke programme for delegates to take away with them, containing information on mental health adapted for the particular audience.
stem4 has produced information leaflets on common mental health issues: eating disorders, self-harm, depression, anxiety and stress. These provide key facts about the mental health condition and signpost help available. We regularly send out information to individuals, groups and organisations requiring information on the four areas we work in, as well as about resilience. We regularly send out Calm Harm resource packs, which have information about self-harm as well as about the app, and of course the Calm Harm app itself is available as a free download.
Our report on our GP survey is available for download as well as distribution. We share our ideas and suggestions with GPs, school nurses, and teachers. Our survey details on our parents’ survey is also available for distribution.
Our set of educational videos will be available for download and use within the PHSE slot in schools.
