The Calm Harm app by stem4 helps young people resist or manage the urge to self-harm. Developed by Dr Nihara Krause, a consultant Clinical Psychologist, together with ideas from young people, the Calm Harm app uses strategies from Dialectical Behaviour Therapy (DBT) to help users learn to identify and manage their ‘emotional mind’, teaching impulse control, emotional regulation and tracking underlying triggers to harmful urges.
It is not a substitute for the assessment and individualised treatment of a health/mental health professional.
The Calm Harm app is recommended for the ages of 13 years and above. If a younger child would like to use it, it is recommended that this is done under the guidance of a responsible adult.
Please note that the Calm Harm app is not a substitute for assessment and intervention by a mental health professional. It is recommended a GP should be consulted in the first instance.
‘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:
∙ 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
∙ Release provides safe alternatives to self-injury
There is also a breathing technique to help reduce symptoms of stress and anxiety.
The Calm Harm app educates using strategies from evidence-based Dialectical Behaviour Therapy (DBT). DBT has been shown to be an effective treatment for some groups of patients who self-harm.
The focus is on helping the user learn to identify and manage their ‘emotional mind’. The app teaches children and young people impulse control, emotional regulation and tracks underlying triggers to harmful urges. It also helps self-monitor and signposts to help.
The Calm Harm app gives users 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.
Dialectical Behaviour Therapy (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. The Calm Harm app provides a sense of control to deal with problems, helps self-reflection and increases motivation to ask for help.
Mood disorders have been impacted significantly as a result of the pandemic. This is partly because of the stressful nature of the pandemic itself and limited access to treatments and also because stress management and mood enhancement strategies such as exercise and meeting friends are restricted.
In order to support children and young people affected, stem4 has created an animated video and user booklet on how to use the Calm Harm app over this time. This includes specific mood issues that may have increased during or as a result of the pandemic, such as loneliness for example, and also pandemic safe tasks which abide by safety guidelines such as social distancing.
Downloads of the stem4 digital portfolio of apps has increased by 40% subsequent to the pandemic and we will endeavour to use the feedback we receive from our users and our focus groups to update the Calm Harm app.
To develop an evidence-based, widely accessible digital tool to help young people (13 years and over) manage the urge to self-harm (younger with parent involvement).
To be universally acceptable – It can be helpful for young people who are unlikely to accept traditional treatment, whose behaviours do not meet the threshold for help, are waiting for treatment or alongside treatment.
To devise an anonymised analytical model to evidence effectiveness and inform future development.
To comply with NHS digital technology standards.
To raise the profile of stem4 and its work to support teenage mental health.
The model of the Calm Harm app was developed according to Dialectical 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 the Calm Harm app 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 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’.
A clinical study is pending – we are currently having discussions with a possible research partner.
Analytics from the Calm Harm app:
In order to evidence the effectiveness of the Calm Harm app, the following data is collected:
Latest Calm Harm app analytics data (up until the end of December 2020) tells us:
There have been over 1.75 million downloads of the Calm Harm app to date.
92% of the individuals who used the Calm Harm app reported that an activity helped to reduce the urge to self-harm.
The Calm Harm app was developed co-collaboratively with young people. Co-collaborative workshops with young people explored desired outputs, user journeys, visual concepts, security/privacy, user experience, and tone of voice.
Clinical and professional groups provided input on safety, user characteristics, strengths, potential barriers, referrer experience and tone of voice.
stem4 consistently monitors user feedback via emails, social media and reviews on the App Store/Google Play. In addition, we will use annual, small user groups to feedback to update the Calm Harm app.
Over the pandemic, an animated video and booklet were created providing Calm Harm app users with guidance on how to use the app safely. The content for this was created by a Clinical Psychologist together with feedback from a small group of users.
We aim for all our user groups to be diverse and inclusive and represent a cross-section of our youth user community.
Clinical Input and Safety
The clinical content of the Calm Harm app was created by a Clinical Psychologist and the app underwent a clinical safety assessment with a range of clinicians including a GP, Adolescent Psychiatrist, family therapist and Clinical Psychologists.
Our clinical evaluation groups also include a diverse range of different professionals.
We welcome user feedback which can be emailed to email@example.com.
A number of standards were used. These included:
NHS Digital DCB0129 standards. Developed by the NHS, this standard is designed to help manufacturers of health IT software evidence the clinical safety of their products.
User Needs design based on workshop feedback with young people.
Design with data using existing app data.
Iteration – New updates depending on things that have (or haven’t) worked or new functionality.
stem4 strives to be as broadly accessible as possible through the use of industry best practices. For example, contrast colours for those with sight issues, using a font that’s clear to read etc.
stem4 has put a number of measures in place to ensure that the Calm Harm app is clinically safe to use.
The Calm Harm app has been developed by a Consultant Clinical Psychologist and validated by the group it is for. The Calm Harm app complies with the clinical safety standard DCB0129. Developed by the NHS, this standard is designed to help manufacturers of health IT software evidence the clinical safety of their products.
stem4 has a Clinical Risk Management Plan. A Clinical Safety Review with clinical professionals was undertaken for the Calm Harm app and a Clinical Safety Case Report and Hazard Log created. The clinical risk is monitored and laid out in the Hazard Log. A flow chart of hazard mitigation and response is available which outlines how issues will be addressed together with target response times.
The target response time for urgent issues is 24 hours, for high priority issues 72 hours, medium priority 7 working days and low priority 14 working days.
The Clinical Safety Officer (CSO) is Dr Nihara Krause.
stem4 consistently monitors user feedback via emails, social media and reviews on the App Store/Google Play.
The Calm Harm app is reviewed on a quarterly basis during which app efficacy, including the efficacy of the activities, is reviewed, and the app updated as necessary to ensure it is clinically valid.
Users wanted an app with a small digital footprint that was private. No personally identifiable data is collected.
Users are given the option of setting a passcode. However, since no email address is taken if the passcode cannot be remembered we are unable to help reset it. Users are notified of this when setting the passcode.
Whilst some of the tasks are helpful for some users, others may be ‘triggering’ for others. We have therefore provided the option for users to hide particular activities they might find triggering in order to personalise the Calm Harm app for their safety.
When the urges remain high, a message is generated on the log which suggests the user sees a medical professional.
Users are signposted to National resources and emergency numbers.
The Calm Harm app is reviewed every three months and updated as required.
The Calm Harm app is an app that can be used on iOS and Android devices. The content is downloaded the first time the user opens the Calm Harm app and then cached. It can still be viewed and used offline.
The Calm Harm app has been designed with young people to ensure data and device memory/data use in their preferred device (smartphone) is not compromised.
The Calm Harm app does not collect personally identifiable data and an account does not need to be created to use the Calm Harm app. No cookies are used. IP addresses are not captured. The Calm Harm app is standalone and does not connect to any other apps or devices or interact with existing enterprise systems.
Some optional questions are asked in the Calm Harm app. This information is only used for research purposes and is completely anonymous. Anonymised data on whether tasks helped is collected to ensure that we can monitor the effectiveness of the Calm Harm app and individual tasks.
Calm Harm app users can be reassured that all information that is noted information is completely private. stem4 has no access to any of this information.
In order to evidence the effectiveness of the Calm Harm app, the following data will be made available:
Activity is logged to present the user with the following information:
All optional question and feedback data collected via the Calm Harm app is aggregated and cannot be tracked to each user/device. However, the security of this data is still important to us and we will take all steps reasonably necessary to ensure that the data is treated securely. The transfer of data is encrypted over a secure connection (SSL).
Calm Harm app data is stored using Amazon Web Services (AWS) which has certification for compliance with ISO 27001:2013 – https://d1.awsstatic.com/certifications/iso_27001_global_certification.pdf.
This data is retained for no longer than is necessary and destroyed by 5 years after expiration.
The developers of the Calm Harm app, stem4, are not required to register with the ICO (Information Commissioner’s Office) as no personal information is being processed. stem4 is compliant with the Data Protection Act 2018 and the GDPR. stem4’s nominated Data Protection Officer (DPO) is Yvette Nieslony and can be contacted at firstname.lastname@example.org.
The Calm Harm app does not create user accounts. This was based on user research, with young people telling us they valued privacy. This means that if the Calm Harm app is deleted or the device is changed, any app data is lost. stem4, therefore, recommends that screenshots of any data that is to be saved are taken.
To report an issue with the Calm Harm app please email email@example.com providing as many details about the issue as you can.
The developers of the Calm Harm app, stem4, endeavour to respond within target response times. The target response time for urgent issues is 24 hours, for high priority issues 72 hours, medium priority 7 working days and low priority 14 working days.
stem4 assesses and records any clinical risk. The Calm Harm app is reviewed quarterly and updates made where necessary.
stem4 will resolve major bugs that prevent the intended Calm Harm app functionality from working for devices and operating systems supported.
The Calm Harm app uses an evidence-based approach but it does not substitute for the assessment and treatment of a suitably qualified mental health professional. Please contact your GP or physician before use or if you are uncertain of whether the Calm Harm app is for you. As the saying goes ‘no one size fits all’ and digital approaches help some and not others.
If you still have an urge to self-harm after using the Calm Harm app, please try another approach or use the Calm Harm app alongside another approach. The Calm Harm app provides signposting to further help. In the UK you can call Childline (0800 1111), Samaritans (116 123) or SHOUT (text ‘SHOUT’ to 85258).
If you are under the age of 13, please use it with a responsible adult.
stem4 does not offer a counselling service. For any concerns please contact a GP and also the signposts in the Calm Harm app. In an emergency please contact 111 or 999 (UK).
Calm Harm is licensed by Leeds City Council for young people using the Leeds MindMate services.
“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.
FAQ v2 30/03/21