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Understanding pathways to self-harm and suicide ideation in high risk young people: an unmissable opportunity for suicide prevention.

Mental Health Research UK PhD Scholarship 2020 - University of Nottingham 

Supervisors: Professor Ellen Townsend and Professor Jon Arcelus

Lay Summary:

Understanding and responding effectively to self-harm is a vital element of suicide prevention since self-harm is the strongest predictor we have of death by suicide and is related premature death by other causes. Self-harm is complex and changes over time so we have developed the Card Sort Task for Self-Harm (CaTS) to examine how thoughts, feelings, behaviours and events lead to self-harm in high risk adolescents (those with eating disorders and transgender youth). Using novel statistical techniques, we can uncover the significant patterns amongst key factors (e.g. feeling depressed, behaving impulsively) in the months, weeks, days, hours and minutes leading up to self-harm, and what happens after. Three online studies will investigate (i) which key patterns act as warning signals that self-harm is imminent (ii) why some adolescents have thoughts of self-harm but do not act on them and (iii) why another behaviour is carried out sometimes rather than self-harm. Findings will have significant implications for models of, and treatments for, self-harm and suicidality.

Research Student: Katherine Bird, BSc, MSc

I obtained my BSc in Psychology and MSc in Psychological Wellbeing and Mental Health from Nottingham Trent University. I recently began my Mental Health Research UK PhD Scholarship investigating and understanding pathways to self-harm and suicide at the University of Nottingham. My research interests include suicide- and self-harm-related stigma, toxic masculinity and its impact on male help-seeking behaviours, and the development of effective suicide prevention interventions. Additionally, I am interested in social constructs regarding suicide and Mental Health conditions and how they promote or discourage help-seeking behaviours and interaction with Mental Health Services in different populations. In my spare time I love reading, hiking, cooking, and baking. 



Create a new online CaTS-E to examine the key patterns of thoughts, feelings, events and behaviours leading to enaction of self-harm in high risk young people (transgender young people and young people with disordered eating) compared to other young people who self-harm. 

Investigate the key transitions where thoughts do not proceed to action (ideation) (CaTS-I). 

Investigate the key transitions that lead to alternative behaviours which could be positive (e.g. yoga) or negative (e.g. bingeing or purging) using the CaTS-AB.

Katherine Bird photo.jpg

Progress Report year 3, 2023 

This past year I have developed a web-app version of the card sort task for self-harm. I will be using this over the remainder of my PhD to capture large data sets. The web-app (CaTS-E) behaves like an app but doesn’t need to be downloaded on your phone. This will enable participants to access the web-app via a link and perform the card sort task at their leisure. CaTS-E has been bug tested a number of times by colleagues, my supervisor team, and other PhD students. There have been various prototypes of CaTS-E, with changes being made based on usability and function. I also had to adapt the task to ensure it was completed in around 20-minutes. This was based on research which shows participants in online studies lose interest after this time and frequently drop-out. Changes were also made based on feedback from peers and supervisors. These were largely associated with how the cards looked and minor technical errors. The web-app is now ready to be uploaded to university servers and be used in my PhD research. My next steps are to secure ethical approval (this has been sought) and begin recruiting for a small pilot study to measure feasibility and usability of CaTS-E, and whether performing the task has an impact on participants’ mood. I will also be gathering feedback about performing the task and the images used and ensuring data is captured and stored securely. After the pilot testing, I will begin recruiting for the large study which will use large data sets to identify key targets for self-harm in LGBTQIA+ and general populations.


Additionally, this past year, I have captured qualitative data from LGBTQIA+ people regarding CaTS. This is important to ensure it is appropriate and meaningful to LGBTQIA+ people, otherwise it may not be suitable to capture their experiences. I am still recruiting participants but have performed and transcribed some interviews already. Early and tentative findings suggest we need to include some cards specific to LGBTQIA+ experiences, such as discrimination, trans/homophobia, and sexual or gender identity issues. There were also suggestions to include school-, social media- and covid-related cards. This study is still underway, so findings may change as more data is collected. Finally, last year, I completed a systematic review: Risk and Protective Factors for Self-Harm in Transgender People: A Systematic Review. Briefly, findings show discrimination, drug use, and depression are key risk factors, and family/peer support and safe school environments are significant protective factors. This review has been submitted to journal and I am awaiting a response from them.

Progress Report Year 2, 2022

Understanding pathways to self-harm and suicide in high-risk youth using the novel Card Sort Task for Self-Harm (CaTS): An annual update


Self-harm (non-fatal intentional self-injury or -poisoning regardless of intent) is a significant public health concern. Self-harm is linked to reduced physical and psychological wellbeing, reduced educational attainment, increased drug and/or alcohol abuse, and the exacerbation of existing mental health conditions. Some youth groups are at increased risk of self-harm: trans* youth and young people with disordered eating. Despite their increased risk there is a lack of understanding of factors influencing each group’s self-harm pathway. Because of their increased risk and the lack of understanding of their self-harm pathway, these groups are the focus of my PhD research.


During the past year I have researched and almost completed a systematic review of risk and protective factors for trans* self-harm. Improving understanding of factors for trans* self-harm will identify meaningful and appropriate targets that can be addressed during intervention. In total, 40 studies were included in the review. The key findings are:


  1. Significant heterogeneity of risk and/or protective factors investigated. Many factors were only investigated by a single study. Therefore, the findings cannot be applied to the wider trans* population. Further research is necessary to reduce this heterogeneity and provide a robust evidence base regards the impact of risk and protective factors for trans* self-harm.

  2. Studies largely investigated general risk factors (i.e., depression). The impact of trans*-specific risk factors (i.e., transphobia) is less well-established. Future research should focus on trans*-specific risk and protective factors to clarify their impact on trans* self-harm.

  3. There is some evidence protective factors (particularly social support) mitigates self-harm risk in trans* people. However, few studies investigated protective factors. More research is necessary to further clarify the protective nature of these factors.

  4. Measures used have not been validated in trans* populations. This is problematic as they be insufficient or inappropriate to capture trans* experiences. Validating measures in trans* populations is necessary to increase their appropriateness for capturing trans* experiences.


I am currently recruiting participants for small focus group study asking trans* participants their views of the existing CaTS. This is to ensure CaTS is meaningful and appropriate to capture trans* self-harm and relates to the fourth finding of the systematic review. I have also been developing an online ‘app’ version of the novel Card Sort Task for Self-Harm (CaTS). I will use this later in my PhD to gather large data of the self-harm pathway of each high-risk group. Figure 1. is a picture of how CaTS is performed in-person. However, this is not appropriate for an ‘app’ version. I have been working with a Masters student in the School of Computer Science and we have designed CaTS differently. Instead of having a timeline at the top and cards placed beneath the timecards, the user will begin at the ’12-month’ time stamp and be presented with 6 CaTS cards. They will select the cards relevant to them at that timepoint, then be presented with another 6 cards, and so on. They will do the same process for each time point until they have worked through all time points. This format should reduce the amount of time it takes to complete the task and, consequently, reduce the number of participants dropping out. My next steps are a systematic review of shared risk factors for self-harm and disordered eating, a focus group asking young people with disordered eating their views of CaTS, finish designing and creating CaTS-app and testing it in a small pilot study, and a large-scale study using CaTS-app to examine each high-risk groups self-harm pathway.

Progress Report 2022.jpg

Figure 1. An example of CaTS done in-person. Performing a similar task on a smartphone would be difficult, so the 6-card selection for each timepoint is thought to be more user-friendly

Progress Report Year 1, 2021

This past year was the first of my PhD so was a training year.  Therefore, I undertook several modules which would help me develop the skills necessary to complete my PhD.  These were: Systematic Reviews; Individual and Group Differences; Advanced Methods in Psychology; and Professional Skills in Behavioural Science.  These spanned the whole year and involved weekly lectures and at least one assignment.  These assignments varied including academic essays, research articles, and short presentations of my work to a non-academic audience.  They all required me to think about research from multiple perspectives and write accordingly.  I achieved high academic grades in all modules so feel confident I have learnt and further-developed skills that will aide my research during and beyond my PhD. 


The two high-risk youth groups which are the focus of my PhD are transgender youth and young people with disordered eating.  Understanding factors associated with each groups self-harm and suicidal behaviour is essential to understanding each groups pathway.  Therefore, I began a systematic review during which I will review existing evidence of risk and protective factors for self-harm and suicidal behaviour in transgender youth.  I have a similar review planned for later in my PhD for young people with disordered eating. 


The next step of my PhD is to begin developing an online version of an existing card sort tasks for self-harm (CaTS; see Figure 1 for example).  This task was developed previously and allows young people to describe their individual pathway to self-harm using 117-cards with concepts associated with self-harm.  During my PhD I will use my newly-developed online version of CaTS to investigate factors present in the pathway to self-harm and suicide ideation in each high-risk youth group.  The aim is to identify group-specific targets which can be addressed during intervention.  I have begun investigating the suitability of different software and have recently been advised of a team within the University of Nottingham which can support me in developing the online CaTS.


Figure 1. An example of the Card Sort Task for Self-Harm (CaTS)


This year I presented my research at several conferences, including MHRUK’s Scholar’s Day.  These were great opportunities to create presentations aimed at either academic or non-academic audiences and present them accordingly.  I also attended several online conferences.  They were great because I heard from researchers with similar research interests.  This inspires me to consider how other techniques or methods may be suited to my research.  Finally, despite being online, these conferences were great networking opportunities and I have begun building relationships with people with similar research interests who I can collaborate with in future. 

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