At least 700 000 people worldwide die by suicide every year.1 In Taiwan, suicide was the 11th leading cause of death, accounting for 15 deaths per 100 000 people in 2021. Self-harm is a key risk factor for suicideReference Favril, Yu, Uyar, Sharpe and Fazel2 and could include a wide range of behaviours such as skin cutting, head hitting and self-poisoning.Reference Skegg3 The suicide rate among individuals with a history of self-harm was 37–49 times greater than that in the general population.Reference Olfson, Wall, Wang, Crystal, Gerhard and Blanco4,Reference Hawton, Bergen, Cooper, Turnbull, Waters and Ness5 Moreover, a recent systematic review showed no decrease in the incidence of repeated self-harm and suicide in those presenting to hospitals with self-harm during the 10 years before the review.Reference Carroll, Metcalfe and Gunnell6 Therefore, there is an urgent need to develop evidence-based interventions to reduce repeated self-harm behaviours.
Acute healthcare settings, such as emergency departments, could be the first contact point for many individuals who self-harm and may provide a window of opportunity for support.Reference Betz, Wintersteen, Boudreaux, Brown, Capoccia and Currier7 However, existing evidence-based interventions to reduce repeated self-harm behaviours, such as cognitive–behavioural therapy,Reference Hawton, Witt, Salisbury, Arensman, Gunnell and Hazell8 are not applicable in acute healthcare settings because of the need for substantial human and time resources. Therefore, a growing body of literature focuses on developing brief interventions, which can be delivered in a single time-limited encounter, require fewer resources, and have greater potential to reach more individuals in need. Recent meta-analyses showed that brief acute-care suicide prevention interventions, such as safety planning and other brief therapeutic interventions, were associated with reduced repeated suicide attempts.Reference Doupnik, Rudd, Schmutte, Worsley, Bowden and McCarthy9,Reference Nuij, van Ballegooijen, De Beurs, Juniar, Erlangsen and Portzky10
Volitional help sheet
The volitional help sheet (VHS), one type of brief intervention, has been recently examined regarding its effect on reducing repeated suicidal behaviours. The intended goal of the VHS is to apply a self-regulatory strategy known as implementation intention, to support people to link a critical situation (‘if’) with an appropriate response (‘then’), and thus form ‘if–then plans’.Reference Gollwitzer and Sheeran11 The VHS was developed based on several theories, including the integrated motivational–volitional model of suicidal behaviourReference O'Connor and Kirtley12 and the transtheoretical model of change.Reference Prochaska and DiClemente13 Two randomised controlled trials investigated the effect of VHS on reducing self-harm and showed inconsistent results. A study in Malaysia found that the VHS could reduce suicidal ideation and behaviour at a 3-month follow-up,Reference Armitage, Rahim, Rowe and O'Connor14 whereas a study in the UK found that the VHS had no overall effect on reducing self-harm repetition at a 6-month follow-up.Reference O'Connor, Ferguson, Scott, Smyth, McDaid and Park15 One reason for mixed research findings regarding the effectiveness of the VHS could be that the VHS, or part of it, lacked acceptability for some individuals who self-harmed.
It is increasingly acknowledged that acceptability should be a key consideration when developing new interventions. As highlighted by Medical Research Council guidance, developing a deep understanding of the feasibility and acceptability of an intervention is critical to increase the likelihood of successful implementation.Reference Skivington, Matthews, Simpson, Craig, Baird and Blazeby16 Acceptability is a multifaceted construct, and the perspectives of the target population of the intervention, such as individuals with self-harm, are crucial.Reference Sekhon, Cartwright and Francis17 This study aimed to explore the perceptions of individuals presenting to hospitals with self-harm toward the acceptability of the Chinese version of the VHS (VHS-C), with a focus on their perceived intended goal and effectiveness of the VHS-C and feedback on the language clarity, implementation settings and format of the VHS-C.
Method
Participants
We used purposeful sampling to recruit participants. The inclusion criteria were that participants were adults (i.e. over 20 years old) with self-harm experiences over the past month. Eligible participants from the in-patient and out-patient units of the Department of Psychiatry at a medical centre in Taipei, Taiwan, were referred to the research team by treating psychiatrists. Patients who were assessed by psychiatrists and found to have hallucination symptoms, current high risk of suicide or limited verbal expression were excluded.
Data collection and analysis
The original VHSReference Armitage, Rahim, Rowe and O'Connor14 was forward-translated into Chinese by the research team and then backward-translated into English by a bilingual board-certified psychiatrist. The research team discussed the translation statement by statement to reach a consensus.
After providing their written consent, the participants were asked to complete the paper-based VHS-C (Fig. 1) with paper and pencil, and then the web-based VHS-C (Fig. 2) on their own. The web-based VHS-C was designed to be accessible through smartphones or tablets. The participants were provided with a tablet to complete the web-based VHS-C in the study. After completing both formats of the VHS-C, the participants were interviewed for their perspectives on the VHS-C. The interview topics included the following: if they found the VHS-C potentially helpful in reducing future self-harm behaviours, if they experienced any difficulties in understanding the listed critical situations and solutions (i.e. ‘if–then’ statements) in the VHS-C, if they felt that anything missing in the VHS-C and their preferred format of the VHS-C (i.e. paper-based versus web-based). The interviews were conducted between November 2017 and May 2018, lasting 40–60 min each.
Fig. 1 Paper-based Chinese version of the volitional help sheet (VHS-C), with English translation.
Fig. 2 Web-based Chinese version of the volitional help sheet (VHS-C), with English translation.
The interviews were audio-recorded and analysed using the framework method, with the following steps: transcript, familiarisation with the interview, coding, developing a working analytical framework, applying the analytical framework, charting the data into the framework matrix and interpreting the data.Reference Gale, Heath, Cameron, Rashid and Redwood18 The recorded interviews were transcribed verbatim. The first and second authors read and re-read each transcript, and proposed potential coding labels independently. Then, the first author incorporated the agreed coding labels to develop the initial analytical framework (i.e. codebook or coding manual). The analytical framework was then revised and finalised based on multiple discussions among the research team members. The first author then applied the final version of the analytical framework to each transcript consistently. We used the qualitative analysis software package ATLAS.ti for Windows (version 8.4.26.0, ATLAS.ti Scientific Software Development GmbH, Berlin, Germany; https://atlasti.com) to summarise the data as a framework matrix and to compare the experiences across participants. The research team members met as a group to identify themes regarding the perceived intended goal and effectiveness of the VHS-C, the clarity of the ‘if–then’ statements and the preferred implementation settings and format of the VHS-C.
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. All procedures involving human patients were approved by the National Taiwan University Hospital Research Ethics Committee (approval number 201708008RINB), and the trial was registered with ClinicalTrials.gov (identifier NCT03376113).
Results
Fourteen participants completed the interviews. The participants comprised five males and nine females aged 20–47 years. All of the participants reported having a psychiatric diagnosis (Table 1). We categorised participants’ perceptions of the VHS-C into four themes: (a) the perceived intended goal of the VHS-C, (b) the perceived effectiveness of the VHS-C, (c) the clarity of ‘if–then’ statements and suggestions, and (d) the preferred implementation settings and format. Supporting quotes for each theme are provided in Table 2.
Table 1 Demographic and self-harm characteristics of the participants
All participants were recruited from an in-patient ward except for participant 14, who was recruited from the out-patient clinic.
Table 2 Participant quotes
VHS-C: Chinese version of the volitional help sheet.
The perceived intended goal of the VHS-C
Four participants indicated that they could understand the intended goal of the VHS-C without any problems by simply reading the written instructions. Some other participants indicated that, on top of the written instructions, the interviewer's verbal instructions also helped them to better understand the intended goal of the VHS-C. By contrast, three participants indicated that, by reading the content of the VHS on their own, they could not perceive that the intended goal of the VHS-C was to help people decrease self-harm behaviours; instead, they perceived the VHS-C as simply a list of questions, as one participant said, ‘It [VHS-C] just asks me some questions but does not solve my problems’ (participant 5).
The perceived effectiveness of the VHS-C
Six participants shared that they found the VHS-C helpful. The main reasons included (a) the ‘if’ statements are relatable to the participants’ own experiences; (b) the ‘then’ statements provided the participants with new coping strategies that they were not aware of, and the participants were willing to try these new strategies; and (c) the instructions of the VHS-C, such as ‘We understand that you have just been through some very unpleasant experiences’, made them feel understood and accepted.
However, some participants shared that the VHS-C might not be helpful because of the following reasons. First, nine participants indicated that some ‘if–then’ statements were not specific enough (e.g. the statements did not specify whom they could talk to when having suicidal thoughts). Second, ten participants indicated that the VHS-C might not be helpful when they were ‘at the moment’ of having suicidal thoughts, as a participant said, ‘I feel it would be hard for me to read these sentences when I want to hurt myself’ (participant 2). Some indicated that they might not check the VHS-C or would be unable to read it at the moment. Finally, three participants reported that the VHS-C might trigger negative emotions, such as feeling frustrated or being condemned. Examples are included in Table 2.
The clarity of the ‘if–then’ statements and suggestions
The participants indicated that most ‘if–then’ statements were clear, but they found some ‘then’ statements confusing. For example, seven participants indicated that the statement, ‘Then I will make sure I am rewarded by others if I don't self-harm’, was hard to understand. Four participants were confused by the statement, ‘Then I will tell myself that society is changing in ways that make it easier for people to stop self-harming’, as they found it unclear about the specific kinds of societal changes that the statement was referring to, as one participant said, ‘I don't understand this one. I felt the society is getting worse’ (participant 5).
Seven participants suggested adding more ‘if–then’ statements that could reflect their lived experiences. Examples were included in Table 2. One participant suggested that the VHS-C could provide open-ended spaces for them to fill in additional ‘if–then’ statements based on their experiences.
The preferred implementation settings and format
When asked if emergency departments would be an appropriate setting to implement the VHS-C, half of the participants disagreed. The participants felt that some individuals who have suicidal thoughts or behaviours might not be ready to read through the VHS-C at emergency departments as they may be experiencing emotional outbursts or feeling uncomfortable physically at the moment.
Regarding the comparison between paper-based and web-based versions of the VHS-C, the majority of participants preferred the web-based version of the VHS-C (nine out of 14). The main reason for preferring the web-based version was that, compared with the paper-based version that could have multiple lines on the same page, the web-based version made the VHS-C more visually appealing and easier to use because they could focus on the ‘if–then’ statement one at a time. Regarding the preferred format, texts and emails received a similar number of supporters. The preferred frequency of follow-up reminders ranged from one per week to one every 4 months. The participants indicated that the preference could depend on each individual's habits and personal situations, so they should decide what works best for them.
Discussion
We conducted interviews with 14 individuals with self-harm experiences and explored their perceptions regarding the acceptability of the VHS-C. The content of the VHS-C was felt to be acceptable, and participants also reported the reasons why the VHS-C could be helpful or unhelpful, suggestions for improvement, that emergency departments may not be an appropriate setting to implement the VHS-C, and their preferred format of the VHS-C, as well as the preferred format and frequency of follow-up reminders.
Although our participants could understand the intended goal of the VHS-C based on the current written instructions, they would like more information and verbal instructions. Similarly, the acceptability studies in the UK highlighted the need for clearer instructions,Reference Keyworth, Quinlivan, Leather and Armitage19,Reference Keyworth, O'Connor, Quinlivan and Armitage20 which would be helpful for people to understand the purpose of the VHS.
We noted two key factors that may influence the acceptability of a brief intervention, like the VHS-C, in individuals with self-harm experiences. The first factor is relevance, i.e. if the target population find the intervention relevant to their lived experiences and needs. In the UK studies, participants also highlighted that the intervention should contain relevant situations, and the relevance level may influence how the participants felt when using the VHS and their confidence in using it.Reference Keyworth, Quinlivan, Leather and Armitage19,Reference Keyworth, O'Connor, Quinlivan and Armitage20 Given the diverse experiences among individuals who self-harm, one possible way to enhance the relevance is to provide open-ended spaces so that individuals could add ‘if–then’ statements based on their own experiences. Another way is to revise the instructions to proactively acknowledge the diversity of individual experiences and that not all statements will be perceived as relevant to everyone, as shown in the UK study.Reference Keyworth, Quinlivan, Leather and Armitage19 For example, the instructions could be revised to: ‘The experiences of each person might vary a lot. We try to provide a wide range of situations to capture the experiences as much as possible. You might find some statements relevant or irrelevant to your situation. Please feel free to skip to the next statement if the statement does not fit your situation’.
The second factor is the potential emotional responses triggered by the brief intervention. In our study, feelings toward the VHS-C included a feeling of being understood or judged. In the UK study, some participants pointed out that the VHS may induce negative emotions, such as feeling guilty for wanting to self-harm.Reference Keyworth, O'Connor, Quinlivan and Armitage20 One way to address this concern is to remove or revise the statements and wordings that may lead to negative emotions.
Our participants pointed out two confusing statements. One of them, ‘Then I will make sure I am rewarded by others if I don't self-harm’, was also considered inappropriate in the UK study and removed in the revised version.Reference Keyworth, O'Connor, Quinlivan and Armitage20 The VHS-C was not considered by our participants to be helpful ‘at the moment’ of having suicidal thoughts, and they pointed out that emergency departments might not be the most appropriate place to implement the VHS-C. In the UK, some participants indicated that the VHS might be more useful before the crisis point,Reference Keyworth, O'Connor, Quinlivan and Armitage20 and some participants believed that people might benefit from the VHS only in certain situations or contexts, such as having the willingness to change.Reference Keyworth, Quinlivan, Leather and Armitage19 More research is needed to explore when and how potential users want to use the VHS/VHS-C to support themselves.
Strengths and limitations
This is among the first studies exploring the acceptability of the VHS-C and ways of improvement from the perspectives of individuals with self-harm experiences. According to the findings, we revised the VHS-C. The web-based VHS-C can be found in Supplementary Fig. 1 available at https://doi.org10.1192/bjo.2023.78/. However, there are several limitations of this study. The findings were restricted to the experiences of 14 participants with mental health diagnoses recruited from the in-patient and out-patient units. This group received more intensive care than those who did not seek medical help. Many individuals with self-harm experiences did not seek mental health services,Reference Han, Batterham, Calear and Randall21 and their perspectives regarding the VHS-C could be different. Further research is needed to include a more diverse group of participants to inform the design and implementation of aftercare interventions that use the VHS-C.
Supplementary material
Supplementary material is available online at http://dx.doi.org/10.1192/bjo.2023.78
Data availability
Because of the nature of this research, participants of this study did not agree to share their data.
Author contributions
I.-T.H. contributed to study conceptualisation and methodology, formal analysis, wrote the original draft of the manuscript and reviewed and edited the manuscript. Y.-C.C. contributed to study conceptualisation, project administration and formal analysis, wrote the original draft of the manuscript and reviewed and edited the manuscript. C.J.A. reviewed and edited the manuscript. C.-Y.H. contributed to study methodology and reviewed and edited the manuscript. S.-S.C. contributed to study conceptualisation, methodology and formal analysis, obtained the funding, wrote the original draft of the manuscript and reviewed and edited the manuscript.
All authors have read and approved the manuscript for publication.
Funding
This study was supported by the National Taiwan University and Academia Sinica Innovative Joint Program grant awarded to S.-S.C. (grant numbers NTUAS-106R104508 and NTUAS-107L104308), and by the grant awarded to S.-S.C. by the Population Health Research Center, National Taiwan University from the Featured Areas Research Center Program within the framework of the Higher Education SPROUT Project by the Ministry of Education (MOE), Taiwan (grant number NTU-112L9004). S.-S.C. and I.-T.H. were supported by the National Science and Technology Council, Taiwan (grant number MOST 109-2314-B-002-144-MY3). C.J.A. is supported by the NIHR Manchester Biomedical Research Centre and the NIHR Greater Manchester Safety Translational Research Centre. The views expressed in this publication are those of the authors and not necessarily those of the NIHR.
Declaration of interest
None.
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