Fourteen participants were enrolled in DELVE (see [14]). Four dropped out after baseline interview, and one declined to complete diaries. The remaining nine participants returned at least one diary and were included in this sub-study. These participants were men and women, representing a range of ages and ethnicities and reported engaging with self-harm and suicide content on a wide variety of online platforms. All had self-harmed; most within the past year. There were no observable differences between participants who did and did not return diaries (Table 1).
Table 1
Demographic characteristics of participants who completed at least one diary entry vs. participants who did not complete a diary entry.
| | Completed Diaries N = 9 N (%) | No Completed Diaries N = 5 N (%) |
| Gender | | |
| Female | 6 (66.7) | 4 (80.0) |
| Male | 3 (33.3) | 1 (20.0) |
| Ethnicity | | |
| Asian British | 2 (22.2) | 0 (0.0) |
| Black British | 1 (11.1) | 0 (0.0) |
| White British | 4 (44.4) | 3 (60.0) |
| Asian Other | 1 (11.1) | 1 (20.0) |
| Black Other | 0 (0.0) | 0 (0.0) |
| White Other | 1 (11.1) | 0 (0.0) |
| Mixed Race | 0 (0.0) | 1 (20.0) |
| Age (years) | | |
| 16–24 | 5 (55.6) | 3 (60.0) |
| 25–45 | 3 (33.3) | 1 (20.0) |
| 46–54 | 1 (11.1) | 1 (20.0) |
| Last episode of self-harm | | |
| More than a year ago | 3 (33.3) | 0 (0.0) |
| In the last year | 3 (33.3) | 2 (40.0) |
| In the last month | 0 (0.0) | 3 (60.0) |
| In the last week | 3 (33.3) | 0 (0.0) |
| Social media sites/apps or internet forums used to access self-harm or suicide related contenta |
| Instagram | 2 (22.2) | 2 (40.0) |
| Facebook | 3 (33.3) | 1 (20.0) |
| TikTok | 0 (0.0) | 1 (20.0) |
| Tumblr | 1 (11.1) | 2 (40.0) |
| Twitter | 2 (22.2) | 5 (100.0) |
| Discord | 0 (0.0) | 1 (20.0) |
| WhatsApp | 1 (11.1) | 0 (0.0) |
| YouTube | 2 (22.2) | 2 (40.0) |
| Google | 1 (11.1) | 2 (40.0) |
| Other (Weibo) | 0 (0.0) | 1 (20.0) |
| Pro-choice suicide Forum | 1 (11.1) | 1 (11.1) |
| a Participants could select more than one platform |
Of the 9 participants, 4 (44.4%) completed all 5 diaries, 4 (44.4%) completed 3 or 4, and 1 (11.1%) completed 2 diaries. While some fields were left blank, between 77.4% and 100% of end of week summary questions were completed across the diaries.
Positive impacts
All participants reported deriving personal benefit from completing the diary and stated this outweighed any burden of completion. Benefits included valuing the responsibility of having to fill out a diary (ID84), feeling accomplished once this was completed (ID10) and finding it useful to track moods and experiences (ID3, ID4, ID84) and be reminded to ‘check in with yourself’ (ID10). In this way, completion could promote ‘interesting’ insight (ID24) about patterns in one’s mental health and coping.
Specific benefits were also discussed relating to individuals’ online use. Three participants stated that logging activities had drawn attention to how long they spent online, allowing them to monitor and potentially modify their usage:
The first questions about ‘when have you been online?’, that made me realise that at the beginning I went online far too much basically (ID4)
Similar awareness could be prompted around types of content accessed, motivations for engaging with self-harm content and how or when this may be unhelpful:
Keeping this diary has made me reflect on my online behaviour and I guess that (online use) could probably count as self-harming - seeking out something I know will make me feel worse because I feel bad about myself and I have urges to harm myself. Even though I didn’t cut, I still felt a lot of the same emotions like guilt and shame for looking (ID11).
I find reflection very helpful and I found it really helpful for me to reflect on how I use the internet and whether I’m doing it always for the best reasons (ID4).
Two participants indicated that keeping a record of content viewed also provided a route for discussing difficult content with others – in this case, the study interviewer:
It also helps me to talk about what I have seen online which is also good for my mental health (ID84)
If I saw something which I felt uncomfortable with or I thought that was worth talking about then I took a photo of it and uploaded it. So, I think overall it was a good experience… I probably wouldn’t have talked about them [self-harm images]… I think there’s tangible benefits [to completing the diary]. The tangible ones are reflecting. The tangible ones are talking to you (ID10)
When asked, ID84 also recognised potential benefits of sharing the diary with a mental health professional:
It would be really good because generally, it would lead to more help, and some kind of conclusion and solutions. (ID84)
Behaviour change
In view of reported benefits, participants were asked if completing the diary had altered their online behaviour. While one (ID2) stated it had not, another presented the opposite viewpoint:
I’m one of the very lucky ones who spends less time online as a result of the work you do… Even though I’ve only done [diary] for six months… I think I’ve learned more about [the internet] as a result and I’m a bit more streetwise (ID10).
The remaining participants presented more nuanced accounts, implying that habitual patterns of use had been disrupted and that they exercised more agency as a result of completing the diary, or now had an intention to change:
Towards the start of the study, I think I was blindly interacting with just about everything, whereas now I won’t just like a post because it’s on my feed. I’ll like it if I want to (ID24).
This shit is complex… I think moving forward I need to be a LOT more aware of my own urges online (diary free-text) (ID11).
It was evident that for another participant, the impact of diary completion had evolved during the study period:
Midpoint interview - Int: Did you find completing the diary changed the way that you interacted with any of the self-harm or suicidal content? ID4: No, I don’t think so. No. I wondered about that.
Final interview
It’s [diary] helped me understand more about how social media impacts upon me...I think you need to recognise that sometimes you need a break and the writing down, going in a diary and that has helped me understand more about that.
Final diary entry
I’ve learnt a lot about myself and it’s a good reflection on how things have changed… the growing list of what I do to distract etcetera [from online content] and changes around self-harm. I feel really proud of it.
Some participants said they would consider continuing a diary after the study having appreciated the reflective space it provided.
Acceptability and adherence
All participants found the diary acceptable and felt willing to disclose their online activities and associated feelings, though it should be noted that these comments were collected about the diary as a research tool rather than an intervention. They described themselves as ‘really honest’ (ID3) and not editing responses: ‘I included everything, there wasn’t anything missed out’ (ID2). One participant related this openness to a belief that the audience - mental health researchers - were likely to understand the content:
As long as you can understand everything I don’t mind sharing because it’s a safe space… I think a lot of the stuff you either know about, or because of the work you do you … you’ve got a good understanding of (ID10).
Some participants were used to journalling about their mental health so found the diary a familiar activity, but lengthy compared to other diaries. Daily completion was problematic for most participants for reasons such as forgetting (ID2), finding the structure repetitive (ID2, ID10), or finding it tiring (ID10, ID84) or ‘overwhelming’ (ID3, ID10). Two explicitly stated that mood impacted on their ability to complete:
I didn’t think, ‘I don’t feel like doing it,’ or ‘I don’t want to do it.’ It was in terms of where I was at with my mental health and I thought, ‘I will do stuff that has to be done to make it through.’ The diary wasn’t one of those things (ID11).
Completion was more difficult for high-volume online users:
I thought, ‘this is going to be really easy. Five minutes sitting down and doing a diary, really easy.’ But then you realise that actually there’s a lot more to it. I mean I spend most of my time on the phone. You look at your phone 7, 10, 15 times a day and I think I spent three hours in one day on Twitter... then you realise that actually you have to write about it and suddenly you can write a lot about it. You know, you can write an essay (ID10).
Completion barriers led to missing entries or adaptations in how the diary was completed. Several participants completed it in retrospective blocks, rather than daily, with an acknowledged effect on recall and three took screenshots to make recording their activities manageable:
I would just screenshot stuff and then at the end of the week maybe go in and do the whole diary of whatever days that I’d got these screenshots for and fill it out retrospectively rather than doing it daily (ID3).
Commitment to the study led three participants to experience feelings of anxiety or guilt about whether they were completing their diaries satisfactorily.
Negative impacts and ethical considerations
Only one participant criticised the diary, explaining that completing it could interfere with benefits they perceived from online engagement and implying that readiness to change was key to acceptability:
I can barely put my phone down for ten minutes, so I’m already very aware that it’s a bit of an issue... and it’s just not something that I want to deal with right now. [Online use] is a distraction. Sometimes reading about somebody else’s story takes you away from thinking about your own for five minutes… then having to stop and think, ‘Oh no, I’m doing this in the real world. I’m filling out this diary, so I must now make a note of this,’ which breaks that. It stops that from working so well. (ID3)
Unintended consequences also emerged. Two participants indicated logging engagements could increase attention to, or even consumption of, self-harm/ suicide content due to curiosity or desire to return an ‘interesting’ diary, though the impact of this was not clear.
When you’re keeping a diary, this sounds strange, but you want to see what’s really out there. You’re more inquisitive… I think I would have still looked at those things. I still would have done those things, but I think there’s more thought there (ID10)
I felt that perhaps my input into this study was a little useless as I wasn’t seeing any posts noteworthy for my diary. Then, towards the end of the week, I slowly started seeing more posts and then felt bad that I’d perhaps willed the posts onto my feed! (ID24, Diary free-text)
I think maybe I just am more aware when I’m looking at it, whereas before, I’d look at a post and scroll past. Now, sometimes I’ll read it and actually pay attention to what I’m looking at. So, I think it’s actually made me more conscious (ID24).
Similarly, revisiting content in order to log it, or the practice of screenshotting (above) increased exposure and created a record of content on the participants’ devices unless this was deleted.
I’m scrolling through [social media] all day long and then I forget that I’ve read something. I’ll then go back looking for it. Like I say, I tried the screenshotting for a while because that was a bit easier… That felt very much like ‘Oh god, I’ve got to go back through and relook at stuff now (ID3).
Two participants included online images of self-harm within their first diary but not in later diaries despite reporting increased engagement with such images. One (ID84) explained choosing to exclude these “to avoid that pressure of downloading them”.
In a research context, one participant (ID3) raised the issue of possible repercussions of disclosing online activity in a diary, expressing fears this could create a negative impression or necessitate action. Such concerns could also be relevant if used in clinical practice, though this was not explored.
Because I’ve been really honest in my diary… there were some times that I was a little bit anxious about whether or not you were going to do something because, like I say, I’ve got this real fear of being sectioned (ID3)
Suggestions for improvement
Four participants suggested the diary should be made electronic and ‘phone friendly’, for instance as an online form or app. One participant (ID11) specifically stated they would continue completing the diary for their personal benefit if it were delivered in this format. It was also suggested that the diary should prioritise weekly reflection, particularly around triggers and impacts resulting from online engagement (rather than logging daily content), to make completion more manageable, less repetitive and more useful – particularly for communicating online experiences with others.