Visual content and thematic analyses of images shared on social media before and after episodes of self-harm in a UK clinical youth sample

OBJECTIVES: Little is known about how young people use social media during periods of self-harm. This study aimed to explore how they express themselves online through images posted on social media before and after self-harm and how this expression may change across these periods, employing visual content and thematic analyses. DESIGN: A prospective cohort study, with qualitative analysis conducted using a recurrent cross-sectional approach and codebook methodology, accounting for chronological changes across time points before, during and after episodes of self-harm. SETTING: Participants were recruited from a mental health NHS Trust in the UK. PARTICIPANTS: Image data during episodes of self-harm was available for 20 participants. The majority of whom were aged 18 years or older (n=15), female (n=14) and met criteria for moderate or severe anxiety and depression (n=18). The sample reflected diverse ethnic backgrounds, with six participants identifying as Asian or Mixed/Multiple ethnic backgrounds. RESULTS: None of the images investigated had direct visual presentations of self-harm. A few images referenced self-harm through the medium of text, and this was largely to normalise and promote help-seeking. Several themes were identified, including participation in activities that support well-being, love and relationships, connecting through humour, expressions of distress, and promoting mental health awareness and support. Subtle temporal changes were also observed. CONCLUSIONS: Findings suggest that young people may temporarily withdraw from social media on the day of a self-harm event and rarely post graphic self-harm images around that time. This may reflect concerns about being stigmatised, but also improved platform moderation. Instead, platforms may serve as spaces for expressing self-care behaviours and connecting with others about both positive and challenging emotions, and across a range of topics including mental health. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov: NCT04601220.