Calm Harm is intended to help adolescents regulate their emotions and work through overwhelming feelings without harming themselves. Users are taught to “surf the urge” to self-harm—in other words, use coping skills until their emotions are under control and their urge to self-harm is less intense. As you use the app, Calm Harm walks you through different coping strategies in real-time, providing clear, straightforward steps to take. If you’re still in distress after trying a coping strategy, you will be directed to try the coping strategy again or try a different strategy.
When you open the app for the first time, you’ll be asked to set some preferences. You can choose your color scheme and a set of characters to guide you through the activities in the app. These preferences can be changed at any time. Once you’ve set your preferences, you’ll see a brief description of the urge to self-harm being “like a wave”, and assured that “once you surf the wave, the urge will fade.” This screen appears every time you open the app. Clicking the “ride the wave” button opens up a menu of six coping strategy categories (“activity types”), illustrated by the characters you chose. The activity types include: comfort, distract, express yourself, release, breathe, and “random” (i.e., the app chooses for you).
Clicking on an activity type opens up a menu of options within that category. You can select from a list of five- or fifteen-minute activities. The exception to this is the “breathe” category, which uses an animation to walk you through deep breathing exercises, 60 seconds at a time. Both the five-minute and fifteen-minute time frames can be extended if you are still struggling with self-harm urges. If you select a five-minute activity, the app will pause your activity timer after each minute and ask you whether the urge has subsided yet. With fifteen-minute activities, you’re given just one fifteen-minute countdown. If the urge passes before then, you can press “pause” and report that the urge has passed.
When you report that the urge has passed, you are told that you have “surfed the wave” and told to remember the activity next time you feel the urge to self-harm. Then, you are brought to the diary portion of the app, which helps you track self-harm urges over time. You are prompted to report what triggered the urge to self-harm and how strong it was. Categories of triggers include: “I was cross”, “I was sad”, “It all went wrong”, “I felt stressed”, “I felt numb/empty”, “Friends/relationships”, “I can’t break the habit”, and “don’t know”.
You’re also given the option of journaling, and given ideas for managing the self-harm trigger you reported. The log keeps track of this information and gives you feedback on how strong your urges have been over the past week and what times of day they’ve been strongest. You can access the log at any time to review your journal entries, triggers, and urges. The app is password-protected for privacy.
Recommendations for Use
This app is intended for teenagers who struggle with self-harm, but the strategies are largely applicable to adults as well. The app could also be used by anyone who wants to improve their ability to feel emotions and act on them in a healthy way (i.e., emotion regulation), even if they don’t struggle with self-harm specifically. The techniques are not specific to self-harm and they can help with people struggling with other issues related to emotion dysregulation, such as substance use (Maffei et al., 2018) and binge eating (Telch et al., 2001). Clinicians who work with teenagers or adults who struggle with self-harm, or emotion dysregulation in general, may find Calm Harm useful. Although the app does not have any features that allow clinicians to review clients’ logs independently, reviewing the log together may help clients and clinicians understand specific patterns of triggers and behaviors.
Because DBT skills work best when used regularly (Neascsiu et al., 2014), I would suggest using the app whenever emotions feel overwhelming. Practicing distress tolerance may decrease the need for the app’s guidance over time as users learn to implement the strategies on their own. Although the app is fairly simple to use, it may be helpful for new users to review the app for the first time when they’re not feeling a lot of distress. Experiencing frustration while already struggling with intense emotions may do more harm than good. Users can set up their account and their preferences and take a quick “tour” of the app before they really need it.
The app’s content aims to teach users Dialectical Behavior Therapy (DBT) skills that they can use to improve their ability to tolerate overwhelming emotions and urges to self-harm. DBT is an evidence-based treatment for adolescent self-harm (Iyengar et al., 2018). The app focuses specifically on distress tolerance, which is one of the four components of DBT (Linehan, 1993). Building distress tolerance skills is very important for adolescents who self-harm, as they’re typically less able to tolerate overwhelming emotions than their peers who do not self-harm (Nock & Mendes, 2008). Overall, the content in the app is evidence-based and highly relevant to adolescents who self-harm. The activity categories in the app are aimed at distracting, soothing, and expressing oneself—all of which are key components of DBT as an evidence-based treatment (McKay et al., 2007). The app effectively targets adolescents who self-harm, with the clear goal of replacing self-harm behaviors with healthier behaviors.
However, some of the activities do not fit clearly into the time frame for which they’re intended. For example, “Have half an hour less social networking per day and ring someone in that time instead” is considered a five-minute activity, as is “Can you ask your friends to write something about you on a sticky note? Stick these in your room.” Although these may be good suggestions, they don’t fit into the five 60-second intervals the app guides you through. Others, such as “sing loudly to songs that make you happy” and “do some light yoga stretches” do fit quite well within the time frames (5 minutes and 15 minutes, respectively).
Some of the activities may require more detailed instructions than those provided. For example, the app suggests doing a progressive muscle relaxation exercise. Although this exercise is a DBT distress tolerance skill (Linehan, 2015), the instructions provided are very simplistic. Aside from a 60-second timer, users are not guided through the exercise. I found it hard to do the exercise correctly using the instructions provided, even though I am familiar with the exercise.
Moreover, the suggestions for coping with specific triggers may be too general to be novel or effective. For instance, when users report that they had the urge to self-harm because they “can’t break the habit”, the only suggestion is to “speak to someone”. Although the app covers several common self-harm triggers, there is little flexibility for users to track their own triggers that don’t fit cleanly into the options provided. There is a “don’t know” option, but there is no “other” option. Allowing users to fill in the blanks would enable them to track their urges more effectively.
The app’s main premise is urge surfing, which is an evidence-based skill (Bowen & Marlatt, 2009). Although the app does a good job of explaining it in simple terms, a brief animated video would help explain the concept to users more thoroughly. It is also worth noting here that the app uses British English, and some of the dialect (e.g., “I was cross”, “sticking plaster”, “jumper”) may be unfamiliar to American adolescents.
Ease of Use and User Experience
The app is relatively easy to learn, navigate, and use. First-time users are guided through a brief set of tasks, including setting a password and security question (a “memorable word”) and choosing a color scheme and characters if desired. These preferences can be changed at any time. Although the steps are relatively simple, again I would suggest going through them and getting a feel for the app before it is really needed. The steps may be frustrating and overwhelming when experiencing strong distress and urges to self-harm. The explanations are brief and straightforward, and I’d suggest clicking on them and reading them right away. Preferences, log entries, and referrals to resources can easily be accessed at any time from a drop-down menu in the upper right corner of the screen.
I used the app on an iPhone 6S and an iPad Pro. It worked very well on the older model iPhone, but not as well on the newer iPad. The screen did not rotate on the iPad, so I could not use it with my keyboard. My overall evaluation of the app is based on its usability with the iPhone. Importantly, although I used the same account on both devices, the log did not sync. Entries from my iPhone did not appear when I opened the app on my iPad.
Visual Design and User Interface
The app is simple, attractive, and organized. Users can select from three color schemes and two sets of characters to guide them through the activities. The characters are cute, but don’t seem too childlike for adolescents and adults to enjoy. The app can also be used without characters. These preferences can be changed at any time. Menus of options are organized into neat boxes on the screen. Scrolling through options is manageable even on a small iPhone screen. Settings can be easily accessed and changed.
The app guides users through each activity in a logical way. During five-minute activities, a visual timer shows users how much time is left in each five-minute block. After using the app a few times, I felt very comfortable with navigating it and going through the exercises. The simple interface and straightforward instructions are appropriate for adolescents who may already be feeling overwhelmed when they open the app.
Calm Harm is an appealing app that aims to teach adolescents evidence-based strategies for getting through urges to self-harm without acting on them. As an adult, I found some of the strategies to be helpful. For example, the guided breathing exercise on the app can easily be used during stressful times, even if you’re in public. Some of the coping strategies in the app aren’t very well-explained or realistic. However, there are many strategies to choose from, and most people will probably find ideas that work for them.
Because DBT skills require a lot of practice to be fully effective, it’s important for users to stick with the app and use it frequently. For those who struggle with motivation to change their behaviors, or whose emotion dysregulation is too strong to use a self-guided tool, using the app consistently may be tough. Ideally, the app would be used in conjunction with psychotherapy.
- Bowen, S., & Marlatt, A. (2009). Surfing the urge: Brief mindfulness-based intervention for college student smokers. Psychology of Addictive Behaviors, 23, 666-671. Doi: 10.1037/a0017127
- Iyengar, U., Snowden, N., Asamow, J. R., Moran, P., Tranah, T., & Ougrin, D. (2018). A further look at therapeutic interventions for suicide attempts and self-harm in adolescents: An updated systematic review of randomized controlled trials. Frontiers in Psychiatry, 9, 583. doi: 10.3389/fpsyt.2018.00583
- Linehan, M. M. (1993). Skills training manual for treating borderline personality disorder. New York: Guilford Press.
- Linehan, M. M. (2015). DBT skills training handouts and worksheets. New York: Guilford Press.
- Maffei, C., Cavicchioli, M., Movalli, M., Cavallaro, R., & Fossati, A. (2018). Dialectical behavior therapy skills training in alcohol dependence treatment: Findings based on an open trial. Substance Use & Misuse, 53, 2368-2385
- McKay, M., Wood, J. C., & Brantley, J. (2007). The Dialectical Behavior Therapy Skills Workbook. Oakland, CA: New Harbinger Publishers, Inc.
- Neacsiu, A. D., Eberle, J. W., Kramer, R., Wiesmann, T., & Linehan, M. M. (2014). Dialectical behavior therapy skills for transdiagnostic emotion regulation: A pilot randomized controlled trial. Behaviour Research and Therapy, 59, 40-51. doi: 10.1016/j.brat.2014.05.005
- Nock, M. K., & Mendes, W. B. (2008). Physiological arousal, distress tolerance, and social problem-solving deficits among adolescent self-injurers. Journal of Consulting and Clinical Psychology, 76, 28-38. doi: 10.1037/0022-006X.76.1.28
- Telch, C. F., Agras, W. S., & Linehan, M. M. (2001). Dialectical behavior therapy for binge eating disorder. Journal of Consulting and Clinical Psychology, 69, 1061-1065. Doi: 10.1037/0022-006X.69.6.1061