The Experience of Goals and Rewards in Young People Who Self-Harm: A Qualitative Exploration

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This is a qualitative paper looking at motivational processes in self-harm. Whilst I think the focus is interesting and the paper well written it feels like there are some major methodological flaws, noted below.

“The most frequently reported function of self-harm is to manage negative emotions [8]” – there are more recent reviews and meta-analyses on this topic so please cite those. It would be good to report the actually prevalence of different functions of self-harm.

“A few studies have shown that at a neurocognitive level, positive reinforcement of self-harm might be explained by increased sensitivity to reward” I think further comment is needed here on why an increased sensitivity to reward would lead to self-harm, specifically.

The language of the introduction is very much presenting differences amongst those who self-harm in terms of abnormality and impairment. I note that early adversity is not uncommon amongst those who self-harm and I wonder if for some the differences seen in things like motivational systems may be better understood as adaptations (even if not effective in the long-term) to such environments. At any rate, I feel like talking about difference sin functioning is preferable to framing them as abnormalities, given the stigma that already surrounds self-harm.

The introduction needs to more clearly spell out how difference sin motivational processes might lead to self-harm, and consider where these may arise from. Currently this is a little vague.

Given the focus here seems to be on how people who self-harm may have different motivational processes to those who do not, I am unsure about the suitable of a qualitative design. The focus groups are a good way to explore motivational processes in this group, but do not allow for any sort of comparisons with those who do not self-harm. Some further justification of the qualitative approach is needed here. The decision to use focus groups compared to one-to-one interviews also requires a brief justification. There is no comment on the epistemological assumptions behind the analysis or on reflexivity, both of which I’d expect to see with this type of approach and analysis. There does not appear to be any sample size justification.

As noted above, a difficulty here is its unclear if results reflect common aspects of goal seeking and motivation or tell us anything particular about those who self-harm. Much of what is covered feels like it may apply to many people. For example, in the discussion a point is made about the finding that some people avoided enjoyable activities that did not seem productive, but this is a phenomena that occurs outside of self-harm and its unclear to what extent this deviates from what is normative. Culturally there is a lot of focus on productivity and so I wonder if this is a relatively common way to feel. Possibly this experience is more extreme in those who self-harm but we have no way to know this. This issue becomes problematic in the discussion as the findings are interpreting as being indicative of processes linked to self-harm but we cannot say this here. It does not seem to be the case that participants were directly linking these phenomena to self-harm (or at least this is not indicated in the results). There a theme that relates more to self-harm (theme 6) but this seems to be describing anhedonia, and may be more about co-occurring low mood than self-harm specifically. Unfortunately, this issue of not knowing whether findings are related to self-harm or not feels like quite a fundamental limitation as it makes it very hard to conclude much from a large part of the results. I think having a topic guide that actively asked about how motivation interacted with self-harm would have avoided this issue, but it seems like the topic guide was designed to avoid this.

The thematic map requires some explanation including clarity around the meaning of colours and arrows, if any.

Author Response

Please see attachment

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

The authors present a qualitative analysis of subjective experience of rewards and goal related behaviour in a group of people with lived experience of self harm. While an interesting study, there are several aspects of the paper which could be strengthened prior to publication.

Abstract: The abstract is clear and provides a concise rationale for the study, however, the aim could be worded more clearly, and the interchangeable use of terms like “goal pursuit” and “goal attainment” should be clarified. The focus on “motivational mental imagery” is introduced without sufficient justification, why this focus, and how does it address the identified gap? It would be helpful to explicitly state the research question and include an example question from the focus groups to contextualise the results. Including the mean age of participants and clarifying the gender breakdown would strengthen the abstract. The conclusion feels broad and slightly unclear: what is meant by “intricate relationship”? Additionally, APA formatting should be checked (e.g., italicising N).

Introduction: The opening paragraphs effectively situate self-harm in the real world, supported by relevant statistics and a clear identification of the limitations of current practices. However, key terms such as “self-harm” and “mental imagery” as well as goal related concepts are not defined, and the rationale for exploring motivational mental imagery is underdeveloped. The introduction lacks a coherent narrative in places, with ideas introduced abruptly (e.g., the link between self-harm and addiction leading to mental imagery). Could the authors provide some specific detail of the prior work around mental imagery, goal related processes and processing of everyday rewards and goals. Please provide the research question here in addition to aims.

Method: In the design, please provide rationale for the approach taken, and include a comment on the epistemological position adopted. In participants, how was ‘adequate number’ of participants decided? The data generation section begins by stating 2 focus groups were held but 4 dates were given, did each focus group meet twice, if so, why was this the case, did these sessions differ in focus/content? The procedure for developing the focus group guide is well explained, but the role of the YPAG and advisory team needs clarification. The data generation section reads more like a procedural account and might be better integrated with earlier sections. Audio transcriptions were used for analysis, the authors indicate that nonverbal behaviours were recorded, could they elaborate on how these were included and coded? The authors cite Braun and Clarkes 2012 work for their methodology, however these authors have published updated versions of this methodology (2015 and 2022) which should be considered and included by the authors. In line with this, the authors should also provide reflexivity/positionality statements, and step by step details of how the analysis was conducted. Transcript review should be mentioned earlier as should content from section 2.6.

Results: Per APA guidelines, please refer to participants as men and women rather than male and female. Participant demographics are well outlined, but the rationale for group composition (e.g., uneven numbers) and the use of identifiers (participant, group, session – why were there 2 sessions, and how did they differ) should be clarified. The formatting of Table 1 needs attention (e.g., typo in the note). Depression scores suggest severe depression in some participants—why was suicidal ideation not included in the measures here, given the exclusion criteria? Thematic analysis relies heavily on quotes; more comprehensive summaries linking themes to constructs under study would be beneficial. Consider whether group differences (e.g., gender, depression scores, self-harm history) influenced focus group dynamics. In addition, the lack of a clear research question leaves the reader a bit unclear on how these themes come together. It would be really interesting to see how these participants responses might differ from people without self-harm behaviour, did the authors consider recruiting a comparison group? Thematic map is visually interesting but confusing—clarify the meaning of boxes vs. ovals, dotted lines, and colour choices (e.g., why is low motivation green?). Reordering themes to align with the map could improve coherence. Consider the impact of aphantasia on visualization of goals (theme 5). Theme 6 could be more specific, self-harm seems to alter in similar ways for everyone.  The interaction between participants and how conversations evolved could be discussed to enrich interpretation.

Discussion: The discussion provides a clear structure and real-world implications, but some findings are repeated and could be summarised more effectively. The connection between self-harm and reward activity is well made, but further integration with prior neurobiological literature would strengthen the argument. The paragraph on goal setting misses an opportunity to explore the role of mental imagery in short- vs. long-term goals. The inclusion of the IMV model is problematic—it is a model of suicidal behaviour, rather than self-harm and is not adequately justified here. The discussion of control is inconsistent, particularly the intersection between external locus of control and participants’ desire for control. Bringing in ACEs feels disconnected from the participant data reported. Section 4.2 seems to go a little beyond the data and needs to be more clearly grounded in the results. The argument for using mental imagery is unclear and seems to advocate for a training program without sufficient grounding in the findings. Limitations should also be interpreted in terms of their impact on the study’s conclusions, especially the retrospective nature of self-harm reporting. Consider discussing aphantasia and its relevance to mental imagery experiences. Conclusions – more explicitly explain motivational biases suggested, what are these?

Author Response

Please see attachment

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Regarding this sentence, “Another hypothesis, drawing on the addiction literature [17, 18], posits that a reduced neural response when anticipating common rewards such as money [20] may lead to seeking out other more salient rewards such as self-harm”. So the suggestion is people self-harm because they are not concerned enough with money? This seems rather implausible and I think either needs removing or the case for this hypothesis strengthening.

Supporting evidence for the concept of thematic saturation (e.g. relevant citations) is needed. Its worth noting the premise of data saturation in qualitative research has been criticised but I appreciate there are different views on this.

The authors now do a better job of clarifying the limits of what can be inferred from the data. I do still have some concerns about this as I can imagine people who do not read the article properly or just read the abstract making inferences here that are unfounded. I think a clear statement needs adding to the abstract noting that it is not possible to know to what extent the experiences identified are specific to people who self-harm or reflective of the wider population, and this needs holding in mind when considering the results.

Author Response

Comment 1:

Regarding this sentence, “Another hypothesis, drawing on the addiction literature [17, 18], posits that a reduced neural response when anticipating common rewards such as money [20] may lead to seeking out other more salient rewards such as self-harm”. So the suggestion is people self-harm because they are not concerned enough with money? This seems rather implausible and I think either needs removing or the case for this hypothesis strengthening.

Response 1:

Thank you for the opportunity to clarify this point. The suggestion is not that people self-harm because they are not concerned with money, that would be a "literal" and incorrect interpretation of neuroimaging findings.

The incentive delay task reported in the paragraph mentioned by the reviewer is a well established neuroimaging paradigm to model the brain response to a general rewarding stimulus such a money. It has been tested e.g. in individuals with depression and addiction (as referenced in the manuscript). Within this literature the interpretation of a blunted neural response to monetary cues is that - possibly - the brain areas that process general rewards are hypofunctioning when anticipating such rewards ('hypo' is not a value statement but signals less cerebral blood flow). This could translate to common rewards having less incentive value than they have in individuals without addiction / depression. If one posits that behaviour is also grounded in brain function, this difference in the neurobiological function could be *one of the contributors* to seeking high incentive stimuli such as drugs in addiction, and to not seeking rewards in depression. Such interpretation also seems to reflect subjective experience e.g. of how individuals describe anhedonia, i.e. that they don't find rewarding the things they used to enjoy. Hence, whilst not literal, we don't think the interpretation is implausible when applied to self-harm, especially as self-harm does elicit a value signal in the brain (Plener et al., 2012; Hooley et al., 2020).   

 

 

Comment 2:

Supporting evidence for the concept of thematic saturation (e.g. relevant citations) is needed. Its worth noting the premise of data saturation in qualitative research has been criticised but I appreciate there are different views on this.

Response 2:

We apologise for missing the reference, which we have now added: 

Hennick., M. (2007) International Focus Group Research: A Handbook for the Health and Social Sciences. Cambridge University Press, pp. 135 - 151. https://doi.org/10.1017/CBO9780511619458.008

 

Comment 3

The authors now do a better job of clarifying the limits of what can be inferred from the data. I do still have some concerns about this as I can imagine people who do not read the article properly or just read the abstract making inferences here that are unfounded. I think a clear statement needs adding to the abstract noting that it is not possible to know to what extent the experiences identified are specific to people who self-harm or reflective of the wider population, and this needs holding in mind when considering the results.

Response 3

We thank the reviewer for their critical stance; however, we wonder whether to some degree their comment doesn't apply to all qualitative research... Anyway, we have added the statement below to the Abstract, Results section: "However, our data can not determine if these experiences are specific to young people who self-harm."