PONE-D-24-36301“People in my life just play different roles” A retrospective qualitative study of friendships among young adults who self-harmed during adolescencePLOS ONE

Dear Dr. Bilello,

Thank you very much for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. While there is much to admire in your paper, in particular, having read your paper and the referees' comments, I would like you to address carefully the comments of both referees, who suggest that your manuscript needs to discuss better the following points:

1) Greater consistency and clarity when discussing the types of friends involved in the study. 

2) Inconsistency in the terminology used to describe the participants' developmental stages throughout the manuscript. 

3) Think carefully about potential limitations to your study.

4) Further reflection on how the researcher’s position as a student may have influenced their interactions with participants, who were also students.   Please submit your revised manuscript by Dec 13 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

Reviewer #2: N/A

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

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Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: OVERALL SUMMARY

Thank you for the opportunity to peer-review this important manuscript on the impact of friendships among young adults who self-harmed during adolescence. The paper addresses an underexplored topic in self-harm research, offering valuable insights into the interrelationship between friendships and self-harm, and the complexities involved.

The study’s findings emphasise that friendships not only influence self-harm behaviours but are also shaped by them, which is an important contribution to the field. The use of semi-structured interviews within a retrospective qualitative design, alongside a modified CaTS sort task and reflexive thematic analysis, constitutes a strong and appropriate methodology for capturing the subjective experiences of participants. It was particularly commendable to see the focus on both the onset and maintenance of self-harm in relation to friendships. The CaTS-AF task was used effectively to capture these temporal aspects, and the researchers made full use of this tool to enhance their analysis. Overall, the study identifies relevant and significant themes, and the interpretation of the findings is well-grounded, offering fresh perspectives on the connection between adolescent friendships and self-harm.

MAJOR CONCERNS

However, I have a few concerns that might be considered more “major”.

1) There needs to be greater consistency and clarity when discussing the types of friends involved in the study. It’s not always clear whether the focus is on same-age friends, online friends, or offline friends, as these distinctions are not consistently made in the methods or results. For example, the method section on line 136 notes that the interview schedule included questions about participants’ “offline and online friend relationships,” but in the results, there isn’t always clarification about which type of friend is being referred to, assuming participants specified this at all. At times, same-age peers are mentioned, but it’s not explicitly outlined whether this is the primary type of friend captured throughout the study. If the intention is to refer to "friends in general" unless otherwise specified, this should be made clear in the results, particularly since the majority of interviewees appear to discuss same-age friends. For example, in the discussion, the phrase "given their status as same-aged peers" (line 529) is used, but it’s unclear if participants consistently referred to same-aged peers throughout the study. This ambiguity could be addressed by more clearly specifying in the methods and results which types of friends—whether peers, online friends, offline friends, or same-age friends—are being discussed. If there were different types, it might be important to reflect on this in the discussion.

2) There is some inconsistency in the terminology used to describe the participants' developmental stages throughout the manuscript. Terms such as "adolescent" "young adult" "young person” are used. Given that adolescence is now often considered to extend up to age 24 (e.g., Sawyer et al. 2018 “the age of adolescence”), university students can still technically fall within this period. And given that the mean age of participants was 19 (with a range of 18 – 20) it might help to clarify that the developmental stage being discussed is still adolescence, but with self-harm recollected from early adolescence. This would ensure alignment with the current understanding of adolescence as extending into the mid-20s.

3) The limitations section could be expanded to address some important aspects that are currently missing. At present, the section is brief, only spanning two paragraphs, but there are several additional limitations that could be considered. For instance, the fact that the sample consists entirely of university students introduces an undergraduate population bias. The unique cultural and institutional context of the university may shape the participants' experiences and responses, and this should be acknowledged. While qualitative research is not focused on large sample sizes, but rather on the concept of data "saturation," it could still be valuable to address this explicitly in the limitations section. A brief comment on how saturation was approached or achieved would strengthen the methodological transparency of the study.

4) Lastly, it would be useful to include further reflection on how the researcher’s position as a student may have influenced their interactions with participants, who were also students. This shared status could have affected the rapport between the researcher and participants, as well as the dynamics of the interviews. For instance, participants might have felt more comfortable or, conversely, may have withheld certain views based on perceived similarities or differences. On line 200, it is noted that a reflective diary was kept to account for the researcher’s impact during interviews and the analysis process, which is an important practice. However, it would be valuable to expand on this reflection in the discussion section. Even a brief mention of the specific insights or challenges arising from the researcher’s reflexive process could provide important context for interpreting the findings. If word count is a concern, this discussion could be summarised in one or two sentences within the main text, with more detailed reflections placed in the supplementary materials. A comment on reflexivity in the discussion, whether brief or expanded, would strengthen the study’s rigor by demonstrating an awareness of how the researcher’s positionality may have shaped the research process.

MINOR SUGGESTIONS

Additionally, below are some minor suggestions specific to different sections of the manuscript, that may help to improve it further.

TITLE/ABSTRACT

• Title could better reflect the study by saying “role of friendships” e.g., [“People in my life just play different roles” A retrospective qualitative study of the role of friendships among young adults who self-harmed during adolescence”]

• Abstract – lines 9/10 – might be better to have the (M=19.09; SD= 0.70; M=2, F=9) after the phrase young adults – because I read that as though the age they self-harmed was a mean age of 19.09 rather than that being the age of the sample.

• Line 15 , could say “but they acquire” rather than “these acquire”.

INTRODUCTION

• Line 56– maybe add in what friendships are defined as in the first place e.g., same age friends? Perhaps just outlining exactly what is meant by friendship in this context (this links in with the more ‘major’ concern comment 1 above).

• On line 97, the research aim states “Describe participants’ perceptions of the role, importance and impact of friends on experiences of self-harm over time”. However, the study is also focused on exploring what the “meaning” of friendship in relation to self-harm is too, so that could be added/reflected in the aims. Also a suggestion - wonder if the aim stating “explore how friendships… were shaped by self-harm” the phrasing might suggest an assumption that self-harm shaped friendships, rather than an open exploration of all possible dynamics between self-harm and friendships i.e., implies that you are already expecting to find this. I appreciate that data has already been collected and analysed and this may have been your aim, but if your aim was intended to be more neutral and it is not too late to refine the wording for clarity and neutrality - instead of “how friendships were shaped by self-harm” - a more neutral phrasing could be “explore the relationship between self-harm and friendships” or “explore how self-harm and friendships interact”, which doesn’t assume a one-way effect.

METHODS

• Line 128 – 133 in the study materials section “Depending on their preference, participants were given access to the CaTS-AF through a link to an online visual collaborative space (Mural), or received a paper copy by post. Participants were instructed to familiarise themselves with the CaTS-AF, pick cards that were relevant to their experiences (onset and most recent self-harm) and, if needed, write their own cards for experiences that were not already represented. Participants placed the selected cards along the timeline, and used stickers to identify cards they did not wish to discuss (Figure 2)” might be better placed in the procedure section on/after line 153.

• Line 89 “here we adapted this tool and framework to the study of friendship and self-harm to consider the dynamics of friendships and self-harm from a first-person perspective” – not quite clear exactly how you adapted it – what was the process of adapting it? You mention on line 124 “adding 18 new social cards based on team discussions and relevant literature” but could maybe add a bit more about how these cards were derived/any things that were discussed but maybe did not go in there and if there was any kind of consensus approach to this.

• Line 169 “participants who responded emphasised positive aspects of participation (Dazzi et al., 2014)” – could state what they were/unpack this a bit more as it’s not quite clear what you mean. Also not sure if this citation should be here i.e., the reference is titled “Does asking about suicide and related behaviours induce suicidal ideation? What is the evidence?” - which may/or may not be relevant to this comment.

• Ethical considerations – The manuscript could benefit from more detail regarding how potential participant distress was handled, especially given the sensitive topic of self-harm. For example, it would be useful to clarify how the study followed up on participants who might have experienced distress during or after the interviews (e.g., line 145 mentions addressing potential distress). It would be helpful to specify what steps were taken to mitigate this, such as offering support or referrals, and whether any participants required follow-up. If relevant, including this in the results section would provide transparency about how such situations were managed

• It would be beneficial to provide examples of the specific questions or prompts used in the interviews, to give readers a clearer understanding of how data was collected. Additionally, please clarify how the interviews were handled after data collection, particularly in terms of data storage. For instance, were the recordings deleted after transcription, and if so, what were the procedures to ensure data security? It would also be helpful to mention whether the interview guide evolved during the study and, if so, how changes were made throughout the course of data collection.

RESULTS

• Line 337: I may be misunderstanding the concept, but I’m unclear about how the "notion of isolation appears as a paradox given that participants also reported feeling alone and rejected by others." Feeling alone and rejected seems to support, rather than contradict, the idea of isolation. Could you clarify how isolation contrasts with other experiences, such as being physically present with others but still feeling emotionally isolated? This distinction could highlight how individuals can be around people yet still experience a sense of disconnection. If this is not the intended meaning, it might be worth reconsidering whether the term "paradox" is the most appropriate choice in the original sentence. If isolation leads to feelings of loneliness and rejection, then it doesn’t necessarily present a paradox. Alternatively, is the paradox meant to convey that adolescents feel isolated when, in fact, they are not—perhaps due to their friends perceiving them as the ones pushing others away? This could suggest a distorted perception of isolation. In the discussion on line 516, you mention that "first, feelings of shame, burdensomeness and thwarted belongingness are characteristically experienced in the context of self-harm” and interestingly, they also contribute to social withdrawal and isolation. This implies a paradox where young people who self-harm experience thwarted belongingness yet also choose to withdraw socially. If this is the case, it would be beneficial to unpack this idea more clearly in the results section to clarify what you mean by "paradoxical."

DISCUSSION

• See major concerns point 3 and 4.

FIGURES

• Flow diagram – where it says "n=30" I initially interpreted that as you had posted 30 recruitment adverts. It could be clearer that it means 30 people responded to the advert? E.g., maybe put “Participants that responded to the recruitment advert posted in the research participant scheme, n =30” . Also not clear why some bits are capitilised e.g., Informed consent.

• Figure 3 – should “self-harm” be a box around the circles to show self-harm as the context? Just a thought. Do ignore though if this isn’t what you are trying to capture here.

SMALL COMMENT ON GRAMMAR

• I apologise if this comes across as pernickety, but there are some phrases in the manuscript that could be refined for clarity and consistency. For example, in line 7 of the abstract, you state, 'the present study conducted…' It might be clearer to say, 'in the present study, we conducted…' because attributing the conducting to the people rather than the study enhances clarity. If you do change this, be consistent throughout the manuscript.

I hope you find this feedback helpful, and I wish the authors continued success in their future work!

Reviewer #2: Thank you for the opportunity to review your manuscript. It was very clear and well-written and I believe the topic is relevant and important. You did a nice of describing the study, clearly articulating the findings, and connecting your findings to current literature. I have just a couple of minor suggestions that may help with clarity and consistency. In some places you use the term "adolescents" and in other places "young adults." I would stick to one term for clarity and consistency. Also, the language of the themes is slightly different in the abstract/results/discussion. I find it helps the same language is used throughout.

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Reviewer #1: No

Reviewer #2: No

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“People in my life just play different roles” A retrospective qualitative study of friendships among young adults who self-harmed during adolescence

PONE-D-24-36301R1

Dear Dr. Bilello,

Thank you for submitting your revised manuscript and the careful responses to the reviewers' comments on your paper. We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Professor Sriya Iyer

Academic Editor

PLOS ONE

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