Absence of digital intervention: exploring the motivations behind self-harm adolescents’ avoidance of psychological support techniques

Abstract

Background

From the perspective of behavioural psychology and adolescent psychopathology, non-suicidal self-harm (NSSI) among adolescents is a multidetermined behaviour shaped by biological, psychological and social factors. Digital mental health interventions are vital for adolescent self-harm support, yet their acceptance among self-harming adolescents is low with significant avoidance tendencies. Existing research focuses on technical attributes of these tools but rarely explores the psychological motivations and contextual factors driving avoidance in this group, and few studies interpret such avoidance behaviour under a unified biopsychosocial framework.

Methods

A grounded theory approach was adopted, complying with the COREQ criteria. Semi-structured interviews were conducted with 21 emotionally stable adolescents aged 12–18 years who had engaged in NSSI in the past year, recruited from a tertiary hospital emergency department. Data were analysed via open, axial and selective coding with ethical approval obtained.

Results

Guided by the biopsychosocial behavioural framework, this study identified that adolescents’ avoidance of digital psychological interventions is a comprehensive outcome of interactions among biological traits, psychological mechanisms and social contextual factors. Three core psychological pathways driving avoidance were extracted: emotional avoidance, trust deficit and feelings of ineffectiveness and frustration. Physiological stress responses linked to shame and anxiety (biological dimension) amplified these psychological barriers, while situational social factors moderated the entire behavioural process.

Conclusions

Adolescents’ avoidance of digital interventions is a layered, dynamic, multidetermined behavioural phenomenon embedded in the Chinese cultural context, which can be systematically interpreted via the biopsychosocial behavioural framework covering biological traits, individual psychology, interpersonal and ecological social factors. Future digital tools require trauma-informed, context-adaptive design to reduce emotional triggers, enhance user control, strengthen privacy protection and rebuild trust, thereby improving acceptability and effectiveness.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Family and school environments drive adolescent self-harm, yet few studies examine their links to digital psychological intervention avoidance; existing work overlooks biopsychosocial lenses and leaves a research gap explaining this multi-factor avoidance behaviour.

WHAT THIS STUDY ADDS

• This research built a biopsychosocial model of digital avoidance for self-harming adolescents, uncovered unique multi-layered mechanisms differentiating them from typical teens, and verified avoidance as a complex multi-determined behaviour instead of a single psychosocial response.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• Its results guide holistic, trauma-aware digital mental health tool design, offer clinical and policy evidence centred on teen privacy and trust, and urge researchers and practitioners to incorporate biological, psychological, social and technical ecological factors into interventions.

Introduction

In China, adolescent non-suicidal self-harm (NSSI) has emerged as a major public health concern, with epidemiological studies indicating a 15%–28% prevalence among middle and high school students, markedly higher than in many Western contexts.¹ Sociocultural factors, such as collectivist norms, high academic pressure, stigma around mental illness, restricted in-person help-seeking and limited access to child and adolescent psychological services, create unique barriers to formal support. Under such constraints, digital mental health interventions (DMHIs) have been rapidly promoted in national mental health policies and school-based services as accessible, anonymous and scalable alternatives.² It is critical to acknowledge that avoidance of mental health support is not exclusive to digital intervention tools: adolescents engaging in NSSI also commonly avoid in-person, face-to-face psychological therapy due to overlapping barriers including self-stigma, shame and fear of judgement.³ Digital avoidance represents a distinct subtype of help-seeking avoidance shaped by unique sociotechnical privacy and surveillance risks that differentiate it from offline treatment disengagement.⁴

However, despite their advantages of strong anonymity, high accessibility and flexible usage, these tools have not achieved the expected high acceptance rate among adolescents, particularly those with self-harm tendencies who often exhibit significant avoidance tendencies. Existing research primarily examines technical attributes, usability and intervention effectiveness, yet rarely explores the unique psychological experiences and underlying motivations of this group in practical usage contexts.⁵ Notably, recent international reviews emphasise that sustained engagement and retention, rather than initial uptake, constitute the primary challenge for digital mental health tools among youth.⁶ However, for self-harming adolescents, avoidance often emerges before any sustained use, driven by shame, fear of exposure and distrust. Adolescents with self-harm behaviours typically exhibit characteristics such as strong shame, sensitivity to peer evaluations, emotional regulation difficulties and lack of security.⁷ These psychological vulnerabilities may render digital intervention tools not only ineffective as safe emotional spaces but also perceived as potentially risky forms of contact.⁸

Therefore, it is essential to deeply understand why adolescents choose to avoid digital interventions, under what circumstances this avoidance occurs and the psychological decision-making logic behind such behaviours.⁹ Using grounded theory as a methodological framework and complying with COREQ, this study conducted semi-structured interviews with adolescents who had experienced self-harm.¹⁰ Through systematic exploration of their attitudes, emotional experiences, trust judgments and usage behaviours regarding digital mental health interventions, we aim to construct a theoretical model reflecting digital avoidance pathways.

From the perspective of behavioural psychology and adolescent psychopathology, NSSI and its derivative help-seeking avoidance behaviours are not simply caused by isolated psychological or social factors. According to the classic biopsychosocial behavioural framework, individual behaviours are jointly determined by three interrelated dimensions: biological traits, psychological cognition and emotion, and external social environments.⁹ Adolescents with NSSI have inherent differences in neural emotional regulation and physiological stress response, which interact with individual psychological states and social situations to jointly shape their behavioural choices. At present, no studies have applied this mature framework to interpret digital intervention avoidance among self-harming adolescents, leading to fragmented understanding of this behaviour.¹¹

Therefore, it is essential to deeply understand why adolescents choose to avoid digital interventions, under what circumstances this avoidance occurs and the psychological decision-making logic behind such behaviours. Using grounded theory as a methodological framework and complying with COREQ, this study conducted semi-structured interviews with adolescents who had experienced self-harm.⁷ Through systematic exploration of their attitudes, emotional experiences, trust judgments and usage behaviours regarding digital mental health interventions, we aim to construct a theoretical model reflecting digital avoidance pathways and further integrate all findings into the biopsychosocial behavioural framework to form a complete multidimensional interpretation system.

This study is rooted in the Chinese sociocultural context, where family monitoring, school device policies, data privacy concerns and mental health stigma strongly shape adolescent digital behaviour.⁹ It also addresses whether avoidance reflects initial refusal or later disengagement, an important distinction in the global digital mental health literature.¹²

Methods

Study design

This qualitative study employed a grounded theory approach to systematically analyse the digital avoidance behaviours of 21 self-harming adolescents, with the goal of establishing a conceptual framework, categorical structure and core theoretical model of avoidance. The research followed the classic three-step coding approach: open coding, axial coding and selective coding. All qualitative data reported adhere to the 32-item Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist for semi-structured interviews.¹⁰

The study was conducted in accordance with the Declaration of Helsinki and received ethical approval from the Ethics Committee of The First Affiliated Hospital of Wenzhou Medical University (Approval No. KY2023-117). Written informed consent was obtained from all participants’ parents/guardians, and voluntary verbal consent was obtained from the adolescent participants themselves prior to data collection.

Patient and public involvement statement

Patients and the public were not formally involved in setting the research question, designing the study protocol, recruiting participants or interpreting the study results. However, adolescents with lived experience of non-suicidal self-harm were the central data source via semi-structured interviews, and their views, experiences and narratives directly informed all stages of data analysis and the final study findings. Appropriate consent processes, private interview spaces and emotional support resources were implemented to ensure participants’ participation was safe, informed and voluntary with the option to withdraw from the study at any time without consequence.

Sample

Purposive sampling was used to recruit adolescent participants from the emergency department of the first affiliated hospital of Wenzhou Medical University. Inclusion criteria were as follows: (1) aged 12–18 years. This range was selected because it captures the peak period of self-harm onset and spans early to late adolescence, a developmental phase with rapid cognitive and emotional maturation while digital behaviour remains strongly shaped by family and school. Developmental heterogeneity exists within this range, but core avoidance mechanisms were consistent across ages; (2) having engaged in at least one episode of non-suicidal self-harm in the 12 months prior to recruitment; (3) assessed by a clinical psychologist or psychiatrist as emotionally stable; (4) able to use digital devices and has had exposure to digital psychological intervention tools. Exposure included mood-tracking apps, rule-based chatbots, early AI systems, online assessment modules and asynchronous counselling platforms. Participants did not use contemporary LLM-based systems.⁶ Exclusion criteria were as follows: (1) severe psychiatric disorders requiring inpatient treatment; (2) cognitive impairment or communication difficulties; (3) emotional instability at recruitment.

Following risk screening and ethical briefing, the research team obtained written informed consent from parents/guardians and voluntary consent from adolescents. A total of 21 eligible adolescents were enrolled in the study, all of whom could clearly describe their emotional experiences and perceptions of using digital psychological intervention tools. No further participants were recruited as theoretical saturation was achieved, with no new concepts or categories emerging from the final three interviews.

Data collection

Semi-structured in-depth interviews were conducted in private, quiet hospital wards between January 2023 and December 2025 to ensure environmental privacy and emotional safety for participants. Interviews were guided by a pre-developed interview outline covering four core dimensions: (1) participants’ usage experience of digital psychological intervention tools; (2) emotional responses and attitudes toward these tools; (3) trust judgments and privacy concerns related to digital usage; (4) specific reasons, situational triggers and psychological processes behind avoiding, discontinuing or refusing digital tools.

Interviews were conducted by two trained researchers to ensure consistency in questioning style. Researchers used follow-up probes (eg, “Can you describe how that made you feel?” “What made you decide to stop using the tool?”) to gather richer contextual and experiential insights. Each interview lasted 30–60 min, was audio-recorded with written consent from participants and their guardians and no interviews were interrupted or terminated early.

All audio recordings were transcribed verbatim within 24 hours of the interview by a third independent researcher, with all personally identifiable information removed and replaced with pseudonyms (P1–P21) to ensure data confidentiality and anonymity. Transcripts were cross-checked by two research team members against the audio recordings to verify accuracy and completeness.

Data analysis

Interview transcripts were analysed using a grounded theory-based systematic coding strategy, with the qualitative data analysis software NVivo 12 used to manage coding, categorisation and data retrieval. The analysis process was conducted by three researchers (two qualitative researchers and one clinical psychiatrist) to reduce researcher bias and followed three sequential steps:

Open coding: Line-by-line analysis of anonymised transcripts extracted, labelled and defined initial avoidance-related concepts, with cross-participant narrative comparison for consistency.

Axial coding: Initial concepts were clustered into four core categories by contextual links, mapping avoidance mechanisms.

Selective coding: A core digital avoidance category was identified, forming a coherent theoretical model validated for logical coherence and saturation via iterative reviews.

Results

Guided by the biopsychosocial behavioural framework (figure 1), systematic analysis of interview data from 21 self-harming adolescents confirmed that digital avoidance is a multidetermined behavioural phenomenon driven by the interaction of biological traits, psychological mechanisms and social situational factors. Among them, individual psychological factors constitute the direct core pathways of avoidance, the unique biological characteristics of adolescents with self-harm amplify psychological negative emotions and external social situational factors play a critical moderating role in the whole behavioural chain. Three core psychological pathways were identified: emotional avoidance, trust deficit and feelings of ineffectiveness and frustration. Below is a multi-dimensional interpretation combined with the framework.

Figure 1. Biopsychosocial Behavioural framework of digital intervention avoidance among self-harming adolescents.

This framework divides the formation of digital avoidance behaviour into three interactive dimensions: (1) biological dimension: neurodevelopmental traits of emotional dysregulation and physiological stress responses (shame and anxiety-induced somatic reactions); (2) psychological dimension: three core avoidance pathways (emotional avoidance, trust deficit, feelings of ineffectiveness and frustration) and (3) social dimension: situational moderators (parental monitoring, school rules, peer attitudes, privacy constraints and social stigma). The three dimensions interact dynamically and jointly lead to final avoidance behaviours (initial refusal, discontinuation and long-term avoidance). Bidirectional arrows indicate mutual influence between dimensions.

Biological dimension: physiological stress and emotional regulation traits

All participants presented typical biological and neuropsychological traits of adolescents with NSSI, impaired emotional regulation ability and hyperactive physiological stress response. When facing scenarios involving self-harm disclosure and emotional expression on digital platforms, adolescents rapidly experienced a series of somatic reactions including palpitations, sweating and nervousness, which are typical manifestations of anxiety and shame at the physiological level. These inherent biological traits do not directly cause avoidance but act as an important amplifying factor: they intensify negative psychological experiences and further push individuals to choose avoidance behaviours to relieve physical discomfort. This biological basis is a universal characteristic of adolescent self-harm psychopathology, and it runs through all subsequent psychological avoidance pathways.

Emotional avoidance (core psychological pathway 1)

As the most immediate and fundamental psychological barrier, emotional avoidance interacts with the above-mentioned physiological stress responses to become the primary driver of digital avoidance across all 21 participants. Most adolescents reported intense shame and exposure anxiety when using emotion-tracking apps, AI chatbots or online counselling platforms. The physical discomfort triggered by anxiety and shame (biological trait) intensified their psychological rejection, with these negative emotions developing rapidly from the start of usage and prompting immediate withdrawal or deliberate avoidance of expressing their feelings.

The inherent secrecy of self-harm behaviours made adolescents particularly vulnerable to feeling exposed when expressing vulnerable emotions on digital platforms. Many feared their authentic emotions might be perceived by AI systems, online counsellors or even strangers, leading to judgement or social stigma. This shame stemmed from negative self-perception, amplified by the structured questioning of digital platforms, rather than the platforms themselves. P1 shared: “I get so nervous typing even a single sentence in the app--it feels like someone’s watching me from behind. The more I write, the worse I feel, so I eventually stopped using it altogether.” P5 directly linked this discomfort to shame: “When asked about self-harm questions, my palms would sweat. I’d think 'Why am I the one?’The more I filled out, the more ashamed I felt, and I’d want to close it immediately.” Some teens worry about digital intervention’s recording feature becoming invisible exposure. P7 said: “It saves all my past entries. Seeing those records makes me want to escape, I don't want to leave traces.” P9 expressed similar exposure anxiety: “I’m afraid my parents will see these. If they know what I wrote, they’ll definitely scold me, so I’d rather not touch it.” P10 viewed digital records as evidence, further reinforcing withdrawal: “Everything online is traceable. Whatever I say gets recorded. I don't dare keep my emotions.”Even without explicit external risks, some teens experience intense discomfort during use and actively discontinue it. P15 described a classic “automatic exit experience”:“I initially wanted to try, but the more I wrote, the more uncomfortable it became, like exposing my most vulnerable part to something unfamiliar. Eventually, I deleted it outright.”

These authentic accounts reveal the essence of emotional avoidance: not that the tools themselves are ineffective, but that adolescents’sense of self-exposure, visibility, and shame are rapidly triggered when confronting digital tools. Combined with their inherent physiological stress response traits, this leads to immediate withdrawal, avoidance or outright rejection of digital interventions. Emotional avoidance forms the primary and most fundamental psychological driver behind adolescents’ resistance to digital psychological interventions. It not only influences their actual usage behaviour but also profoundly shapes their initial attitudes towards digital tools, shutting down digital interventions before they can truly take effect, transforming them from supportive resources into emotional triggers to be avoided.

Trust deficit (core psychological pathway 2)

Trust deficit constituted the second core pathway of digital avoidance, with participants perceiving digital intervention tools as potentially risky monitoring systems or unreliable helpers rather than safe psychological spaces. This deficit manifested in three interrelated forms: privacy concerns, doubt about AI system capabilities and scepticism about online professional competence.

First, strong concerns about privacy breaches, data logging and external surveillance significantly undermined participants’willingness to continue using digital platforms. Even platforms claiming anonymity or encryption failed to alleviate anxieties that content might be seen by parents, schools or healthcare providers, leading to negative consequences. P2 stated: “Some platforms claim confidentiality, but I don’t believe it. If my school finds out what I wrote, I’m ‘finished’.” P6 also emphasised similar surveillance fears: “Those records are online, I don’t know who can see them. If my parents find out, I’ll be scolded to death.” This distrust of privacy protection makes them avoid leaving sensitive content on digital tools, even when they genuinely need help.

Second, participants generally questioned the capabilities and reliability of AI counselling or automated systems, describing responses as mechanical, formulaic and unable to understand complex painful experiences. P8 said: “AI just recites textbook answers. Whatever I say, it responds with the same phrases. It feels like it doesn't understand me at all.” P13 added: “I tried that chatbot, it kept making me take deep breaths, making me feel like it was just going through the motions.” For adolescents in highly emotional states, inhumane responses intensify feelings of neglect and misunderstanding, thereby strengthening their psychological defenses.

Third, trust in online professional counsellors remained relatively low. Participants questioned whether online counsellors possessed the same professional competence as in-person therapists, and feared misjudgments or misinterpretations of their condition due to the lack of in-person interaction. P17 shared: “I can't trust online counselling. I don't even know if they’re professionals, I’m afraid saying something might lead to misunderstandings.” P19 expressed scepticism about professionalism: “They can’t see my true self. How can they know if I’m genuinely distressed? I find it unreliable.”

Collectively, these concerns transformed digital intervention tools from potential resources into potential threats, leading adolescents to avoid or discontinue use.

Feelings of ineffectiveness and frustration (core psychological pathway 3)

For some participants, deliberate avoidance of digital interventions stemmed not from fear or distrust but from accumulated feelings of ineffectiveness and frustration after repeated attempts to use the tools. Participants reported that during emotional peaks, the systematic, programmed processes of digital tools failed to capture their subjective pain, leading to the conclusion that such tools could not provide meaningful support.

A key complaint across participants was the lack of depth and flexibility in AI or app responses, which made them feel even more isolated at critical moments of emotional distress. P3 said: “Its replies were always the same. I described my situation in detail, yet it kept responding with templates… It seemed completely unaware of my struggles.” Similarly, P4 described their frustration: “I was already in a state of collapse when it told me to take deep breaths and stay calm. I felt it didn't understand my pain.” This sense of being replaced by programmed responses was repeatedly mentioned by multiple participants. P14 stated: “When I told it I wanted to hurt myself that night, it immediately popped up with a safety warning. I knew it meant well, but in that moment, I felt completely processed by the system.”

Participants also described hollow, unfulfilling interactions with digital tools, lacking the sense of accompaniment critical for emotional support. P16 emphasised the hollow interaction: “You say something, it responds with something else, and it ends quickly. I never felt truly accompanied.” Some adolescents even developed stronger negative expectations after multiple attempts. P18 said: “I tried three or four similar apps before, and they all felt the same. None could genuinely calm my emotions, so I eventually stopped using them.”

This accumulation of failure experience makes them think that it is meaningless to continue to use digital tools, which not only reduces the appeal of digital tools, but also weakens their openness to seek online support in the future. The sense of ineffectiveness makes digital intervention lose its value in the eyes of these teenagers and deepens their subjective feeling that no one can understand their own dilemma.

The moderating effect of social situational factors (social dimension)

As the key component of the social dimension in the biopsychosocial framework, situational factors were not passive background variables but key moderating conditions determining adolescents’ usage experience and avoidance levels, directly shaping the expression of the three core psychological avoidance pathways and interacting with biological traits. Four primary situational factors were identified: parental monitoring, access to private space, peer attitudes and school environment. Beyond family monitoring, private space, peer attitudes, and school environment, socioeconomic background and parental education may further shape digital literacy, privacy awareness, and access to low-surveillance environments. These social factors form an ecological system that amplifies or reduces avoidance behaviours.¹² Parental monitoring and lack of private space significantly amplified emotional avoidance and trust deficit. Participants in high-monitoring family environments perceived digital interventions as potential risk sources, fearing discovery of their self-harm thoughts or behaviours. P11 stated: “My mom would suddenly enter my room. I couldn’t even text on my phone for fear of being seen.” Similarly, P12 mentioned: “My dad controls all the Wi-Fi at home. He can see which apps I download, how could I dare use them?” Lack of personal space is also considered a significant barrier to using digital interventions. P20 said: “With six people in the dorm, even typing on my phone gets noticed. I couldn’t possibly record my emotions in that environment.”

Peer attitudes and support reduced wariness and shame, moderating emotional avoidance and increasing willingness to try digital tools. Positive peer perceptions of digital interventions normalised usage for participants, while peer demonstration enhanced trust. P9 described: “My friend said he found the app normal, which made me feel safe to try it. Otherwise, I’d have thought it weird.” Some adolescents even increased their trust and willingness to try after peer demonstration. P15 said: “Seeing others using it made me feel it wasn’t so scary.” The school environment also plays a crucial moderating role. In campuses with electronic device bans or excessive monitoring, usage difficulty increases exponentially.

School environment influenced the practical usability of digital tools, with electronic device bans or excessive monitoring increasing usage difficulty exponentially. P17 said: “Our school confiscates all phones during classes. How could I possibly use them on time every day?” Moreover, some respondents noted that emergencies or acute emotional states could also affect usage opportunities. P21 explained: “I was out and about when the episode occurred, so I couldn’t even open the app.”

Overall, these situational factors shape a dynamic digital avoidance process: heightened surveillance and limited privacy amplify exposure anxiety and trust deficit, while increased social support and private spaces boost willingness to use digital interventions.

Discussion

This study systematically explores digital intervention avoidance among adolescents with NSSI based on the biopsychosocial behavioural framework of behavioural psychology and adolescent psychopathology. The results fully prove that this avoidance is not a single psychosocial phenomenon but a multidetermined behavioural outcome formed by the interaction of biological traits, individual psychological mechanisms and external social ecological factors. The three core psychological pathways (emotional avoidance, trust deficit, feelings of ineffectiveness and frustration) are the direct drivers of avoidance, the unique physiological stress response and emotional regulation defects of self-harming adolescents (biological dimension) amplify negative psychological experiences and various situational factors in the social dimension play a strong moderating role in the whole behavioural chain. The following is a multi-dimensional in-depth discussion combined with relevant theories and existing literature.

Biological dimension: psychopathological traits as the inherent amplification basic

Adolescents with NSSI have long been confirmed to have abnormalities in neural emotional regulation and stress response systems, which are important biological markers of this kind of psychopathology. In this study, all participants showed obvious somatic symptoms such as sweating and palpitations when facing emotional expression and privacy exposure scenarios on digital platforms. These physiological stress reactions are not caused by digital tools themselves but are the external manifestations of their long-term emotional dysregulation. From the perspective of behavioural psychology, uncomfortable physical sensations will generate negative reinforcement, prompting individuals to take avoidance behaviours to eliminate discomfort. Therefore, biological traits do not independently cause digital avoidance, but act as a stable inherent amplification factor, making psychological barriers more likely to be transformed into actual avoidance behaviours. This also explains why self-harming adolescents show stronger avoidance tendencies than ordinary adolescents when facing the same digital intervention scenarios.

Psychological dimension: three core avoidance pathways and behavioural logic

Three interrelated psychological pathways directly drive adolescents’ avoidance of digital mental health interventions: emotional avoidance, trust deficit, and feelings of ineffectiveness and frustration. These psychological mechanisms are amplified by biological stress reactivity and jointly moderated by social situational factors, and each pathway aligns with established clinical and self-injury theories as elaborated below.

First, emotional avoidance acts as the primary psychological barrier, rooted in intense shame and fear of judgement when disclosing vulnerable self-harm-related feelings on digital platforms. This aligns with the classic functional model of non-suicidal self-injury, which frames NSSI as a coping strategy for an overwhelming negative affect.¹³ For adolescents with self-harm histories, digital tools’ permanent recording functions and visible input interfaces raise perceived exposure risks and their innate physiological stress responses further intensify shame, turning digital platforms into emotional triggers rather than safe outlets.¹⁴ Existing literature confirms that persistent self-stigma and negative self-evaluation commonly hinder help-seeking, and digital recording features uniquely magnify such psychological costs compared with one-off in-person conversations.¹⁵

Compounding emotional avoidance, trust deficit emerges from adolescents’ perceived sociotechnical risks embedded in digital intervention systems, covering privacy leakage fears, doubts about AI competence and low confidence in online counsellors.¹⁶ Consistent with trust-enabled privacy frameworks for youth digital design, perceived surveillance from parents, schools or third-party platforms pushes young users to adopt self-censorship or complete disengagement.¹⁷ This lack of trust extends beyond data security to professional credibility: participants questioned whether automated chatbots or remote online therapists could accurately capture their complex distress, weakening their willingness to rely on digital support resources.¹⁸

The third core pathway, feelings of ineffectiveness (why invalidation?) and frustration, arises from repeated unhelpful interactions with rigid automated digital systems, which generate emotional invalidation and cumulative frustration.⁶ Standardised, formulaic AI replies fail to match adolescents’ acute, personalised emotional suffering during crisis states, leaving participants feeling unheard and isolated.¹⁹ This finding supports global digital mental health research noting that mechanical automated responses reduce sustained user engagement.²⁰ While offline psychological interventions can deliver tailored empathic responses through real-time interpersonal interaction, digital tools lack this flexible humanised support, reinforcing adolescents’ belief that such platforms cannot deliver meaningful relief and prompting voluntary avoidance.²¹

Comprehensive interpretation of multidetermined behaviour

Combined with the above three dimensions, this study fully responds to the perspective of behavioural psychology and adolescent psychopathology: digital avoidance of self-harming adolescents is a typical multidetermined behaviour. It cannot be fully explained by a single emotional appraisal or social context. Instead, it is the result of the joint action of inherent biological psychopathological traits, individual psychological cognition and emotion, and external social ecological environment.²² The three dimensions interact dynamically throughout the whole behavioural process, which also makes the avoidance behaviour more persistent and complex than ordinary adolescent groups. While help-seeking avoidance is a widespread phenomenon across both online and offline mental health services for self-harming adolescents, the biopsychosocial interactions identified in this work specifically capture context-laden digital risks that distinguish digital avoidance from disengagement with in-person care.²³

It is important to contextualise digital avoidance within broader help-seeking avoidance among self-harming adolescents. Consistent with existing clinical observations, this population regularly avoids in-person psychotherapy driven by shared core barriers of shame, self-stigma and negative self-evaluation.²⁴ However, digital avoidance exhibits unique layered risks absent from face-to-face support, persistent data recording, cross-platform surveillance by families and schools, opaque data privacy governance and mechanical automated responses that amplify emotional invalidation.²³ While offline and online avoidance share identical root psychological vulnerabilities, the biopsychosocial moderators shaping avoidance intensity diverge substantially between digital and in-person service contexts.

Strengths and limitations

The main strength of this study is that it first interprets digital intervention avoidance among self-harming adolescents under the unified biopsychosocial behavioural framework, integrating biological, psychological and social dimensions, and making the categorical model more theoretically integrated and logically rigorous. Meanwhile, this study adopts grounded theory and strictly complies with COREQ criteria, with sufficient sample size and verified theoretical saturation. Limitations include a sample limited to hospital emergency departments, potential social biases in qualitative interviews and the inability to quantify avoidance mechanisms’ impact on tool abandonment. Generalisability was restricted to the Chinese sociocultural context; there was no explicit analysis of socioeconomic or educational gradients. Future research should use mixed methods to quantify avoidance behaviours and explore how technical and environmental factors can enhance intervention effectiveness from a multidimensional perspective.

This study also acknowledges that support avoidance is not exclusive to digital tools as adolescents with NSSI routinely avoid face-to-face therapy due to shared stigma and shame barriers. The present framework uniquely isolates digital-specific socio-technical moderators that exacerbate avoidance in online settings. Limitations include a sample limited to hospital emergency departments, potential social biases in qualitative interviews and the inability to quantify avoidance mechanisms’ impact on tool abandonment. Generalisability restricted to the Chinese sociocultural context. There was no explicit analysis of socioeconomic or educational gradients. Future research should use mixed methods to quantify avoidance behaviours and explore how technical and environmental factors can enhance intervention effectiveness from a multidimensional perspective.

Conclusion

Adolescents’ avoidance of digital psychological interventions is a layered, dynamic, multidetermined behavioural phenomenon, which is jointly shaped by three interactive dimensions: biological emotional regulation traits, three core psychological avoidance pathways (emotional avoidance, trust deficits and perceived ineffectiveness) and social ecological situational moderators including family monitoring, school environment, privacy concerns and socioeconomic context. Under the guidance of the biopsychosocial behavioural framework, future interventions should be trauma-informed, user-centred and context-adaptive. Designers need to fully consider the psychopathological characteristics of self-harming adolescents at the biological level, reduce emotional triggers at the psychological level, optimise privacy protection and social adaptation at the social level, so as to rebuild trust, relieve negative emotions and improve user engagement of digital interventions.

Relevance to clinical practice

This study emphasises the need for trauma-informed, user-centric digital designs based on the biopsychosocial perspective. Interventions should fully consider the biological emotional dysregulation traits of self-harming adolescents, minimise emotional triggers, enhance user autonomy and rebuild trust through transparent, non-judgemental interfaces. Meanwhile, clinical practitioners need to cooperate with families and schools to improve the external social environment so as to reduce the moderating effect of negative situational factors. Clinicians should recognise that digital avoidance coexists with widespread avoidance of in-person therapy and integrated support strategies combining low-pressure offline contact and trauma-adapted digital tools are required to reduce multi-setting help-seeking avoidance.

Data availability statement

Data are available upon reasonable request.