Evidence
Alert

GPs may help people at risk of self-harm by asking open questions, acknowledging distress, and exploring positive reasons for staying alive

Simple changes to the way doctors ask questions about self-harm and suicidal thoughts could improve conversations with vulnerable patients and enable access to help and support. 

A new study found that doctors tend to ask closed questions and, in some instances, inadvertently reinforce the stigma associated with suicide. These approaches made it difficult for patients to speak openly and honestly.

Many people who die by suicide have seen their GP in the month before their death, which provides an opportunity to offer help. But discussing self-harm and suicidal thoughts can be difficult for both patients and doctors. Doctors may worry about exacerbating a patient's suicidal thoughts or putting the idea in their head. Patients may approach such conversations with a great deal of shame and guilt.

As part of the DeSTRESS Project on mental health, researchers sought to explore how these conversations unfold by analysing real-life recordings of primary care consultations. They wanted to identify ways of improving the communication between doctor and patient. 

This small, detailed study concluded that the way doctors ask questions can influence the openness and level of discussion that follows. The findings may help doctors have better conversations with patients who have mental health problems.

What’s the issue?

Someone who self-harms deliberately poisons or injures themselves, often as a way of coping with emotional distress. Self-harm in England has tripled in the last twenty years. Long term, it is linked to developing suicidal thoughts.

In 2018, more than 6,500 suicides were recorded across the UK. The number of deaths by suicide is rising; during 2018, it increased by 10%.

Conversations about self-harm and suicidal thoughts can be difficult for both patients and doctors. The associated stigma means that many patients feel shame and guilt and are reluctant to seek help.  

But GPs play an important role in discussing mental health concerns, self-harm, and suicidal thoughts with their patients. Almost half of those who die by suicide have seen their GP in the previous month.

Several previous studies have looked at how healthcare professionals pose questions about self-harm. In this study, researchers wanted to explore real-life consultations to see what happens next. They wanted to see how patients respond and how the conversation unfolds. 

What’s new?

Researchers searched the One in a Million database of video-recorded consultations between GPs and people from diverse backgrounds. They identified 18 consultations for mental health conditions in which doctors asked patients about self-harm or suicide. The researchers carried out an in-depth analysis of how these discussions unfolded.

Researchers considered the wording of the doctors’ questions alongside patients’ verbal responses and body language. They found that the way doctors asked questions about self-harm and suicide could make it difficult for patients to talk freely. Patients’ responses were often hesitant or ambiguous, downplaying the seriousness of their thoughts or behaviours. 

Doctors usually initiated the discussion about self-harm but they often inadvertently limited it. Unhelpful aspects of conversations included: 

    • closed questions framed for a ‘no’ response, that made it difficult for patients to answer ‘yes’: “But you’ve not had any thoughts of harming yourself or suicide or anything like that?” Even patients who answered ‘yes’ downplayed their response: “I have in some ways
    • a change of topic after an ambiguous ‘no’ response (such as a long pause before the patient said ‘no’) and not referring to self-harm again in the consultation
    • one tightly coupled question addressing both self-harm and suicide: “Sometimes when people feel low and stressed, they think of harming themselves – is that ever something that crosses your mind?”
    • a focus on prevention without acknowledging distress: “So do you ever get far enough that you think of making plans to harm yourself? Or is it thoughts coming into your head and you’re able to get rid of them?"
    • moral issues around suicide - raised rarely by doctors - did not prompt people who were already feeling shame to open up: “It rebounds on other people … a terrible thing to leave other people with.”

Why is this important?

The findings from this study can help doctors have better conversations with patients who may be self-harming or considering suicide.

Given the vital role of GPs in offering help to these people, the researchers suggest many doctors could do more to seek clarity and encourage discussion from those who seem hesitant or reluctant to discuss their feelings. 

They suggest that:

    • adopting a more open questioning style and asking about self-harm and suicide separately could encourage patients to talk about self-harm and suicidal thoughts. 
    • acknowledging suicidal thoughts as distressing in themselves could help patients get the most suitable help.
    • exploring patients’ positive reasons for wanting to stay alive, rather than focusing on the problems suicide causes for others, could help to counter guilt and shame.

What’s next?

This was a small exploratory study, but the findings could help improve the way in which doctors ask patients about self-harm and suicidal thoughts. They could be used to develop a new standard of questions to open up discussions.

A larger, more long-term study would be needed to influence policy. This kind of research could directly target people approaching their GP with mental health problems and follow them over time to explore the outcomes of consultations. 

This study was based on GP consultations that took place between 2014 and 2015. It may be important for further research to use more recent data to reflect the changes to general practice during COVID-19.

You may be interested to read

The full paper: Ford J, and others. Asking about self-harm and suicide in primary care: Moral and practical dimensions. Patient Education and Counselling 2020;104:4 

The website for the DeSTRESS study, which this research formed a part of

The recordings used in this research came from the One in a Million data archive, which is run by the Bristol Archive Project and funded by the NIHR School for Primary Care Research and the South-West GP Trust.  

NHS information: Help for suicidal thoughts

A paper that used the same approach to explore how healthcare professionals assess suicide risk: McCabe R, and others. How do healthcare professionals interview patients to assess suicide risk? BMC Psychiatry 2017;17:122 

A paper that used the same approach to explore how young people are asked about self-harm and suicide: O'Reilly M, and others. “This is a question we have to ask everyone”: asking young people about self‐harm and suicide. Journal of Psychiatric Mental Health Nursing 2016;23:8 

 

Funding: The DeStress Project was funded by the Economic and Social Research Council. One author is supported by the NIHR Applied Research Collaboration (ARC) South West Peninsula. The One in a Million database was funded by the NIHR School for Primary Care Research and the South West GP Trust.

Conflicts of Interest: The study authors declare no conflicts of interest.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Commentaries

Study author

With this kind of research, you’re often looking at phenomena that vary across individuals. But in this case, we saw consistent patterns in the consultations. This suggested that we were getting at something that was clearly an overarching issue and something of great relevance to many different groups of patients and doctors. 

A more targeted, in-depth study is needed to make specific recommendations, but I think this paper could influence practice in its current form. When I’ve met with practitioners and gone through the paper or listened to the consultation recordings with them, it seems to help them think more deeply about how they hold conversations with patients.  

If the paper can encourage reflection and help practitioners think about something that can be habitual, that to me is a great thing.

Joseph Ford, who at the time of the study was Postdoctoral Research Associate, College of Medicine and Health, University of Exeter 

Public contributor 

If you really think about how you ask questions, it can support someone who is in a negative frame of mind. GPs are in that position and can have a great impact. It’s important to make sure that questions are asked in the right way.

Ruby Bhatti OBE, Public Contributor, Bradford 

Samaritans

Self-harm and suicide are both complex. At Samaritans we recognise just how important the human connection is when having difficult conversations.

Samaritans volunteers are trained to be active listeners and ask open questions – an effective way to encourage people to explore and express their emotions – but this approach applies to many different walks of life, including GPs.

As our Pushed from pillar to post report found, 1 in 5 people who had self-harmed reached out to their GP afterwards. This makes GPs one of the most common sources of support following self-harm and demonstrates the key role they play in supporting this group.

For 20 years, rates of non-suicidal self-harm have been increasing, and tackling self-harm has been recognised by government as a policy priority for suicide prevention. However, we still know little about what good quality support looks like. People who do find the courage to seek help, despite prevalent stigma and shame around self-harm, are being let down.

As such, this study into some simple but effective ways of helping GPs offer even better support to people who are struggling is welcome.

Mette Isaksen, Senior Research and Evidence Manager, Samaritans

Mental Health Foundation

Suicide prevention is both important and complicated. This study makes some excellent recommendations which chime with our experience. Creating a distinction between self-harm and suicide is an important step in encouraging more constructive conversations in primary care settings.

More research is needed into gender differences. Suicide is overwhelmingly a killer of men; self-harm and depression are associated with suicide but are much more frequently reported in women. Women are also more likely to visit GPs and more likely to be referred to IAPT (Improving Access to Psychological Therapies) programmes. It seems likely that the nature of conversations with GPs will therefore differ according to gender. It is not clear from the study whether or how this is addressed, but it is noted as a study limitation.

This is interesting and important research but most of what we need to do to prevent suicide (particularly with men) remains outside the consulting room.

David Crepaz-Keay, Head of Applied Learning, Mental Health Foundation 

GP

These findings may change the way that conversations on suicide are conducted and is hugely relevant to me in my daily practice as a GP. 

This research enables me to help my patients talk about any suicidal thoughts they may have had. We can then develop a safety management plan together that minimises risks and maximises support. It is especially important that one of the findings is to ask about positive reasons for wanting to stay alive because this can lead on to making such plans. 

The findings are likely to reflect true practice because the researchers looked at all consultations from an established database and doctors were not aware of what aspects of the consultation would be analysed at the time of the recording.

Aarti Bansal, GP & Clinical Academic, Sheffield