This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.
People who self-harm often have few services available to them apart from accident and emergency (A&E). A new study found that many do not receive meaningful care. A+E patients receiving treatment for self-harm said that a human connection, such as being listened to, gave them hope. But this was not always recognised by emergency staff.
Current guidelines recommend that people presenting to A&E with self-harm should have a psychosocial assessment (of their mental and emotional health and their social wellbeing). Not all receive this assessment. Some who do receive the assessment, experience it as a ‘box-ticking’ exercise which does not address their distress. The result can be a cycle of repeated A&E attendance which is frustrating for staff and patients alike.
People who self-harm are at increased risk of ending their lives by suicide, compared to people who do not self-harm. Improvements to the assessment, and to how people are followed up after attending A&E, might prevent further episodes of self-harm and also reduce the number of people who die by suicide.
This study explored the experiences of patients, their carers and staff in A&E. The findings informed a clinical trial to test a new psychosocial assessment for people who self-harm. The research team hopes the new assessment, with rapid follow-up care, will help clinicians build a human connection with patients, acknowledge their distress, and leave them feeling more supported and hopeful about the future.
What’s the issue?
Self-harm is damage to your own body, sometimes through self-poisoning or other forms of injury. People who self-harm may or may not intend to die, or may not have a clear intention. Regardless, self-harm is the strongest risk factor for suicide. Approximately 6,000 people die by suicide each year in the UK, and almost half (43%) have attended an emergency department in the year before their death. Around 220,000 episodes of self-harm are treated in A&E in England annually.
Guidelines from the National Institute of Health and Care Excellence (NICE) say that people who self-harm and attend A&E should have their physical needs met by general medical staff and be assessed by a liaison psychiatry team (which works alongside medical staff and includes psychiatrists, mental health nurses and psychologists). This study was set up to find out how patients, carers and staff experience the system. It investigated whether improvements could help reduce the numbers of people who self-harm and go on to die by suicide.
Researchers interviewed 19 patients, 8 carers, 15 emergency department staff and 37 liaison psychiatry staff. The staff were recruited from four hospitals in London and the South West of England, while the patients and carers were recruited through mental health charities and patient groups. In focus groups and through semi-structured interviews, the researchers compared the experiences and perspectives of the people receiving treatment for self-harm, with those of A&E and psychiatry staff.
Four themes emerged from the research:
- A failure of the wider system – both primary care and specialist services - to support people who self-harm. This was reported by staff, carers and patients alike. Patients were unable to get specialist care; staff reported a lack of services to refer patients to. People lacked support in the community to prevent them reaching crisis point, which led to unhelpful cycles of repeat attendance at A&E. Carers felt over-relied on and ill-equipped to keep the person safe.
One liaison psychiatry practitioner said: ‘‘people … don’t have a necessarily diagnosable mental disorder, they therefore have no access to a service. But everybody else isn’t sufficiently skilled to manage their risk… there really is very little for those people. They sit in that kind of middle of the gaps.”
- Self-harm raised difficult feelings for both staff and patients in A&E. People often felt shame when seeking help after self-harm; staff felt powerless. Staff’s attitudes could harden, partly through frustration at being unable to help. Some people reported feeling judged and disapproved of by staff and this could worsen their distress.
One patient said: “I’ve almost put myself here, when there could be someone who’s having a heart attack … I feel bad, because I feel like I’m taking up their time.”
- A human connection was valued by people, who said that being listened to and having their experiences validated was helpful and gave them hope. However, staff did not feel it was their role to provide this. They felt under pressure to complete psychosocial assessments to enable the patient to be discharged. Patients and carers felt the pressure was transferred back to them, without the experience at A&E having been helpful.
One patient said: “You want to be heard, you want to be seen… I want to be hearing something with a bit of depth rather than the superficial things that you’re trying to tell me to, that doesn’t do me anything.”
- Fear of blame if someone takes their own life. Brief question and answer risk assessments made staff feel safer and demonstrated that their department had met organisational requirements. But patients felt this was not a valid way of assessing risk or addressing their needs.
A member of staff said: “With the work we do, our head is always thinking its risk risk risk…how do you mitigate those risks, that’s the way we think.”
Why is this important?
Staff's negative attitudes and feelings of frustration towards people who self-harm were reported in a review published a decade ago. This study suggests that little has changed. Large numbers of people self-harm and there is a clear need to improve their experience in A&E. This could potentially reduce the numbers of people who take their own lives.
Patients and carers in the study had responded to leaflets and social media posts and the researcher say they may have volunteered because of negative experiences. By contrast, the staff who took part may have had a greater interest in mental health and self-harm. This means that the study group might not give a true representation of the situation this group is in.
Nevertheless, the study recommends:
- building a human connection, so that people have their distress validated and feel safer; this might reduce further self-harm
- assessments that are less formulaic and less focused on risk
- training to reduce stigma
- better follow-on support services to prevent further admissions to A&E.
This study is part of a larger study called ASSURED (‘Improving outcomes in patients who self-harm – Adapting and evaluating a brief psychological intervention in emergency departments’). The aim is to develop and test a new intervention for people presenting to emergency departments with self-harm.
NICE guidelines recommend that people who self-harm should be referred to a liaison psychiatry team and receive a psychosocial assessment. This approach has been shown to reduce the risk of repeat self-harm but the guideline is not widely followed. Previous work has found that only 3 in 5 (60%) people in A&E for self-harm receive the assessment. Similarly, in this study, staff said they would not necessarily refer people who self-harm to liaison psychiatry.
The researchers have analysed the psychosocial assessment for people in A&E who have self-harmed and developed a new approach to the assessment, based on the findings of this study. The new assessment is intended to help build a human connection with patients, acknowledge their distress and leave them feeling safer. Clinicians will also conduct an in-depth personalised safety plan to support the patient to manage future crises. The clinician who carries out the assessment will follow-up the patient and provide continuity of care.
The new intervention has been tested in four hospitals in London, with 60 patients taking part. The team is now recruiting for a 1,000 patient study to be carried out in 10 hospitals in London, the Midlands and the South West. This further study will determine whether the improved assessment as part of the new intervention can make a difference to patients’ experience of care and outcomes.
This study focuses on A&E departments but improvements are needed throughout primary and specialist systems to help people who self-harm.
You may be interested to read
The paper this NIHR Alert is based on: O’Keeffe S, and others. Experiences of care for self-harm in the emergency department: comparison of the perspectives of patients, carers and practitioners. BJPsych Open 2021;7:e175
Pushed from pillar to post: a report from the Samaritan’s charity on support after self-harm.
A study of risk assessments for suicide: Graney J, and others. Suicide risk assessment in UK mental health services: a national mixed-methods study. The Lancet Psychiatry 2020;7:1046-1053
A study on brief psychological treatments for people at risk of suicide: McCabe R, and others. Effectiveness of brief psychological interventions for suicidal presentations: a systematic review. BMC Psychiatry 2018;18:1-13
A study on trends in primary care-recorded self-harm throughout the first year of the Covid-19 pandemic: Steeg S, and others. Temporal trends in primary care-recorded self-harm during and beyond the first year of the COVID-19 pandemic: Time series analysis of electronic healthcare records for 2.8 million patients in the Greater Manchester Care Record. EClinicalMedicine 2021;41:101175
A paper identifying factors that contribute to positive experiences of therapy: Sass C, and others. Valued attributes of professional support for people who repeatedly self-harm: A systematic review and meta-synthesis of first-hand accounts. International Journal of Mental Health Nursing 2022;31:424–441
A review of first-person accounts of what has helped to reduce or stop self-harm: Brennan C A, and others. What helps people to reduce or stop self-harm? A systematic review and meta-synthesis of first-hand accounts. Journal of Public Health 2022;fdac022
Research exploring help-seeking for self-harm during the COVID-19 pandemic: Sass C, and others. “They have more than enough to do than patch up people like me.” Experiences of seeking support for self harm in lockdown during the COVID-19 pandemic. Journal of Psychiatric and Mental Health Nursing 2022; doi: 10.1111/jpm.12834
Funding: This research was funded by the NIHR Programme Grants for Applied Research.
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.