Abstract
BackgroundEach year, 220 000 episodes of self-harm are managed by emergency departments in England, providing support to people at risk of suicide.AimsTo explore treatment of self-harm in emergency departments, comparing perspectives of patients, carers and practitioners.MethodFocus groups and semi-structured interviews with 79 people explored experiences of receiving/delivering care. Participants were patients (7 young people, 12 adults), 8 carers, 15 generalist emergency department practitioners and 37 liaison psychiatry practitioners. Data were analysed using framework analysis.ResultsWe identified four themes. One was common across stakeholder groups: (a) the wider system is failing people who self-harm: they often only access crisis support as they are frequently excluded from services, leading to unhelpful cycles of attending the emergency department. Carers felt over-relied upon and ill-equipped to keep the person safe. Three themes reflected different perspectives across stakeholders: (b) practitioners feel powerless and become hardened towards patients, with patients feeling judged for seeking help which exacerbates their distress; (c) patients need a human connection to offer hope when life feels hopeless, yet practitioners underestimate the therapeutic potential of interactions; and (d) practitioners are fearful of blame if someone takes their life: formulaic question-and-answer risk assessments help make staff feel safer but patients feel this is not a valid way of assessing risk or addressing their needs.ConclusionsEmergency department practitioners should seek to build a human connection and validate patients’ distress, which offers hope when life feels hopeless. Patients consider this a therapeutic intervention in its own right. Investment in self-harm treatment is indicated.
Highlights
Each year, 220 000 episodes of self-harm are managed by emergency departments in England, providing support to people at risk of suicide
One was common across stakeholder groups: (a) the wider system is failing people who self-harm: they often only access crisis support as they are frequently excluded from services, leading to unhelpful cycles of attending the emergency department
Three themes reflected different perspectives across stakeholders: (b) practitioners feel powerless and become hardened towards patients, with patients feeling judged for seeking help which exacerbates their distress; (c) patients need a human connection to offer hope when life feels hopeless, yet practitioners underestimate the therapeutic potential of interactions; and (d) practitioners are fearful of blame if someone takes their life: formulaic questionand-answer risk assessments help make staff feel safer but patients feel this is not a valid way of assessing risk or addressing their needs
Summary
220 000 episodes of self-harm are managed by emergency departments in England, providing support to people at risk of suicide. In the UK, approximately 6000 people take their own life each year.[1] Self-harm is the strongest risk factor for suicide, defined as intentional self-poisoning or self-injury, irrespective of motive or the extent of suicidal intent.[2] Self-harm includes acts intended to result in suicide, those without suicidal intent (such as it supports a coping mechanism) and acts where the motivation is mixed or unclear.[3] For people who self-harm, emergency departments are often the first point of contact with healthcare services: up to 43% of people who take their life attend the emergency department in the year before death.[4] This makes emergency departments a crucial support system for people in crisis with potential for lifesaving interventions. Emergency departments must meet the complex physical and psychiatric needs of people who self-harm, who are known to be at increased risk of suicide
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