Gatekeeping and factors underlying decisions not to refer to mental health services after self-harm: Triangulating video-recordings of consultations, interviews, medical records and discharge letters

Bergen, Clara; Lomas, Matthew; Ryan, Mary

doi:10.1016/j.ssmqr.2023.100249

Cited by 6 publications

(6 citation statements)

References 39 publications

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“…Indeed, the implementation plan of Ireland's mental health strategy, Sharing the Vision [23], highlights the need to improve access routes into mental health services to ensure comprehensive and integrated services for the provision of mental healthcare are available in acute hospitals. A recent qualitative study in the UK examined factors underlying the decision to not refer persons attending the ED in crisis to mental health services [24]. The pressure on under resourced mental health services was highlighted, suggesting that clinicians in the ED have to take on a role as gatekeeper of mental health services, rationing referrals to those that are deemed most in need [24].…”

Section: Discussionmentioning

confidence: 99%

“…A recent qualitative study in the UK examined factors underlying the decision to not refer persons attending the ED in crisis to mental health services [24]. The pressure on under resourced mental health services was highlighted, suggesting that clinicians in the ED have to take on a role as gatekeeper of mental health services, rationing referrals to those that are deemed most in need [24]. Indeed, the decreased risk of non-referral among those presenting with higher lethality methods of self-harm, with repeat self-harm and those aged under 18, indicates that referrals may be prioritised for those who are perceived to be at higher risk for further selfharm or suicide.…”

Section: Discussionmentioning

confidence: 99%

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Discharged from the emergency department following hospital-presented self-harm: referral patterns and risk of repeated self-harm

Cully,

Russell,

Joyce

et al. 2024

Ir J Med Sci

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Background Presentation to the emergency department (ED) with self-harm provides an important opportunity for intervention. Aims To investigate characteristics and self-harm repetition risk of those discharged from the ED without a referral for mental health–related aftercare. Method Data on consecutive self-harm presentations to EDs for the years 2013–2019 (n = 55,770) were obtained from the National Self-Harm Registry Ireland. Multilevel Poisson and Cox regression models were estimated. Results Half of the self-harm presenters were discharged from the ED (49.8%) and almost half of them did not receive a mental health–related referral (46.8%). Receipt of a psychosocial assessment was associated with a 50% reduced risk of non-referral (IRR 0.54; 95% CI 0.51–0.57). Non-referral was also less likely for young people (< 18 years), presentations involving attempted hanging, persons with previous self-harm presentations, and in the latter half of the study period (2017–2019 vs. 2013–2016), but was more likely for those brought by ambulance, presenting outside 9 am–5 pm and admitted to an ED medical assessment unit. Of those not referred, 19.3% had a repeat presentation within 12 months, compared to 22.4% of those referred. No difference in repetition risk between these two groups was evident in adjusted analyses. Self-harm history had the strongest association with repetition, with highest risk among individuals with four or more previous presentations (HR 9.30, 95% CI 8.14–10.62). Conclusions The findings underline the importance of assessing all individuals who present with self-harm and highlight the need for comprehensively resourced 24hr services providing mental health care in the ED.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Discharged from the emergency department following hospital-presented self-harm: referral patterns and risk of repeated self-harm

Cully,

Russell,

Joyce

et al. 2024

Ir J Med Sci

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“…Hence, they are under pressure not to report their clinical assessment of need and risk of harm when treatment is not available. As such, undermining and recharacterizing peoples’ experiences may be unconsciously used to justify no further care where services are unavailable or inaccessible, reflecting a wider context of practitioners as gatekeepers, forced to ration mental health services in the UK National Health Service ( 43 ).…”

Section: Discussionmentioning

confidence: 99%

“…As shown in the extracts above, recharacterizations can be built up during an assessment and can be cited to justify decisions not to provide specialist care. In the following extracts, we demonstrate how these recharacterizations can be used to shift the burden of care off of the healthcare system and back onto the patient ( 43 ).…”

Section: Implying Implausibility and Undermining Peoples’ Experiencesmentioning

confidence: 99%

Implying implausibility and undermining versus accepting peoples’ experiences of suicidal ideation and self-harm in Emergency Department psychosocial assessments

Bergen,

Bortolotti,

Temple

et al. 2023

Front. Psychiatry

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BackgroundPatients seeking emergency care for self-harm and suicidality report varying experiences from being believed and taken seriously to not being believed and taken seriously. Epistemic injustice provides a conceptual framework to explore how peoples’ experiences of self-harm and suicidality are believed or not. We use an empirical method –conversation analysis – to analyze epistemics in clinical communication, focusing on how knowledge is claimed, contested and negotiated. In courtroom, police and political interaction, conversation analysis has identified communication practices implying implausibility in a person’s story to contest and recharacterize their accounts.AimsTo investigate communication practices in Emergency Department (ED) biopsychosocial assessments that may (1) undermine, imply implausibility and recharacterize or (2) accept peoples’ experiences of suicidal ideation and self-harm.MethodsUsing conversation analysis, we micro-analyzed verbal and non-verbal communication in five video-recorded biopsychosocial assessments with people presenting to the ED with self-harm or suicidal ideation, and conducted supplementary analysis of participants’ medical records and post-visit interviews. We present three cases where experiences were not accepted and undermined/recharacterized and two cases where experiences were accepted and validated.ResultsWhen peoples’ experiences of suicidality and self-harm were not accepted or were undermined, questioners: did not acknowledge or accept the person’s account; asked questions that implied inconsistency or implausibility (“Didn’t you tell your GP that you were coping okay?”); juxtaposed contrasting information to undermine the person’s account (“You said you were coping okay before, and now you’re saying you feel suicidal”); asked questions asserting that, e.g., asking for help implied they were not intending to end their life (“So when you called 111 what were you expecting them to do”); and resistinged or directly questioned the person’s account. Multiple practices across the assessment built on each other to assert that the person was not suicidal, did not look or act like they were suicidal; that the person’s decision to attend the ED was not justified; that an overdose was impulsive and not intended to end life; asking why the person didn’t take a more harmful medication to overdose; that self-harming behaviors were not that serious and should be in the person’s control. Alternative characterizations were used to justify decisions not to provide further support or referrals to specialist services. At times, these practices were also delivered when speaking over the patient. When peoples’ experiences were accepted, practitioners acknowledged, accepted, validated suicidality/self-harm and introduced a shared understanding of experiences that patients found helpful. Non-verbal feedback such as nodding and eye contact was central in acceptance of patients’ accounts.ConclusionThese findings advance our understanding of how peoples’ experiences of suicidality or self-harm are undermined or accepted in mental health encounters in the ED. They have important clinical implications: patients report that when their experiences are not accepted or undermined, this makes them more distressed, less hopeful about the future and discourages future help-seeking when in crisis. Conversely, acknowledging, accepting and validating suicidality/self-harm and introducing a new ways of understanding peoples’ experiences may make people less suicidal and more hopeful, generates shared understanding and encourages future help-seeking.

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“…However, patients have often described being discharged without a clear treatment plan in place and treatment failing to meet their needs ( 7 , 11 ). There are limited services available with little flexibility in options for patients, with long waiting lists and exclusionary thresholds for referrals ( 12 , 13 ). To address issues with mental health service provision for patients who self-harm, a small number of psychiatric liaison teams have initiated outpatient clinics to improve support for these patients, and there is preliminary evidence supporting the use of these approaches ( 14 ).…”

Section: Introductionmentioning

confidence: 99%

Re-imagining crisis care: experiences of delivering and receiving the Assured brief psychological intervention for people presenting to Emergency Departments with self-harm

Shah,

O’Keeffe,

Hayward

et al. 2024

Front. Psychiatry

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BackgroundRisk of suicide is increased immediately following emergency department (ED) attendance for self-harm. Evidence suggests that brief psychological interventions delivered in EDs are effective for self-harm. The Assured intervention comprises an enhanced biopsychosocial assessment in the ED, collaborative safety planning and three rapid solution focused follow-up sessions.AimWe addressed the following research questions: What were ED mental health liaison practitioners’ and patients’ experiences of the Assured intervention? What were the barriers and facilitators? What might the mechanisms be for improving experiences and outcomes?MethodsWe conducted a feasibility study of the Assured intervention in four EDs in Southeast England. Semi-structured interviews were conducted with 13 practitioners and 27 patients. Interviews were transcribed, coded line-by-line in Nvivo and thematically analysed using an inductive approach. Inter-rater reliability was calculated with a kappa coefficient of 0.744.

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Gatekeeping and factors underlying decisions not to refer to mental health services after self-harm: Triangulating video-recordings of consultations, interviews, medical records and discharge letters

Cited by 6 publications

References 39 publications

Discharged from the emergency department following hospital-presented self-harm: referral patterns and risk of repeated self-harm

Discharged from the emergency department following hospital-presented self-harm: referral patterns and risk of repeated self-harm

Implying implausibility and undermining versus accepting peoples’ experiences of suicidal ideation and self-harm in Emergency Department psychosocial assessments

Re-imagining crisis care: experiences of delivering and receiving the Assured brief psychological intervention for people presenting to Emergency Departments with self-harm

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