Attitudes towards clinical services among people who self-harm: systematic review

Authors:
TAYLOR Tatiana, et al
Journal article citation:
British Journal of Psychiatry, 194(2), February 2009, pp.104-110.
Publisher:
Cambridge University Press

A search of electronic databases was conducted and experts in the field were contacted in order to identify relevant worldwide qualitative or quantitative studies. Data were extracted independently by two reviewers with more weight given to studies of greater quality and relevance. Thirty-one studies met the inclusion criteria. Despite variations in healthcare systems and setting, participants' experiences were remarkably similar. Poor communication between patients and staff and a perceived lack of staff knowledge with regard to self-harm were common themes. Many participants suggested that psychosocial assessments and access to after-care needed to be improved. Specific aspects of care that might increase service user satisfaction and treatment adherence include staff knowledge, communication and better after-care arrangements. A standard protocol could aid regular audits of users' experiences of services.

Extended abstract:
Author

TAYLOR Tatiana L.; et al

Attitudes towards clinical services among people who self-harm: systematic review.

Journal citation/publication details

British Journal of Psychiatry, 194(2), February 2009, pp.104-110.

Summary

Thirty-one, mainly qualitative, studies (including 16 from the UK) are reviewed and reveal common experiences among those presenting at hospitals after a self-harm episode. These include poor staff-patient communication and a perceived lack of staff knowledge about self-harm. Many participants suggest that psychosocial assessment and access to after-care need to be improved.

Context

The prevalence of self-harm, together with the high rate of repetition and eventual suicide, make this a major health care problem in many parts of the world. There is widespread variation in services, and a general trend towards including consumer views in the evaluation of service outcomes. However, little attempt has been made to review the evidence on how people perceive services. This review aims to fill that gap, focusing on medical management, in-hospital psychiatric management and post-discharge management.

Methods

What sources were used?

The following databases were searched: AMED (Allied and Complementary Medicine Database); British Nursing Index; CINAHL (Cumulative Index to Nursing and Allied Health Literature); EMBASE (Excerpta Medica); Global Health; HMIC (Health Management Information Consortium database); IBSS (International Bibliography of the Social Sciences: Medline; PsycINFO; SIGLE (System for Information on Grey Literature in Europe – ceased March 2005); and Sociofile. The reference lists of relevant studies were checked and experts working in non-English speaking countries were consulted.

 

What search terms/strategies were used?

The search terms used were those employed by the National Collaborating Centre for Mental Health in the development of Clinical Guideline 16 on ‘Self-harm: the short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care’, published in 2004. The search strategies used in this review are in Appendix 7, available as an online supplement to those with a subscription to the British Journal of Psychiatry or at http://www.nice.org.uk/nicemedia/pdf/CG16FullGuidelineAppendices.pdf.

 

What criteria were used to decide on which studies to include?

Eligible quantitative and qualitative studies examined participants of either gender and any age who had engaged in self-injury or self-poisoning and had contact with hospital services. No language restrictions were applied. Quantitative studies were used to provide general evidence about the experiences of those who self-harm, with qualitative studies providing examples to extend understanding.

 

Who decided on their relevance and quality?

Of the 1,014 identified studies, 946 were excluded as irrelevant or duplicates on the basis of abstracts and a further 37 when examined in full text. Responsibility for the filtering process and for quality assessment of quantitative studies is not reported. Qualitative studies were assessed independently by at least two authors using referenced tools developed by the Social Care Institute for Excellence and the Critical Appraisal Skills Programme. All relevant studies were included but, in interpreting the evidence, more weight was given to those deemed to be of stronger design.

 

How many studies were included and where were they from?

Thirty-one English language studies were reviewed. Table 1, which covers quality assessments and relevance to the review, includes geographical settings: the UK (16); North America (6); Sweden (3); New Zealand (2); Ireland (1); Australia (1); Finland (1); and the Netherlands (1).

 

How were the study findings combined?

Twenty-eight of the studies were qualitative. Quotations and themes relevant to attitudes and experiences were coded using a pen and paper method by the lead author, with a second named author extracting data to ensure that all quotations and themes were recorded, and to reduce possible bias in reporting findings.

Findings of the review

Fourteen of the 31 studies were judged to have a ‘strong’ or ‘strong/acceptable’ design, nine an ‘acceptable’ design and eight an ‘acceptable’ or ‘acceptable/weak’ design. All but five were felt to be of ‘strong’ relevance to the review topic.

 

In fifteen of the studies participants who had self-poisoned predominated, reflecting the fact that ‘most individuals who self-harm and present to hospital do so after a self-poisoning episode’.

 

General perceptions of management

Perceptions of, and satisfaction with, treatment in hospital varied greatly but there were common themes including a desire for involvement in treatment and treatment decisions, clear communication of information, and sensitivity to possible personal preferences such as the gender of staff providing treatment. Staff were often perceived as lacking knowledge about self-harm.

 

Accident and emergency departments

One New Zealand study reported positive experiences among 62% of adolescents but in many other studies participants complained that they were treated differently because they had harmed themselves and that A&E staff focused solely on their physical condition. Long waiting times for treatment, and a lack of information about their physical status, contributed to fear and anxiety among some participants.

 

Physical treatment and psychosocial assessment

Lack of empathy together with perceived threats, overt hostility and humiliation were the main factors behind negative experiences of physical treatment. Although psychosocial assessment is part of recommended care for people who self-harm, many participants were not assessed or found assessment to be superficial and rushed. Where assessment was offered, it was perceived to be more positive when the individual was allowed to speak about problems and was involved in and informed about treatment.

 

Discharge and referral

Discharge was often described as a rushed, negative experience which left participants ill-prepared to leave hospital for either physical or psychological reasons. Some received no referral to after-care beyond provision of telephone numbers, others heard nothing after they had been promised after-care, and yet others faced very long waits. While the majority expressed satisfaction with overall treatment, some said they would not return to hospital after another self-harm episode. Those admitted to in-patient care often felt a lack of control: that they were being constantly watched or punished, rather than treated.

 

Post-hospital management

Most participants were willing to engage with services designed to minimise self-harm, especially when it gave them the opportunity to talk about their problems, and when staff were perceived as genuinely concerned. However, anxiety about revealing problems was common among adult participants in UK and Australian studies, although adolescent participants were generally more positive about after-care.

 

Failure to attend after-care was associated with factors such as difficulty in understanding referral instructions, a belief that therapy would be useless, or a fear of stigma. Ending after-care early was associated with difficulties with therapists, feeling uncomfortable with the location of the sessions, or a belief that no more benefit could be derived from therapy. Adolescent participants sometimes found the involvement of their families caused anxiety and inhibited their ability to be frank, while others welcomed it.

Authors' conclusions

The review shows that ‘in spite of differences in country and healthcare systems, many participants’ reactions to and perceptions of their management were negative.’ Negative experiences were associated with lack of patient involvement in management decisions, inappropriate staff behaviour, lack of staff knowledge, problems with the format of psychological assessment, and problems of access to after-care. Positive experiences were associated with greater participation in care and the perception of staff as sympathetic.

 

Although the review has limitations including varying study methods (making comparisons difficult) and possible reviewer bias in the interpretation of largely qualitative findings, it does also have strengths. These include the range of countries and breadth of topics covered. Future research could usefully include the development of a standard interview schedule to assess service users’ perceptions of care, and to audit services. Further studies are also needed to fill evidence gaps, for example on the experiences of older adults and minority groups, and on the impact of psychosocial assessment.

Implications for policy or practice

The review includes coverage of study participants’ suggestions for service improvement, namely: increased and improved communication between staff and patients; greater staff knowledge and training in self-harm issues; increased staff sympathy; improved access to local services and after-care; and provision of better information about self-harm to patients, carers and the public.

The authors’ suggestions for clinical practice and service improvement to be more ‘accessible, personal and effective’ echo the views of participants, and include a recommendation that hospitals should consider establishing self-harm planning groups to address staff training and other issues. A treatment management protocol specific to the needs of adolescents might also be considered.

Subject terms:
mental health services, self-harm, attitudes;
Content type:
systematic review
Links:
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ISSN online:
1472-1465
ISSN print:
0007-1250

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