By Grace Cully.
“Because the support I had from the members of the crisis team … I had promised them that if I did feel … that I’m getting down, or I would do something … then I promised I would call somebody. Which I did the same day.” 
Over the course of my PhD, I interviewed 50 individuals shortly after they had come close to ending their lives. We recruited people who presented to hospital with self-harm of high lethality or high suicidal intent. Existing research indicates that those who engage in such high-risk acts of self-harm often have enduring mental health conditions and are at high risk of subsequent suicide [2–4]. Despite this, as I met with each new participant, I was struck by the stark variation in people’s experiences of aftercare following their self-harm presentation. While some individuals felt completely supported in their care and recovery, others felt isolated and let down by the services. In order to examine these differences in more depth, I followed up with a subgroup of these participants 6-9 months after they had presented to hospital, documenting their experiences of engagement with healthcare services during that time.
Two central themes emerged from this research explaining variation in people’s experiences of aftercare. The first relates to the management of care. Those who received comprehensive and timely care were more likely to feel supported. While most participants were offered at least one outpatient appointment with a psychiatrist following their presentation to hospital, comprehensive aftercare that also involved regular sessions where individuals were given the opportunity to talk to a mental health nurse, counsellor or other trusted healthcare professional was powerful for many in helping them make progress following the self-harm episode. Others described very different experiences, expressing frustration about: insufficient follow-up, a lack of referrals to specialist care, excessive waiting time, over-reliance on psychotropic treatment and inconsistencies in personnel. This lack of adequate follow-up was described as an obstacle to some participants working their “way out of crisis”  and led to feelings of isolation. Consequently, many of these participants asked for my support in accessing follow-up care outside of the public health service.
These findings are concerning given that lack of timely and comprehensive care following self-harm or psychiatric hospital discharge is associated with increased risk of suicide [5–7]. Such discrepancies in the provision of care are likely to be related to service-level factors including variation in available resources, composition and effectiveness of different acute and community services. It is possible that in some situations, there is a gap between the expectations of the patient and the clinician’s assessment of the most appropriate follow-up care. Where this is the case, to prevent the perception of being abandoned by the services, the clinician’s assessment should be clearly communicated and the reasons underlying the aftercare plan should be discussed collaboratively with the patient. This ties into the second core theme from this piece of research that highlights the crucial role that interpersonal communication plays in the care of those who self-harm.
“When you’re feeling really vulnerable, a little bit of empathy would go a long way”
This quote is one that has stuck with me ever since that interview. It seems so simple, and also so obvious. An empathetic approach is a powerful tool that all health professionals have in their arsenal that can improve the care provided to their patients immediately. Most participants in our study emphasised the importance of being treated with empathy and compassion. Participants described the importance of feeling supported and cared for, and most importantly listened to. The development of a meaningful therapeutic relationship was powerful to their wellbeing and immediate care, but also had a significant impact on shaping future help-seeking intentions and behaviours. Those who felt supported by healthcare professionals were more likely to attend appointments and adhere to their psychotropic treatment, and more inclined to reach out to the services in times of distress. However, not all the individuals I interviewed experienced positive supportive relationships. Lack of “empathy” or “warmth” in the way healthcare professionals interacted with them was as an issue for many participants. For some, consistent negative interactions led to them considering disengagement with care, refusing crisis admission or not reaching out in times of distress.
“… I feel like they’re just covering their back to make sure that you don’t do anything stupid and they’re blamed. Like that’s the impression I get. Like I never feel any kind of warmth there.” 
Relationships between healthcare professionals and their patients may be impacted by prejudice and negative attitudes to individuals presenting with self-harm [8,9]. Previous research indicates that those with a history of repeated self-harm experience greater negativity and intolerance . Consistent with this, in our study, those with a history of prior self-harm and mental health service engagement were those most dissatisfied with their relationships with healthcare professionals. It is important to note that persons presenting with self-harm, particularly high-risk self-harm acts, frequently have persistent and often severe mental health issues that may make it difficult for healthcare professionals to establish supportive relationships with them. Indeed, we found higher levels of depression and hopelessness, and lower self-efficacy among those who reported negative or unsupportive relationships with healthcare professionals. This emphasises the complexity of caring for individuals who engage in self-harm and highlights the need for training programmes to equip healthcare professionals with the knowledge and skills to develop meaningful therapeutic alliances [8,9]. Misconceptions of the inevitability of repeated self-harm also need to be addressed within clinical practice and via formal education programmes. Above all, healthcare professionals need to be acutely aware of the vulnerability of those they are treating and approach all patients in a compassionate and responsiveness manner.
- Cully, G., Leahy, D., Shiely, F., & Arensman, E. (2020). Patients’ Experiences of Engagement with Healthcare Services Following a High-Risk Self-Harm Presentation to a Hospital Emergency Department: A Mixed Methods Study. Archives of Suicide Research, 1–21. https://doi.org/10.1080/13811118.2020.1779153
- Bergen, H., Hawton, K., Waters, K., Ness, J., Cooper, J., Steeg, S., & Kapur, N. (2012). How do methods of non-fatal self-harm relate to eventual suicide? Journal of Affective Disorders, 136(3), 526–533. https://doi.org/10.1016/j.jad.2011.10.036
- Gibb, S. J., Beautrais, A. L., & Fergusson, D. M. (2005). Mortality and further suicidal behaviour after an index suicide attempt: A 10-year study. Australian & New Zealand Journal of Psychiatry, 39(1–2), 95–100. https://doi.org/10.1080/j.1440-1614.2005.01514.x
- Chan, M. K., Bhatti, H., Meader, N., Stockton, S., Evans, J., O’Connor, R. C., Kapur, N., & Kendall, T. (2016). Predicting suicide following self-harm: Systematic review of risk factors and risk scales. The British Journal of Psychiatry, 209(4), 277–283. https://doi.org/10.1192/bjp.bp.115.170050
- Desai, R. A., Dausey, D. J., & Rosenheck, R. A. (2005). Mental health service delivery and suicide risk: The role of individual patient and facility factors. American Journal of Psychiatry, 162(2), 311–318. https://doi.org/10.1176/appi.ajp.162.2.311
- Appleby, L., Dennehy, J. A., Thomas, C. S., Faragher, E. B., & Lewis, G. (1999). Aftercare and clinical characteristics of people with mental illness who commit suicide: A case-control study. The Lancet, 353(9162), 1397–1400. https://doi.org/10.1016/S0140-6736(98)10014-4
- Burgess, P., Pirkis, J., Morton, J., & Croke, E. (2000). Lessons from a comprehensive clinical audit of users of psychiatric services who committed suicide. Psychiatric Services, 51(12), 1555–1560. https://doi.org/10.1176/appi.ps.51.12.1555
- Rayner, G., Blackburn, J., Edward, K., Stephenson, J., & Ousey, K. (2019). Emergency department nurse’s attitudes towards patients who self‐harm: A meta‐analysis. International Journal of Mental Health Nursing, 28(1), 40–53. https://doi.org/10.1111/inm.12550
- Saunders, K. E. A., Hawton, K., Fortune, S., & Farrell, S. (2012). Attitudes and knowledge of clinical staff regarding people who self-harm: A systematic review. Journal of Affective Disorders, 139(3), 205–216. https://doi.org/10.1016/j.jad.2011.08.024
Grace Cully (@grace_cully) is a postdoctoral researcher in the National Suicide Research Foundation and the School of Public Health, University College Cork. Email: firstname.lastname@example.org.