Asking about self-harm and suicide in primary care

Article in review: Ford, J., Thomas, F., Byng, R. & McCabe, R. (2021). Asking about self-harm and suicide in primary care: Moral and practical dimensions. Patient Education and Counselling. https://doi.org/10.1016/j.pec.2020.09.037

Summary

This recent study has assessed recorded conversations between GPs and patients to analyse how self-harm is discussed in primary health care settings. The research focused on how doctors ask questions about self-harm, what is discussed in the resulting conversation and the moral issues and conversational difficulties that can arise when these topics are discussed. The analysis found that questions related to self-harm are overwhelmingly framed for a “no” response. Advice is provided for practitioners to create more open discussions about suicide and self-harm while avoiding language and approaches that exacerbate shame and low self-worth.

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Research context

It is estimated that 45% of people who die by suicide have seen their GP within the month before their death. GPs must often be treating and working with people who have a risk of suicide or self-harm. But discussion about self-harm with at-risk patients can be sensitive for some practitioners, who may worry that conversations may introduce or exacerbate suicidal ideation and behaviours. Other research has found that how questions about self-harm are worded can influence a patient’s response, however, most studies in this area have focused on the wording of a question and the patient’s immediate response. This is the first study to analyse entire conversations in which self-harm has been discussed.

Method and data

A total of 52 recorded primary care consultations of people with mental health conditions such as anxiety, depression and stress were obtained. These consultations were conducted during 2014 and 2015 were taken from a wider collection of recorded interviews. Researchers then searched these consultations for questions asked by a doctor that related to suicide and/ or self-harm.

In these cases, the whole interview was examined to determine if the patient or doctor raised the topics of suicide or self-harm. The assessment found 20 questions about self-harm across 18 consultations. These recordings were then micro analysed using conversation analysis.

The patients involved in these 18 consultations came from a range of socio-economic backgrounds and were seeking support from mental health conditions including anxiety, depression and stress. They were at different points in their treatment- some were presenting for assistance for the first time, while others had long-term, diagnosed mental health conditions.

Of the doctors involved in the interviews, the average age was 46 years and the average span of practice was 18 years. Half of the patients reported that the GP was not their regular consulting doctors, four were the regular doctor and six did not state were the patients

Findings

The analysis found that seemingly minor differences in how questions are worded can be consequential for the outcome. Across the consultations, key findings were:
• The term “self-harm” tended to be used as an umbrella term for both suicidal behaviours and specific acts of self-harm such as cutting. Even when doctors did separate out the two behaviours, they would often combine them within the same question.
• Questions were most commonly polar, inviting with a yes or no response, and were framed negatively, for example, “You’ve not had any thoughts of harming yourself or suicide or anything like that?”
• Questions often focus on “thoughts” or “feelings” of self-harm, rather than the action of self-harm.

Yes and No questions

The phrasing of questions can make it difficult for people to respond to questions in the affirmative, making it difficult to talk about self-harm.

When responding to questions about self-harm with a “no” patients gave both ambiguous and unambiguous “no” responses. This means that they gave a mix of empathic and hesitant “no” responses, typically standalone and not followed by other comments. A hesitant or weak no may be considered a sign that the patients may struggle to respond and were not always deemed a clear “no”. However a “no” response, no matter how uncertain saw the topic being ended in nine out of ten examples.

When responding to questions about self-harm with “yes” patients always either followed up the response with additional information or used a narrative response format. Often with these comments patients sought to downplay the likelihood they would act on their self-harming thoughts. The typical pattern of conversation following a “yes” response was to move on to the identification of protective factors.

Stigma, shame and morality

Some patients were uncomfortable speaking in the affirmative, openly, about self-harm. Many seemed to distance themselves from the negative moral implications of their discussions about suicide and self-harm. The GPs tended to focus on statements to prevent patients from acting up thoughts of self-harm, without the opportunity to discuss the thoughts as a source of distress.

When suicide was discussed, the GPs tended to focus on invoking negative and moralist reasons (for example, leaving a legacy for the family) not to end one’s life, rather than positive reasons for wanting to stay alive (for example, enriching relationships with family).

Practice considerations

Primary health care conversations about the topics of suicide and self-harm should cover these two topics separately. When patients seem hesitant or responses are ambiguous, further discussion should be encouraged. A strong focus on preventing patients from acting on self-harm thoughts leaves little room to discuss the experience of those feelings.