Doctors should change the way that they ask patients about self-harm and suicide

December 21, 2020

Doctors can better help patients with mental health concerns by adopting a different questioning style around self-harm and suicide, experts have said.

New research warns patients may find it difficult to disclose thoughts of self-harm because of the way in which GPs ask about them.

Academics who examined consultations found that GPs were prone to ask questions in a way that invited a "no" response (e.g. "You're not having any thoughts of harming yourself?") and that patients were subsequently more hesitant when reporting thoughts of self-harm.

The study says that discussions about self-harm could be improved by GPs adopting a more open questioning style. This would mean acknowledging the possibility that patients might say "yes" when asked about thoughts of self-harm.

Researchers also say doctors can better help patients with mental health concerns if they ask them separate questions about self-harm and suicide, Doctors should do more to encourage discussion when responses are ambiguous and carry out more extensive checks to see if patients are having distressing thoughts.

Academics studied video-recorded consultations from the One in a Million data archive. These consultations took place between 2014 and 2015. The researchers selected all consultations featuring discussion of self-harm and suicide (18 in total) and carried out an in-depth analysis of how these discussions unfolded.

The research was conducted by Joseph Ford and Felicity Thomas from the University of Exeter, Richard Byng from the University of Plymouth and Rose McCabe from City, University of London and is published in the journal Patient Education and Counseling.

Dr Ford said: "Many patients who die by suicide have seen their GP in the month before death, which shows how important these conversations are. We know from earlier research, though, that many GPs find these conversations to be difficult. They worry about exacerbating a patient's thoughts of suicide, or even putting those thoughts in their head.

"Our aim with this research was to find out how these conversations unfold in practice. By looking at real-life recordings in detail, we have been able to identify ways to improve communication around these important topics."

During the consultations, patients who admitted to having thoughts of self-harm often did so in a hesitant way that downplayed the seriousness of those thoughts. This could mean leaving a long pause before responding or offering a response such as "I have in some ways" rather than a clear "yes".

Professor McCabe said: "People experiencing thoughts of self-harm and/or suicide do not tend to share them with friends or family so conversations with professionals are very important. It is difficult to admit to yourself and to others that you are having these distressing thoughts and people feel a lot of shame and guilt. So questions that further keep these thoughts beneath the surface of the conversation are problematic. GPs and other professionals should be aware of this and ask, for example, 'Sometimes people have thoughts of harming themselves when they are feeling this way, is this something you have experienced?' or 'Sometimes people have thoughts of ending their lives when they are feeling this way, is this something you have experienced?'".

Patients also distanced themselves from the negative stigma associated with self-harm, describing how they would not act upon their thoughts because of the impact it would have on their family. The study suggests that GPs can allay such stigma by asking about the patient's positive reasons for wanting to stay alive rather than the negative impact that their suicide would have on those around them.

The study also found that GPs were overwhelmingly focused on the possibility that patients might act upon their thoughts. While this allowed them to put appropriate measures in place, it risked ignoring those patients who found thoughts of self-harm distressing in themselves. It also potentially avoids examining what some patients want to actively do to address their situation.

Professor Byng said: "While understanding the distress felt by patients and anxiety felt by doctors in these encounters, we propose that practitioners can be supported to shift conversations to either a more therapeutic listening mode or even further around to help individuals see hope through the results of their own positive future actions."
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University of Exeter

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