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
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
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DOI：
10.1016/j.ssmqr.2023.100249
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发表时间：
2023-07-18
期刊：
影响因子：
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通讯作者：
McCabe, Rose
中科院分区：
文献类型：
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作者：
Bergen, Clara;Lomas, Matthew;McCabe, Rose
当一个人参加英国急诊室（艾德）的自我伤害或自杀意念，从业者可能会提到精神卫生服务。虽然有些人要求并得到支持，但其他人要求但没有得到支持。我们探讨了支持的请求，然后决定不转介精神卫生服务。我们分析了46个视频记录的心理社会评估，一周和三个月的随访采访患者和照顾者，医疗记录，转诊过程的文件，和艾德出院信的证据。我们提出了三个详细的案例，揭示了这些决定背后的四个因素：（1）自我控制，自助，社会支持和当前的治疗是有效的治疗计划（“继续使用我的应对策略和深呼吸。但那没用。（2）服务的转诊标准狭窄，包括排除那些“不够病”或“太危险”的人（“这是为了收集证据......她会在几周内监控你，然后把你的情况告诉她。），（3）在饮酒时获得心理健康护理（“我被告知，他们不能处理她的心理健康问题，直到她不是一个酒鬼。”），以及（4）访问一个以上的服务（“与大多数治疗服务一样，我们不会与另一个治疗提供者合作。").这些因素导致处于危机中的人被排除在额外的专业支持之外，造成严重的不良后果，包括自杀企图。患者被迫与这些合理的决定保持一致。从业人员被要求充当守门人，对资源不足的精神卫生服务进行配给。内容警告：详细描述自我伤害的想法和行为，包括自杀、自我伤害和饮食失调。讨论性虐待、身体虐待和心理虐待。对歧视性态度和行为的描述。
When a person attends a UK Emergency Department (ED) for self-harm or suicidal ideation, practitioners may refer to mental health services. While some people ask for and receive support, others ask but do not receive support. We explored requests for support followed by decisions not to refer to mental health services. We analyzed and triangulated evidence from 46 video-recorded psychosocial assessments, one-week and threemonth follow-up interviews with patients and carers, medical records, documentation of the referral proces, and ED discharge letters. We present three detailed cases, revealing four factors underlying these decisions: (1) self-control, self-help, social support, and current treatment as valid treatment plans ("Continue to use my coping strategies and deep breathing. But that ain't working."), (2) narrow referral criteria for services, including exclusion of those 'not ill enough' or 'too risky' ("It's about gathering evidence ... She would monitor you over a period of weeks and then refer."), (3) accessing mental health care while using alcohol ("I'm being told that they can't deal with her mental health issues until she's not an alcoholic."), and (4) accessing more than one service ("Common with most therapeutic services, we would not work in tandem with another therapeutic provider."). These factors lead to people in crisis being excluded from additional professional support, with serious adverse outcomes including suicide attempts. Patients are pressured to align with these decisions as reasonable. Practitioners are required to act as gatekeepers, rationing under-resourced mental health services. This significantly undermines early intervention and patient recovery.Content warning: Detailed descriptions of self-harming thoughts and behaviors including suicide, self-inflicted injuries and disordered eating. Discussions of sexual, physical and psychological abuse. Depictions of discriminatory attitudes and actions.