Professional stigma

The stigmatizing attitudes of professionals were reported in nine studies that examined clinical services. Across EDs and inpatient units, patients experienced negative judgements, service gate-keeping or belittling comments regarding their injuries (Mitten et al., Reference Mitten, Preyde, Lewis, Vanderkooy and Heintzman2016; Quinlivan et al., Reference Quinlivan, Gorman, Littlewood, Monaghan, Barlow, Campbell and Kapur2021; Williams et al., Reference Williams, Nielsen and Coulson2020).

Five studies reported a perception that professional stigma acted as a barrier to disclosure, with shame and fear impairing disclosure within psychosocial assessments and when help-seeking (Byrne et al., Reference Byrne, Bellairs-Walsh, Rice, Bendall, Lamblin, Boubis and Robinson2021; Hunter et al., Reference Hunter, Chantler, Kapur and Cooper2013; Mitten et al., Reference Mitten, Preyde, Lewis, Vanderkooy and Heintzman2016; O'Keeffe et al., Reference O'Keeffe, Suzuki, Ryan, Hunter and McCabe2021; Xanthopoulou et al., Reference Xanthopoulou, Ryan, Lomas and McCabe2022). Patients reported how their own low self-esteem and self-blame were reinforced by professionals' stigmatizing attitudes (Byrne et al., Reference Byrne, Bellairs-Walsh, Rice, Bendall, Lamblin, Boubis and Robinson2021; Quinlivan et al., Reference Quinlivan, Gorman, Littlewood, Monaghan, Barlow, Campbell and Kapur2021; Vandewalle et al., Reference Vandewalle, Beeckman, Van Hecke, Debyser, Deproost and Verhaeghe2021).

Experiences of professionals' stigmatizing attitudes varied between clinical and non-clinical services, with the latter preferred for being more accepting. In one study, patients showed preferences for social services and voluntary sector organizations over hospital services, with the former described as more supportive and having the potential to build long-term relationships with patients (Hume & Platt, Reference Hume and Platt2007). In one community-based program, staff (voluntary sector youth workers) were described as non-judgemental and friendly, reducing any shame felt by clients (Cross & Clarke, Reference Cross and Clarke2022).

Two studies set in clinical services described perceptions of stigma surrounding mental health diagnoses. Patients highlighted how professionals' interest and compassion diminished after disclosure of a diagnosis of a ‘personality disorder’, with labels of ‘time-waster’ and ‘attention-seeker’ applied (Quinlivan et al., Reference Quinlivan, Gorman, Littlewood, Monaghan, Barlow, Campbell and Kapur2021). Whilst one UK-based qualitative study reported experiences of staff withdrawal and rushed assessments`(Hunter et al., Reference Hunter, Chantler, Kapur and Cooper2013), another UK-based qualitative study reported perceptions of psychiatric diagnoses being wrongfully used by professionals to minimize the severity of a patient's self-harm on the basis it was expected or normalized (Quinlivan et al., Reference Quinlivan, Gorman, Littlewood, Monaghan, Barlow, Campbell and Kapur2021).

Young people and adults reported similar experiences of professional stigma, particularly in the ED setting (Mitten et al., Reference Mitten, Preyde, Lewis, Vanderkooy and Heintzman2016; O'Keeffe et al., Reference O'Keeffe, Suzuki, Ryan, Hunter and McCabe2021).

Minimization of distress

A tendency to minimize patients' distress was reported in nine studies, in samples of young people and adults. Across EDs, GPs and inpatient units, staff were described as uninterested and dismissive of physical and psychosocial distress (Ejneborn Looi et al., Reference Ejneborn Looi, Engström and Sävenstedt2015; Hagen et al., Reference Hagen, Knizek and Hjelmeland2018; Lindkvist et al., Reference Lindkvist, Westling, Eberhard, Johansson, Rask and Landgren2021; Mughal et al., Reference Mughal, Dikomitis, Babatunde and Chew-Graham2021; Xanthopoulou et al., Reference Xanthopoulou, Ryan, Lomas and McCabe2022). Three studies set in clinical services reported experiences of staff prioritizing cases that they perceived as more ‘serious’ and patients whose injuries were not self-inflicted, further demonstrating professional discrimination (Ejneborn Looi et al., Reference Ejneborn Looi, Engström and Sävenstedt2015; Fu et al., Reference Fu, Yang, Liao, Shen, Ou, Li and Chen2021; Hagen et al., Reference Hagen, Knizek and Hjelmeland2018). Minimization also resulted in care being withheld; patients were told that pain medication and medical treatments were unnecessary, with staff making comments about a ‘waste’ of beds and resources (Byrne et al., Reference Byrne, Bellairs-Walsh, Rice, Bendall, Lamblin, Boubis and Robinson2021; Hagen et al., Reference Hagen, Knizek and Hjelmeland2018; Quinlivan et al., Reference Quinlivan, Gorman, Littlewood, Monaghan, Barlow, Campbell and Kapur2021). Minimization led to patients viewing services as ‘cold’ and ‘robotic’, only responding if a ‘threshold’ of seriousness was met (Byrne et al., Reference Byrne, Bellairs-Walsh, Rice, Bendall, Lamblin, Boubis and Robinson2021).

We noted apparent age differences in findings, in that minimization of distress was more often mentioned in studies of young people (n = 6) than adults (n = 2). It was reported that some GPs treated young people's disclosure of self-harm casually or were dismissive (Mitten et al., Reference Mitten, Preyde, Lewis, Vanderkooy and Heintzman2016; Mughal et al., Reference Mughal, Dikomitis, Babatunde and Chew-Graham2021), and young people reported being told ‘it's just a phase’, ‘heaps of young people your age do this, it's normal, you'll get over it when you're’ older’ (Byrne et al., Reference Byrne, Bellairs-Walsh, Rice, Bendall, Lamblin, Boubis and Robinson2021). In one study, it was said that presentations were taken more seriously when a young person was accompanied by a family member (Byrne et al., Reference Byrne, Bellairs-Walsh, Rice, Bendall, Lamblin, Boubis and Robinson2021).

Staff-patient relationship

Twenty-one studies presented data describing relationships with staff. Within non-clinical services (social services and voluntary sector services), clients generally described a strong rapport between themselves and staff, based on mutual understanding, non-judgemental care, and trust (Cross & Clarke, Reference Cross and Clarke2022; Hume & Platt, Reference Hume and Platt2007; Leung et al., Reference Leung, Chow, Ip and Yip2019). However, experiences within clinical services were variable. Studies reporting positive experiences highlighted genuine and sensitive contact as well as mutual understanding to empower patients and encourage them to collaboratively explore their distress (Cliffe & Stallard, Reference Cliffe and Stallard2023; Enoksson et al., Reference Enoksson, Hultsjo, Wardig and Stromberg2022; Hagen et al., Reference Hagen, Knizek and Hjelmeland2018; Hassett & Isbister, Reference Hassett and Isbister2017; Lindkvist et al., Reference Lindkvist, Westling, Eberhard, Johansson, Rask and Landgren2021; Michaud et al., Reference Michaud, Dorogi, Gilbert and Bourquin2021; Xanthopoulou et al., Reference Xanthopoulou, Ryan, Lomas and McCabe2022). This rapport allowed staff to respond to patients' individual needs for more effective care, such as reacting to fluctuations in suicidality, distress, and instability (Berg et al., Reference Berg, Rortveit, Walby and Aase2020; Quinlivan et al., Reference Quinlivan, Gorman, Littlewood, Monaghan, Barlow, Campbell and Kapur2021; Worsley et al., Reference Worsley, Barrios, Shuter, Pettit and Doupnik2019). Positive rapport allowed patients to feel acknowledged as human beings, which instilled hope for recovery (Hagen et al., Reference Hagen, Knizek and Hjelmeland2018; Worsley et al., Reference Worsley, Barrios, Shuter, Pettit and Doupnik2019).

However, these findings contrasted with reports of superficial contact within clinical services (EDs, inpatient and psychiatric units), whereby patients perceived staff as being disconnected and making little effort to engage with their individual experiences (Bantjes et al., Reference Bantjes, Nel, Louw, Frenkel, Benjamin and Lewis2017; Cully et al., Reference Cully, Leahy, Shiely and Arensman2022; Idenfors et al., Reference Idenfors, Kullgren and Salander Renberg2015; Miettinen et al., Reference Miettinen, Kaunonen, Kylma, Rissanen and Aho2021; O'Keeffe et al., Reference O'Keeffe, Suzuki, Ryan, Hunter and McCabe2021; Quinlivan et al., Reference Quinlivan, Gorman, Littlewood, Monaghan, Barlow, Campbell and Kapur2021; Simoes et al., Reference Simoes, Dos Santos and Martinho2021; Worsley et al., Reference Worsley, Barrios, Shuter, Pettit and Doupnik2019). Three studies highlighted how perceived mistrust from clinical staff impaired patients' feeling of safety and willingness to engage (Ejneborn Looi et al., Reference Ejneborn Looi, Engström and Sävenstedt2015; Holliday & Vandermause, Reference Holliday and Vandermause2015; Hume & Platt, Reference Hume and Platt2007). In one quantitative study, perceptions of unsupportive care were significantly associated with repeat self-harm (Cully et al., Reference Cully, Leahy, Shiely and Arensman2022). Both young people and adults had mixed experiences of staff-patient relationships, and similar views of what good therapeutic relationships looked like.

Relationships with relatives

Relatives of patients also reported negative experiences within EDs and inpatient units, with four studies highlighting their observations of poor communication from staff. Relatives were often excluded from discussions about patients' care, felt inadequately informed about prognosis and had their concerns dismissed (Fu et al., Reference Fu, Yang, Liao, Shen, Ou, Li and Chen2021; Quinlivan et al., Reference Quinlivan, Gorman, Littlewood, Monaghan, Barlow, Campbell and Kapur2021; Vandewalle et al., Reference Vandewalle, Beeckman, Van Hecke, Debyser, Deproost and Verhaeghe2021). Relatives experienced superficial and judgemental staff contact, particularly during sensitive discussions about the patients' care and self-harm. This led to a lack of confidence in staff and doubts over the quality of care (O'Keeffe et al., Reference O'Keeffe, Suzuki, Ryan, Hunter and McCabe2021; Quinlivan et al., Reference Quinlivan, Gorman, Littlewood, Monaghan, Barlow, Campbell and Kapur2021). Two studies described similar experiences by young people and adults, whereby carers felt under-involved in decision-making but were overly depended on to keep the person safe (O'Keeffe et al., Reference O'Keeffe, Suzuki, Ryan, Hunter and McCabe2021; Vandewalle et al., Reference Vandewalle, Beeckman, Van Hecke, Debyser, Deproost and Verhaeghe2021).

Psychosocial assessment

Attitudes toward psychosocial assessments within clinical settings were reported in eleven studies. Assessments were described as superficial, rushed, and formulaic, where generic tick-box questions denied opportunities to explore individual experiences and psychosocial difficulties (Berg et al., Reference Berg, Rortveit, Walby and Aase2020; Byrne et al., Reference Byrne, Bellairs-Walsh, Rice, Bendall, Lamblin, Boubis and Robinson2021; Quinlivan et al., Reference Quinlivan, Gorman, Littlewood, Monaghan, Barlow, Campbell and Kapur2021; Simoes et al., Reference Simoes, Dos Santos and Martinho2021). While good staff knowledge of psychosocial assessment protocols was reported in EDs and psychiatric wards, knowledge about mental health in those settings was seen as insufficient, with patients recommending staff training to help them better assess the context for and severity of a patient's suicidality (Hagen et al., Reference Hagen, Knizek and Hjelmeland2018; Holliday & Vandermause, Reference Holliday and Vandermause2015).

Across clinical services, patients and relatives reported a lack of involvement in treatment planning, with unnecessary repetition of questions leading them to believe that staff did not listen or understand their individual experiences (Fu et al., Reference Fu, Yang, Liao, Shen, Ou, Li and Chen2021; Quinlivan et al., Reference Quinlivan, Gorman, Littlewood, Monaghan, Barlow, Campbell and Kapur2021). However, care was positively experienced when staff were sensitive to patients' emotional distress when completing an assessment, collaboratively explored the factors leading to self-harm and involved patients in treatment decisions (Johnson et al., Reference Johnson, Ferguson and Copley2017; Michaud et al., Reference Michaud, Dorogi, Gilbert and Bourquin2021; Worsley et al., Reference Worsley, Barrios, Shuter, Pettit and Doupnik2019; Xanthopoulou et al., Reference Xanthopoulou, Ryan, Lomas and McCabe2022). We could not compare young people and adults' experiences or attitudes on psychosocial assessment, as we could not separate findings by age group.

Use of restrictions and coercive care

Eleven studies reported variable attitudes toward coercive care in clinical services. In five studies, patients and relatives described the benefits of restrictions and removal of potentially lethal objects to protect against further self-harm (Berg et al., Reference Berg, Rortveit, Walby and Aase2020; Cully et al., Reference Cully, Leahy, Shiely and Arensman2022; Hassett & Isbister, Reference Hassett and Isbister2017; Idenfors et al., Reference Idenfors, Kullgren and Salander Renberg2015; Vandewalle et al., Reference Vandewalle, Beeckman, Van Hecke, Debyser, Deproost and Verhaeghe2021). Many patients experienced EDs and inpatient wards as ‘safe havens’ that removed them from distressing environments (e.g. difficult home dynamics) meaning patients could effectively shift focus toward recovery (Cully et al., Reference Cully, Leahy, Shiely and Arensman2022; Worsley et al., Reference Worsley, Barrios, Shuter, Pettit and Doupnik2019). Brief admissions were felt to empower some patients as they felt they were given more control over care through joint decision making (Enoksson et al., Reference Enoksson, Hultsjo, Wardig and Stromberg2022; Lindkvist et al., Reference Lindkvist, Westling, Eberhard, Johansson, Rask and Landgren2021). The authors defined these as specialist units where patients had the autonomy to self-refer for brief periods (for example three-day admissions) to manage escalating risk. However, other clinical services such as EDs and more traditional psychiatric inpatient care were experienced more negatively as patients reported feeling disempowered by restrictions (Quinlivan et al., Reference Quinlivan, Gorman, Littlewood, Monaghan, Barlow, Campbell and Kapur2021; Simoes et al., Reference Simoes, Dos Santos and Martinho2021). In light of this, patients and relatives expressed the importance of communicative practice when imposing restrictions: where staff in EDs explained the rationale behind restrictions and used collaborative assessments, these mitigated feelings of anxiety and disempowerment (Quinlivan et al., Reference Quinlivan, Gorman, Littlewood, Monaghan, Barlow, Campbell and Kapur2021). Similar mixed feelings and experiences toward restrictions and coercive care were described by both young people and adults.

Discharge and aftercare

Negative experiences of discharge following an assessment for self-harm in clinical services were reported across 12 studies. Studies reported how patients felt ill-prepared and unsafe at discharge where feelings of abandonment diminished their trust in clinical services and triggered repeat self-harm (Berg et al., Reference Berg, Rortveit, Walby and Aase2020; Byrne et al., Reference Byrne, Bellairs-Walsh, Rice, Bendall, Lamblin, Boubis and Robinson2021; Hume & Platt, Reference Hume and Platt2007; Idenfors et al., Reference Idenfors, Kullgren and Salander Renberg2015; Xanthopoulou et al., Reference Xanthopoulou, Ryan, Lomas and McCabe2022).

Regarding aftercare, some patients were not contacted by services at all, whilst other patients faced long waiting times (Hunter et al., Reference Hunter, Chantler, Kapur and Cooper2013; Quinlivan et al., Reference Quinlivan, Gorman, Littlewood, Monaghan, Barlow, Campbell and Kapur2021). Those who did receive follow-up care were often disappointed due to its brief length, low number of appointments given, and prioritization of discussions about medication over psychology (Cully et al., Reference Cully, Leahy, Shiely and Arensman2022; Holliday & Vandermause, Reference Holliday and Vandermause2015; Miettinen et al., Reference Miettinen, Kaunonen, Kylma, Rissanen and Aho2021; Quinlivan et al., Reference Quinlivan, Gorman, Littlewood, Monaghan, Barlow, Campbell and Kapur2021). However, two studies of clinical services investigating experiences of patients on brief admission units described positive accounts of detailed discharge plans and safety planning which provided patients with a sense of security (Enoksson et al., Reference Enoksson, Hultsjo, Wardig and Stromberg2022; Lindkvist et al., Reference Lindkvist, Westling, Eberhard, Johansson, Rask and Landgren2021). Greater control over their care meant patients could readjust back into society comfortably (Enoksson et al., Reference Enoksson, Hultsjo, Wardig and Stromberg2022; Lindkvist et al., Reference Lindkvist, Westling, Eberhard, Johansson, Rask and Landgren2021). Although the attitudes and experiences of discharge and aftercare were similar between young people and adults, we noted that findings of young people were more focused on concerns about being discharged too early or premature endings in treatment (n = 4) compared to adults (n = 1). Findings with mixed samples of adults and young people, were more focused on dissatisfaction of aftercare (n = 6).

Psychotropic medication

Seven studies reported on attitudes toward medication administration after self-harm, all of which were within clinical services: EDs, inpatient units and community-based psychiatric care. While medication was seen as helpful, staff were perceived to focus more often on describing benefits whilst tending to minimize information on side-effects and risks (Ejneborn Looi et al., Reference Ejneborn Looi, Engström and Sävenstedt2015; Idenfors et al., Reference Idenfors, Kullgren and Salander Renberg2015). Changes in medication without follow-up consultations from staff led patients to view services as negligent (Hagen et al., Reference Hagen, Knizek and Hjelmeland2018; Simoes et al., Reference Simoes, Dos Santos and Martinho2021). Patients and relatives reported that medication was often administered without adjunctive psychological interventions, which they experienced as avoiding problems rather than an effective resolution (Fu et al., Reference Fu, Yang, Liao, Shen, Ou, Li and Chen2021; Hunter et al., Reference Hunter, Chantler, Kapur and Cooper2013; Vandewalle et al., Reference Vandewalle, Beeckman, Van Hecke, Debyser, Deproost and Verhaeghe2021). Similar experiences and attitudes about psychotropic medication were described by young people and adults. Both groups had a desire for more information about medication side effects (Hagen et al., Reference Hagen, Knizek and Hjelmeland2018; Idenfors et al., Reference Idenfors, Kullgren and Salander Renberg2015).

Waiting times

Nine studies described negative experiences in clinical services of long waiting times across services for young people and adults. For EDs, inpatient and crisis management teams, lengthy waiting times for a psychosocial assessment led to feelings of anxiety, particularly when in busy and loud environments (Bantjes et al., Reference Bantjes, Nel, Louw, Frenkel, Benjamin and Lewis2017; Byrne et al., Reference Byrne, Bellairs-Walsh, Rice, Bendall, Lamblin, Boubis and Robinson2021; Miettinen et al., Reference Miettinen, Kaunonen, Kylma, Rissanen and Aho2021; Quinlivan et al., Reference Quinlivan, Gorman, Littlewood, Monaghan, Barlow, Campbell and Kapur2021; Williams et al., Reference Williams, Nielsen and Coulson2020). Patients and relatives also received little communication regarding the purpose of the wait, reasons for delays and progress (Cully et al., Reference Cully, Leahy, Shiely and Arensman2022; Vandewalle et al., Reference Vandewalle, Beeckman, Van Hecke, Debyser, Deproost and Verhaeghe2021). Beyond the ED, there were also experiences of long waiting times for aftercare following an initial assessment (Byrne et al., Reference Byrne, Bellairs-Walsh, Rice, Bendall, Lamblin, Boubis and Robinson2021; Miettinen et al., Reference Miettinen, Kaunonen, Kylma, Rissanen and Aho2021).

In non-clinical settings, experiences were variable. One community-based program had an average waiting time of 1.7 days between assessment and referral contact, which clients cited as a key reason for high satisfaction (Cross & Clarke, Reference Cross and Clarke2022). However, long waiting times within social services were found to heighten client anxiety (Leung et al., Reference Leung, Chow, Ip and Yip2019).

Access to care

Nine studies reported on access to care across clinical services. Young people, adults, patients, and carers, perceived that the broader system was failing individuals who self-harm. They often found themselves limited to crisis support because they face exclusion from services or endure lengthy waiting lists, resulting in a recurring cycle of ED attendance (Byrne et al., Reference Byrne, Bellairs-Walsh, Rice, Bendall, Lamblin, Boubis and Robinson2021; O'Keeffe et al., Reference O'Keeffe, Suzuki, Ryan, Hunter and McCabe2021; Quinlivan et al., 2021, p. 52). EDs, inpatient units and brief admission units were reported as having a lack of beds and staff, which patients felt contributed to excessive waiting times, inappropriate transfers, and premature discharges (Byrne et al., Reference Byrne, Bellairs-Walsh, Rice, Bendall, Lamblin, Boubis and Robinson2021; Enoksson et al., Reference Enoksson, Hultsjo, Wardig and Stromberg2022; Johnson et al., Reference Johnson, Ferguson and Copley2017; Miettinen et al., Reference Miettinen, Kaunonen, Kylma, Rissanen and Aho2021). For brief admission, some patients felt the care was less specialized compared to what they would receive in EDs and wanted more options for psychological support (Lindkvist et al., Reference Lindkvist, Westling, Eberhard, Johansson, Rask and Landgren2021). However, others felt that they could call on staff freely within brief admission wards and also a sense of predictability and safety, unlike in busy and intense EDs (Lindkvist et al., Reference Lindkvist, Westling, Eberhard, Johansson, Rask and Landgren2021).

Many patients were unaware which non-clinical services were available to them and felt that they should be better integrated with clinical services for more accessible care following discharge (Cross & Clarke, Reference Cross and Clarke2022; Leung et al., Reference Leung, Chow, Ip and Yip2019). For social and voluntary services, they suggested extended services hours, telephone/digital appointments, and better staffing to improve accessibility (Idenfors et al., Reference Idenfors, Kullgren and Salander Renberg2015; Leung et al., Reference Leung, Chow, Ip and Yip2019; Williams et al., Reference Williams, Nielsen and Coulson2020).