Gatekeeping access to mental health services after self-harm

Gatekeeping access to mental health services after self-harm: An analysis of video-recorded psychosocial assessments, patient interviews, medical records, and discharge letters.

When a person is seen in a UK Emergency Department (ED) for self-harm or suicidal ideation, practitioners can facilitate a referral 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 specialist mental health services. We analyse and triangulate evidence from 46 video-recorded psychosocial assessments, one-week and three-month follow-up interviews with patients and carers, participants’ medical records, documentation of the referral process between different services in medical records, and ED discharge letters. This paper breaks down three cases in detail, revealing four factors underlying decisions not to refer. We show that patients are pressured to align with these as reasonable. These factors are: (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 form of mental health care (“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. Practitioners are required to act as gatekeepers, rationing under-resourced mental health services. This significantly undermines efforts to promote early intervention and improve long-term mental health outcomes.

Content warning: Descriptions of self-harming thoughts and behaviours including suicide, self-inflicted injuries and disordered eating. Discussions of sexual, physical and psychological abuse. Depictions of discriminatory attitudes and actions. 

About the Speaker

Dr. Bergen is Special Projects Manager at Didi Hirsch Mental Health Services, Health & Innovations Division, as well as an affiliated researcher with the City University of London School of Health Sciences, Division of Health Services Research & Management. Her work explores the intersections of Sociology, Clinical Communication, and Mental Health Service Provision.