"This is a question we have to ask everyone": asking young people about self-harm and suicide

WHAT IS KNOWN ON THE SUBJECT?: An essential part of the mental health assessment is to evaluate the risk of harm to self. Fundamentally this involves asking directly about self-harming behaviour and suicidal thoughts or urges, but practitioners often find it difficult to open up these conversations. This evaluation of risk is particularly important as self-harm and suicidal thoughts are frequently found in young people who attend mental health services. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Young people are not always routinely asked directly about self-harm or suicidal thoughts when they are assessed. There are two ways that mental health practitioners introduce this topic: first, by building up to it by initially asking about general feelings, and second by stating that it is a requirement to ask everyone. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: These questions should not be avoided by mental health practitioners just because they are difficult. We offer suggestions as to how to ask questions about self-harm and suicide based on real-world practice.

ABSTRACT

Introduction Questions about self-harm and suicide are essential in risk assessments with children and young people, yet little is known about how mental health practitioners do this. Aim The core aim was to examine how questions about self-harm and suicidal ideation are asked in real-world practice. Method A qualitative design was employed to analyse 28 video-recorded naturally occurring mental health assessments in a child and adolescent mental health service. Data were analysed using conversation analysis (CA). Results In 13 cases young people were asked about self-harm and suicide, but 15 were not. Analysis revealed how practitioners asked these questions. Two main styles were revealed. First was an incremental approach, beginning with inquiries about emotions and behaviours, building to asking about self-harm and suicidal intent. Second was to externalize the question as being required by outside agencies. Discussion The study concluded that the design of risk questions to young people had implications for how open they were to engaging with the practitioner. Implications for practice The study has implications for training and practice for psychiatric nurses and other mental health practitioners in feeling more confident in communicating with young people about self-harm and suicidal ideation.

Reflecting on what 'you said' as a way of reintroducing difficult topics in child mental health assessments

BACKGROUND

In child and adolescent mental health assessments, questions are integral to the process. There has been limited research focused on the assessment process, or on how questions are constructed within this clinical environment.

METHODS

We examined 28 naturally occurring initial assessments, with particular attention to how practitioners used questions in their communication with children and young people. We utilised conversation analysis to examine the data.

RESULTS

Analysis revealed a particular type of question preface used to reintroduce a prior topic. This was achieved through the use of 'you said x' as a foundation for asking a follow-up question and demonstrated active listening.

CONCLUSIONS

Arguably, this approach is a useful way of gathering assessment-relevant information in a child-centred way.

Discursive Psychology: Implications for Counseling Psychology

In this article, we present discursive psychology (DP), a qualitative approach that focuses on the study of conversational and textual materials, including everyday interactions. Although DP is well-established methodologically and theoretically, and is used widely in Europe and in the Commonwealth countries, it is relatively unknown in counseling psychology in the United States. As such, the purpose of this article is to provide a general overview of DP and offer guidance for researchers who may be interested in studying and using DP. We thus discuss practical considerations for utilizing DP, including the development of research questions, carrying out data collection, and conducting DP-informed analyses. We also provide a general overview of the history of DP and key resources for those interested in studying it further, while noting the usefulness of DP for counseling psychology.

The clinical use of Subjective Units of Distress scales (SUDs) in child mental health assessments: a thematic evaluation

Background: Despite the ubiquitous use of Subjective Units of Distress scales (SUDs) in mental health settings to establish levels of distressing emotion, there has been little empirical research in this area. SUDs are commonly used in therapy and assessments, and are a particularly useful tool for establishing current and previous levels of distress in children and young people.Aims: To explore the use of the SUD analogue rating scale in initial child mental health assessments to better understand its application in this context.Method: The data corpus consisted of 28 naturally-occurring video recordings of children and young people attending their first assessment appointment at Child and Adolescent Mental Health Services (CAMHS). A thematic analysis was utilised to explore the specific interactional use of SUDs.Results: Four themes were identified; recency, longevity, context and miscommunication. The first three themes were found to supplement the child's emotional score on the scale and were important in establishing the necessity for further therapeutic support. Miscommunication as a theme highlighted the need for clarity when using SUDs with children and young people.Conclusions: Recommendations were suggested for practitioners working with children and young people relating to the extended use of rating scales in clinical assessments.

Question use in child mental health assessments and the challenges of listening to families

BACKGROUND

The mental health assessment is a fundamental aspect of clinical practice and central to this is the use of questions.

AIMS

To investigate the frequency and type of questions utilised within a child mental health assessment.

METHOD

The data consisted of 28 naturally occurring assessments from a UK child and adolescent mental health service. Data were analysed using quantitative and qualitative content analysis to determine frequencies and question type.

RESULTS

Results indicated a total of 9086 questions in 41 h across the 28 clinical encounters. This equated to a mean of 3.7 questions per minute. Four types of questions were identified; yes-no interrogatives, wh-prefaced questions, declarative questions and tag questions.

CONCLUSIONS

The current format of questioning may impede the opportunity for families to fully express their particular concerns and this has implications for service delivery and training.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2015. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.

Agenda setting with children using the 'three wishes' technique

The National Health Service (UK) offers initial screening appointments for children referred to child and adolescent mental health services to determine clinical need and assess risk. Conversation analysis was utilized on 28 video recordings of these assessments, lasting approximately 90 minutes each with a multidisciplinary team. This article focuses on the agenda setting strategies used to establish relevant goals with children and adolescents; specifically, the technique of offering 'three wishes'. For example, ' if you had three wishes, what would you like to make happen?' In cases where children initially volunteered an assessment-relevant wish, they tended not to articulate further wishes. Non-assessment-relevant wishes (i.e. fantasy wishes, such as being 'rich') were treated as insufficient, with many approaches used to realign establishing assessment relevant goals. Where responses were not institutionally relevant, practitioners undertook considerable discursive work to realign the focus of the three wishes task to assessment relevance. In these cases, the wish responses were treated as irrelevant and tended to be dismissed, rather than explored for further detail. Such work with the children's contributions has implications for engaging children and child-centred practices.

Mixing qualitative methods versus methodologies: A critical reflection on communication and power in inpatient care

This paper offers an illustrative example to demonstrate one way of combining qualitative methods. The context for the study was a UK inpatient psychiatric hospital. Data set one was collected from weekly ward rounds where inpatient staff met with autistic patients to review medication, listen to patient concerns and make plans or adjustments in light of this. Data set two was reflective discursive interviews with patients and staff. The research objective was to critically consider the potential reasons for discrepancies in dissatisfaction reports from patients in the interviews, compared to relative compliance exhibited by patients in the ward rounds. Utilising a video-reflexive design and critical discursive psychology approach, both data sets were analysed together. It is possible to simultaneously analyse two different data sets, one naturally occurring and one researcher generated because of the epistemological congruence in the overall design. We have presented an argument for the benefits of mixing two qualitative methods, thereby extending the mixed-methods evidence base beyond the traditional discussions of quantitative and qualitative paradigms.

Investigating question-answer sequences in child mental health assessments: Engaging children and families through declarative question design

OBJECTIVE

In mental health settings, before a child can be diagnosed with a mental health condition, they must initially be assessed. These assessments are characterised by question-answer sequences with the child and family members, and our objective is to explore the function of declarative questions.

METHODS

Video recordings of mental health assessments from 28 families were collected, each being approximately 90 min. Referred children were aged 6-17-years. Data were transcribed using the Jefferson approach and conversation analysis was used.

RESULTS

Attention to question-answer sequences identified that one common type was the declarative question. We focus on three identifiable forms: clean language short declaratives, declaratives with extreme case formulations, and reformulation declaratives.

CONCLUSIONS

The response to these three types of declaratives formed the basis for subsequent question-answer elaboration sequences. The question functioned both to engage the child directly and align with other family members.

PRACTICE IMPLICATIONS

Implications for practitioners are that these types of declarative questions offer a resource to engage in fact-checking in a way that is non-face-threatening. Conversation analysis provides a methodological tool for practitioners to engage in reflective practice to enhance their clinical skills in relation to question design.

Towards a suicide-responsive police culture: police experiences of working with suicide

Across the globe suicide rates are creating concern, and the World Health Organisation (WHO) argues that suicide is the responsibility of everyone. The WHO recognises that police have an important role in suicide prevention and the management of mental health crises. We suggest that police officers and staff are inevitably impacted by the emotional labour of meeting the demands of this aspect of the role. We argue for more research attention on the experiences and views of police who work with suicide. This study comprised qualitative reflective interviews with police in the UK, Guyana and New Zealand, with the focus on identifying commonalities in experience across the three locations. Four themes were generated through reflective thematic analysis: (1) the context; (2) the traumatic impact; (3) the difficult aspects of this work and (4) organisational opportunities for supporting police officers and staff. Our data illustrated that suicide is qualitatively different from other forms of death, and the nature of the work did have considerable emotional and traumatic impact on police. We conclude our paper with several recommendations for police forces to build their welfare support for staff. These recommendations could help promote a healthier workforce and recognise the specific issues associated with this part of the role.