Getting comfortable with the uncomfortable

Mind blown! (To the point I had to pause my husband’s 98th viewing of Lord of the Rings to share my disbelief with him!)

Yesterday I came across research using an English self-harm surveillance register which found that only one in five people (21%) who presented following self-harm and received a psychosocial assessment had any recorded discussion about domestic abuse.

These are people who have self-harmed and are being assessed by mental health professionals and NICE guidance is clear: staff working with people who self-harm should ask about safeguarding concerns, including domestic abuse, at the earliest opportunity. So why isn’t it happening?

A later study by Knipe and colleagues asked liaison psychiatry practitioners about exactly that.

Every participant agreed that asking about domestic abuse was important and part of their professional role, but they didn’t routinely ask.

The reasons they described included uncertainty about what to do if somebody disclosed, difficulty fitting the enquiry into the assessment, and something the researchers described as “delving deeper” and the fear of making things worse. The conversations felt uncomfortable and practitioners described feeling ill-prepared to deal with what might follow.

We can tell practitioners to refer someone who is suicidal to the mental health experts, but what if the mental health expert doesn’t ask about the circumstances that may be contributing to that suicidal crisis?
What if domestic abuse, coercive control, entrapment, fear and loss of agency are sitting underneath the self-harm, and nobody asks?
We cannot respond effectively to suicidal distress if we don’t understand what is happening in someone’s life.

This is exactly why suicide prevention and domestic abuse cannot continue to sit neatly in separate boxes. Sometimes they are not two separate problems. They are part of the same process and if we don’t ask, we may never know, and that might be fatal.

We HAVE to give people the appropriate training so that “opening that can of worms” is something they feel confident and capable of doing.

I understand that improving routine enquiry about domestic abuse within mental health services is already being worked on within the NHS, with implementation ambitions extending to 2029 but people are presenting following self-harm today so I’m keen to understand what we can do in the meantime?

How do we make sure that the professionals having these conversations now feel confident enough to ask the question, capable of responding to the answer, and equipped to recognise when domestic abuse and suicidal crisis may be part of the same process?

Perhaps the bigger risk isn’t opening the can of worms – perhaps it’s leaving it closed?