Carer insights into self‐harm in the very old: A qualitative study

Abstract

Objective To examine the insights of carers to better understand self‐harm in their older relatives. Methods An in‐depth interview was conducted with the nominated relative/friend (carer) of a person over 80 who had self‐harmed within the last month. Carer interpretation and experience of the self‐harm and clinical care were explored qualitatively. Audio recordings were transcribed and the content thematically analyzed using N‐VIVO. Results Thirty‐two carers of 30 older people who self‐harmed were interviewed. Physical, social, and psychological issues were identified as contributory to self‐harm. Themes relating to the perceived barriers to seeking help included “they can't communicate,” “suicide and secrets,” and “invalidation.” Themes for the intent of self‐harm were “attention seeking” and “wanting to die.” Themes which emerged for consequences of self‐harm for carers were “anger,” “guilt and self‐blame,” and “it made us ill.” Themes for solutions to address the underlying factors leading to self‐harm were “more practical support and structure,” “improving communication,” “removing means of self‐harm,” “advance care directives as a solution for suffering,” and “ignoring self‐harm.” Clinical care themes were “shared shame and stigma,” “safety and supervision vs being locked up,” “clinicians dismissing the carer,” and “relief and support.” Conclusions Validation of carer perspectives and understanding family dynamics may improve communication at various system levels and inform interventions for older persons, concurrently support families, and potentially reduce risk of repeat self‐harm. Good care must be holistic, be person‐centred, and relieve carer burden. A shared understanding and psychotherapeutic approaches to management of self‐harm in late life should be considered.

Self-harm in the very old one year later: has anything changed?

“…This "what do you expect" societal attitude possibly fuels patient, carer, and GP nihilism and leads to a passive tolerance of suicide in older people. Regardless, the disconnect between patients, carers, GPs, and specialist mental health services was strongly evident and still manifested by frank "suicidal secrets" as we (Wand et al, 2019) and others (Draper et al, 2018) have identified previously, as well as avoidance, denial, and the difficulty asking for help. Such problems recognizing, communicating, or understanding emotions have been associated with both delay in seeking help for mental health problems (Epstein et al, 2010) and with suicide attempts in middle-aged populations (Levi et al, 2008).…”

“…Qualitative approaches that seek the perspective of the older person in understanding the meaning and intent of their self-harm may be especially informative (Van Orden, 2018). In our baseline qualitative studies, 30 people aged 80 + who had self-harmed, their carers, and general practitioners (GPs) were interviewed within a month following self-harm (Wand et al, 2018a;Wand et al, 2018b;Wand et al, 2019). Reasons for self-harm included communicating unmet and unarticulated needs, loneliness, disintegration of self, being a burden, helplessness with rejection, hopelessness, and endless suffering (Wand et al, 2018b).…”

“…While the selfharm facilitated resolution of problems for some, others felt worse off and experienced more rejection, particularly by being "imprisoned" in psychiatric wards. Carers and GPs identified physical, psychological, and social issues that echoed patient perspectives (Wand et al, 2018a;Wand et al, 2019). Carers identified barriers to help-seeking for the older person including invalidation, difficulty communicating with, and being dismissed by clinicians, as well as describing their own intense distress following the self-harm (Wand et al, 2019).…”

“…Carers and GPs identified physical, psychological, and social issues that echoed patient perspectives (Wand et al, 2018a;Wand et al, 2019). Carers identified barriers to help-seeking for the older person including invalidation, difficulty communicating with, and being dismissed by clinicians, as well as describing their own intense distress following the self-harm (Wand et al, 2019). Accordingly, carers suggested a range of solutions to assist the older person.…”

“…Equally important, yet also poorly understood, is the impact of self-harm on carers beyond the immediate effects as we have investigated (Wand et al, 2019), and in turn, the impact of carers on subsequent self-harm in older people. Relatives and friends of older people who self-harmed (Testoni et al, 2018) or died by suicide (Harwood et al, 2002) have reported experiences of shame, stigma, and rejection.…”