Self-harm and Brief Admission by self-referral. Human rights and relational recovery in psychiatry.

People who self-harm have historically not had much say in their healthcare processes. When seeking psychiatric emergency care, people who self-harm have frequently been turned away, or admitted for lengthy hospitalisations that may aggravate self-harm. The attitudes of psychiatric clinicians toward people who self-harm are important to healthcare users’ experience of care, affecting quality and access.

Brief Admission by self-referral (BA) is an intervention in inpatient psychiatry which aims to prevent self-harm by empowering the user to self-admit at will before crisis. Admissions are brief and minimally disruptive in the person’s everyday life, and the user is free to come and go from the psychiatric clinic during admissions. BA was first implemented for adults but has been offered to adolescents since 2018.

This dissertation explored psychiatric clinicians’ attitudes toward people who self-harm and family perspectives on BA in child and adolescent psychiatry (CAP) using four studies: one validating an attitude questionnaire for clinicians, one considering how questionnaire scores related to a number of variables, one exploring the parental lived experience when adolescents self-admitted with BA, and one exploring how family members talked about involvement and responsibilities regarding BA in CAP. The theoretical frameworks of human rights and relational recovery were used to interpret and discuss results.

The attitude questionnaire, SHAS-SR, turned out to be valid and reliable as a self-report questionnaire for Swedish psychiatric clinicians. However, the final version contained only a few items that could imply the relational nature of self-harm and recovery, and none explicating healthcare users’ rights. Clinicians mostly scored according to a sympathetic pattern, though a small group showed some reluctance toward people who self-harm and further minorities demonstrated more judging or antipathic scoring patterns.

The parental experience of adolescent BAs was inherently relational, implying that recovery wasn’t separate for the adolescent versus surrounding family members, but one mutual process. Family members related to involvement and responsibilities in a multitude of ways, where some were happy to remain on the sidelines or exclusively in supportive roles, mainly expressing gratitude that BA was available to adolescents. Others felt under-involved or altogether abandoned by CAP and forced to shoulder responsibilities that weren’t theirs, which was perceived to violate adolescents’ right to health.

The perspectives of human rights and relational recovery divorce from traditional understandings of psychiatry and recovery. This dissertation demonstrates the crucial potential of these frameworks to further improve the BA method and truly transform psychiatric care for people who self-harm.