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Implying implausibility and undermining versus accepting peoples’ experiences of suicidal ideation and self-harm in Emergency Department psychosocial assessments

Bergen, C. ORCID: 0000-0002-6278-7668, Bortolotti, L., Temple, R. , Fadashe, C., Lee, C., Lim, M. & McCabe, R. ORCID: 0000-0003-2041-7383 (2023). Implying implausibility and undermining versus accepting peoples’ experiences of suicidal ideation and self-harm in Emergency Department psychosocial assessments. Frontiers in Psychiatry, 14, doi: 10.3389/fpsyt.2023.1197512


Patients seeking emergency care for self-harm and suicidality often report they are not believed or taken seriously and there is increasing interest in the concept of epistemic injustice in mental health contexts. Communication practices implying implausibility in a person’s story or undermining their experience have been identified outside healthcare settings e.g., courtrooms where they are used to contest and recharacterize a person’s experience.

To investigate communication practices in Emergency Department (ED) psychosocial assessments that may (1) undermine, imply implausibility and recharacterize or (2) accept peoples’ experiences of suicidal ideation and self-harm.

We micro-analysed verbal and nonverbal communication in 5 video-recorded psychosocial assessments with people presenting to the ED with self-harm or suicidal ideation, and conducted supplementary analysis of participants’ medical records and post-visit interviews. We describe 3 negative cases where accounts were not accepted and undermined/recharacterized and 2 positive cases where accounts were accepted.

In the negative cases, practitioners undermined peoples’ experiences of suicidality and self-harm by: not acknowledging or accepting the person’s account; asking questions that implied inconsistency or implausibility (“Didn’t you tell your GP that you were coping okay?”); juxtaposing contrasting information to undermine the account (“You said you were coping okay before, and now you’re saying you feel suicidal.”) ; asking questions that asserted a different characterization (“So when you called 111 what were you expecting them to do”); and resisting or directly questioning the person’s account. Multiple practices across the assessment built on each other to assert that the person was not suicidal, did not look or act like they were suicidal; that the person’s decision to attend the ED was not justified; that an overdose was impulsive and not intended to end life; that self-harming behaviours were not that serious and should be in the person’s control. These alternative characterizations were used to justify decisions not to provide further support or referrals to specialist services. In other cases, communication practices were used to acknowledge, accept and validate suicidality/self-harm and introduce a shared understanding of experiences that patients found helpful.

These findings advance our understanding of how peoples’ experiences are undermined, a phenomenon which has been reported by patients, leads to further deterioration in their mental health and can discourage future help-seeking even when very unwell. Conversely, acknowledging, accepting and validating suicidality/self-harm and introducing a new way of understanding peoples’ experiences generates shared understanding and may reduce epistemic injustice in mental healthcare interactions.

Publication Type: Article
Additional Information: © 2023 Bergen, Bortolotti, Temple, Fadashe, Lee, Lim and McCabe. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
Publisher Keywords: Suicide, Clinical communication, Risk Assessment, Mental Health, Crisis care, Emergency Department (ED), Conversation analysis (CA)
Subjects: B Philosophy. Psychology. Religion > BF Psychology
H Social Sciences > HN Social history and conditions. Social problems. Social reform
R Medicine > RC Internal medicine > RC0321 Neuroscience. Biological psychiatry. Neuropsychiatry
Departments: School of Health & Psychological Sciences > Healthcare Services Research & Management
[thumbnail of Epistemic Injustiice Submitted 1197512_Manuscript.pdf]
Text - Accepted Version
Available under License Creative Commons: Attribution International Public License 4.0.

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