This section explores experiences of access and initial intersection with services
around consumer suicidal crisis. The relevance of a holistic conceptualisation of
suicide, within which intrapersonal and interpersonal factors are of particular
importance, is reinforced. It is also made explicit that gaining access to service was
an essential prerequisite to receiving physical care and safety, treatment of
psychiatric symptoms, and appropriate engagement. It is highlighted that a
particular quality of engagement (with staff and/or significant others) was essential
towards enabling the person to be understood and to gain access in this initial
intersection.
5.2.1. ‘It’s sort of set up to dissuade access’: access to service
The consumer interview data highlights challenges and limitations around gaining
access to service. It is noted that advocacy by significant others and engagement by
staff was essential at this time. Kate, for example, explained that her first interaction
was with the triage nurse in the hospital emergency department and that the nature
of this was less than ideal. Kate recounted explaining to the nurse exactly how she
had tried to kill herself, noting that:
then the nurse said, ‘You can’t kill yourself like that!’...so I had to stand there in the Emergency Department with a lot of people listening and explain the whole thing...there was no privacy, but it was also that accusation. She treated me as though I was lying (Kate).
Kate’s experience, along with several of the other consumers, supports the
argument that consumers may experience ‘stigma or dismissiveness’ in relation to
non‐fatal suicidal behaviour (Mendoza & Rosenberg 2010, p. 45), or that their views
may be minimised, denied or ‘disrespected’ (Lakeman 2007, p. 152, 2010a). Kate
pointed out that she did not think that she could have navigated access to service via
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Revealing another potential challenge to access, Lucy expressed that she ‘didn’t want help at the time’ (Lucy). Such ambivalence – known to be a common feature of
suicidality (Maris et al. 2000a, p. 509) – may have further challenged access to
service. As with Kate, Lucy expressed that staff had to be ‘convinced’ to admit her to
hospital. She explained in this regard that:
my daughter was starting to get worried because they were talking about sending me home and she was saying to them the last thing she wanted was me coming home in that state...I didn’t really care what happened, but luckily I ran around the hospital a fair bit and convinced them...so they decided to put me into the psychiatric section (Lucy).
Lucy also noted that during her time in the emergency department, the nurses:
were nice to me but they were flat out and worked off their feet. They just gave me charcoal and put me out close to the main desk and just kept an eye on me (Lucy).
Thus, both Kate’s and Lucy’s accounts exemplify how access via an emergency
department medical triage system may be challenging, particularly when, as with
Lucy, the person is ambivalent about receiving service. Notably, it is suggested that
advocacy by ‘significant others’ was crucial to access being gained. Clearly, in both
of these examples too, the nature of interactions with nursing staff was suggested to
be less than ideal – from Kate’s accusatory interaction to Lucy being essentially
observed rather than engaged. These accounts reinforce that access and assessment
difficulties may dissuade or prevent people from receiving help via the public health
system (Szasz 1999; MHCA 2005, 2009), particularly when traditional service models
such as medical triage are relied upon (ABC 2010; Dawtrey 2010; Cutcliffe &
Stevenson 2008b), and when problematic staff approaches or attitudes are
encountered (Mendoza & Rosenberg 2010, p. 45; Lakeman 2007, p. 152, 2010a).
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The suggestion that appropriate engagement and support from others (particularly
staff and/or family and friends) was essential to gaining access to service – and to
service being experienced positively – is further reinforced in respect to most of the
other consumers’ experiences of their initial admission to the psychiatric inpatient
units. Claire, for example, described gaining access to the psychiatric inpatient unit
at night time when much of the unit was in a darkened state. Claire had never before
been in such a unit and she explained how her fears about being ‘locked up’ were
overwhelming:
The nurse said that I couldn’t be let out and there was nothing I could do about that. I just felt trapped...The nurses put me in my room and then they went away, and then I slowly got up and started to walk around...I was scared because there were other people there and the thought of being locked up with people with schizophrenia...I felt like I was with all these mental people and it freaked me out ‐ you know, they might hurt me...I was looking around the place for a couple of hours trying to find a way out, and I was scared. Even the nurses walking around checking on people scared me because it was someone moving around and I’d run away and hide around the corner. I don’t know how long until I went to sleep, if I did go to sleep (Claire).
Claire’s account of entering into the locked psychiatric inpatient unit is similar to
numerous other consumers’ accounts in suggesting that this experience potentially
compounded pre‐existing feelings of fear, anxiety and distress. This was apparently
particularly so for those people, such as Claire, who had not spent time in such a unit
previously. Thus it is affirmed that the person who is suicidal and hospitalised, and
potentially already isolated and distressed prior to admission, ‘may feel even more
isolated as a result of psychiatric admission’ (Lineberry 2011, p. 345). Such
experiences reinforce the importance of a particular quality of interpersonal
engagement by staff in order to promote access and the therapeutic potential of
initial intersection with services.
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Lisa’s account highlights that consumers who did have prior experience of admission
could also find admission problematic. In addition to ambivalence around receiving
service, and the need for advocacy, Lisa described how previous admissions had
been involuntary and usually involved her being initially placed in the ‘high
dependency unit’ (HDU) [this is a high‐security, low‐stimulus section of an inpatient
unit which is designed to enable fuller observation and maintenance of physical
safety of consumers considered to pose particularly high risk to themselves and / or
others]. Lisa expressed that being placed initially in the HDU ‘makes me worse...it’s terrible...one of the worst feelings I’ve ever felt, being locked up alone out there’. For
Lisa, the limitations to such treatment centred around a lack of human interaction,
as from her perspective:
the more you have human interaction, the better. You become more stable as you listen and you’re talking to somebody and interacting’ (Lisa).
Thus, the importance of appropriate interpersonal engagement at times of initial
intersection with services was reinforced.
Several of the nurse interviewees also spoke about the challenges and service
limitations consumers could face around gaining access to care. One nurse, for
example, recalled the suicide of a consumer which occurred after she assessed him
in the hospital emergency department but was unable to successfully ‘admit’ him:
It was very busy and he was meant to stay back in the queue. I had to give a rationale for him jumping the queue and seeing me. So I walked away to do that. I talked to a doctor, I got the file organised, I argued for a room. All that took time – five, ten minutes...I came back and he had gone [and he died by suicide several hours later] (AcuteRN11).
It was also noted that someone ambivalent about receiving care may not be
‘embraced’ by the system as, even if access was initially gained, service might be
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colleague had informed the consumer that: ‘if you’re not prepared to accept treatment from us we will discharge you’ (AcuteRN1). Given issues such as consumer
ambivalence around suicidal crisis such features of service can be seen as potentially
problematic. In regard to limitations such as those noted above it was asserted by
several nurses that:
there’s obviously some system issues...it’s set up to probably wipe out the person who is in two minds about suicide; it’s sort of set up to dissuade access in a way (AcuteRN2).
Thus it was inferred that ‘what a lot of services are doing is closing the door rather than opening the door (CommRN6).
The participants’ accounts highlight, then, that access to service and admission to
inpatient units were important and often challenging experiences. It is reinforced,
furthermore, that interpersonal engagement with others (advocacy from significant
others and appropriate engagement from staff) at this initial stage was absolutely
essential, particularly as it promoted access by countering some of the ambivalence,
fear, and isolation potentially experienced by the suicidal person at that time. Thus,
interpersonal engagement was seen as essential to enabling the suicidal person to
navigate a system that could be difficult and daunting to access. The incident
recounted by one nurse regarding the suicide of a person who sought help, but was
not enabled to receive access to service, is a stark reminder that suicidal people
other than those able to participate in this research may fail to have the most basic
need of access to service met.
5.2.2. ‘Not just a question’: the imperative of understanding
Further highlighting the importance of interpersonal engagement with others
around access and initial intersection with services, the majority of the nurse
interviewees described the absolute importance of gaining meaningful
understanding of the person in suicidal crisis as soon as possible (and then
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to be a complex, holistic and unique experience, gaining understanding of the
individual consumer’s intrapersonal experience was seen as central to gaining
meaningful understanding. The majority of the nurse interviewees noted that
generating such understanding required a particular quality of engagement. For
example, it was noted that:
assessing suicide is not just a question of ‘are you suicidal? Do you have intentions of suicide?’ Of course they’re going to be part of what you’re talking about but I need to know the context, what they’re actually thinking...I need them to trust me and be honest with me (AcuteRN3).
Generating understanding of the consumer’s intrapersonal experience was thus seen
as essential to understanding the nature and meaning of relevant risk factors, and
also to planning and enabling quality care. Towards this it was expressed, for
example, that:
I’m trying to find out if they’ve got a plan, how long they’ve had the plan for and all that, but also what sorts of things they can try do to....what do they like doing, what are they able to do...what is an alternative to committing suicide? (AcuteRN1).
Thus the nurses strongly appreciated that gaining understanding via meaningful
engagement with consumers was essential to assessment which could ensure short
term needs such as physical safety, as well as promote further care. This
acknowledges that assessment is only of use if it leads to appropriate and effective
intervention (Cutcliffe & Stevenson 2008a, p. 343), as ‘risk assessment itself never
saved anyone’s life’ (Maris 2007, p. vi). Of particular relevance is the indication that
engagement which enables appreciation of the consumer’s intrapersonal experience
may have particular value in this regard. This is pertinent to consider given the
suggestion that inadequate evidence exists to assert that risk assessment is actually
effective in reducing self‐harm or suicide within mental health care contexts (Wand
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5.2.3. Summary
The participants’ accounts affirm and nuance previous findings that the immediate
care aims for an acutely suicidal person are ‘protection, safety’ and ‘connectedness’
(Maris et al. 2000a, p. 515). Importantly, participants’ accounts suggest that
interpersonal engagement (encompassing connectedness) was a need of primary
importance as it promoted the potential for access, admission, and assessment, to
occur appropriately. How, ultimately, service underpinned by interpersonal
engagement may help restore or generate in consumers hope and empowerment
enabling resolution of crisis and the fuller realisation of recovery has been alluded to
here, and is explored in depth in subsequent chapters. It is evidenced thus far,
however, that interpersonal engagement which enabled adequate understanding of
the suicidal person’s intrapersonal experience was seen to be vital to accessing care,
admission to inpatient settings and initial assessment and care planning.