A total of 24 interviews were conducted with 16 participants: nine older adults and seven support workers. Eight older adults consented to a follow-up interview. All interviews lasted from 28 to 129 minutes. Tables 1 and 2 provide a summary of participant sociodemographic and other characteristics. All older adults had comorbid physical and mental health problems, and over half (n = 4) of the support workers had previous self-harm history. Three major themes were identified throughout participants’ accounts: help-seeking decision factors; sources of support; and barriers and facilitators to accessing primary care. The following illustrative quotations are used to present details of the theme, before turning to look at the implications for intervention, management, and support.
Help-seeking decision factors
Older adults experienced self-harm throughout different stages of the life course. However, it was often hidden:
‘Obviously, it [self-harm in older adults] does happen, but it’s hidden.’
(Male older adult [MOA], aged 60 years, M3 [patient identifier])
Both participant groups mentioned older adults deciding to seek help during different periods in the life course. However, these decisions were seen as difficult, sometimes occurring months or years after starting self-harm behaviour. Experiencing shame due to self-harm was seen by both groups as a key deterrent in accessing support, and they linked it to the stigma associated with mental health and self-harm, which they perceived as accentuated further among older adults:
‘It’s harder for older people to talk about their mental health. You can imagine more so with self-harm.’
(Female support worker [FSW], aged 40 years, F11)
‘It’s just that you are ashamed of some of it [self-harm], so it’s harder to talk about it and ask for help.’
(Female older adult [FOA], aged 60 years, F3)
However, older adults and support worker participants identified self-harm behaviour as reaching a point where it was out of control and was no longer serving as a coping mechanism. Once this point was reached, older adults made the decision to seek help, recognising they needed support:
‘I think a lot of people only turn to help if it’s sorta uh, when it gets out of control, so that I suppose, eventually, they just reach out for some help.’
(FSW, aged 49 years, F10)
‘It wasn’t that I wanted help, I needed [emphasis] help, I couldn’t deal with it any longer.’
(FOA, aged 72 years, F2)
Barriers and facilitators to accessing primary care support
Different barriers to accessing primary care support existed for older adults who self-harm.
As noted previously, feelings of shame and stigma were commonly described, leading older people to live with self-harm in secret, prolonging or delaying the process of help-seeking:
‘They’ll [older adults] mention the physical health to the GP but won’t always mention their self-harm or mental health.’
(FSW, aged 40 years, F11)
Stigma associated with self-harm could still be present and act as a barrier to accessing care even after older adults had made the decision to seek help:
‘I felt embarrassed because of me age, I didn’t wanna ask for help. I’m thinking it’s girls that do it, 16, 17-year-olds you know and they’re self-harming and here is me you know, I should know better.’
(MOA, aged 67 years, M1)
Furthermore, older adults described GPs’ lack of interest to self-harm in older adults, reflecting stigma associated with self-harm by clinicians:
‘You tell them [doctors] and they’re not interested about self-harm. I’ve seen it myself, anyone that comes in with mental health problems they’re just dismissed. It’s still something not taken seriously, like it will go away or grow out of it. When the truth is, you don’t grow out of it if you don’t receive the help.’
(FOA, aged 62 years, F6)
For some older adults, this reflected a lack of trust in their GPs’ ability to help:
‘Most GPs don’t know how to deal with it, much less from an older adult, and much less from a functioning adult.’
(MOA, aged 60 years, M3)
In addition to perceptions that GPs lack expertise, older adults often felt their encounters with GPs were superficial, and described support as mostly pharmacological, with provision of psychological therapies not common practice. This was despite the high level of GP involvement reflected in frequent and regular consultations:
‘Well, I got the medication from my GP and it was a case of seeing him once a week to see how it was affecting me. Now I get a review every 6 months.’
(FOA, aged 72 years, F2)
Such treatments were viewed as insufficient to deal with the complexities of self-harm:
‘There are lots of doctors that just want to pill pop [snaps fingers], here have a pill. That just masks it. You’re just skimming over it, you’re not talking to them. There’s things in people’s heads that a pill doesn’t take. And you know some doctors don’t understand mental health, don’t understand self-harm. And there is people out there that take overdoses and they’re not given the correct support.’
(FSW, aged 46 years, F7)
This sense of superficial engagement on the part of GPs could deepen feelings of personal inadequacy and illegitimacy:
‘You’re just a number. Once you’re out of the bed or consultation room, someone else is gonna come, so to the nurses and doctors you’re just a number.’
(MOA, aged 67 years, M1)
Linked to this, some older adults’ accounts of their experiences with GPs had a predominant focus on treating physical wounds resulting from self-harm, and their overall physical health, reflecting a prioritisation of the physical over mental health:
‘He [GP] just kept looking at his watch. I thought, I don’t want that doctor again, because all he was interested was his watch. He was interested in my physical ability. He was interested in mending me physically but not mentally. And I’ve found that with a lot of the doctors. You try and tell them you need help mentally but all they see and care is your physical abilities.’
(FOA, aged 62 years, F6)
This prioritisation of the physical over the mental could also be on the part of the older person themselves:
M2:‘I do see me GP frequently but it’s mainly for other things like blood tests and these sorts of things.’
Interviewer:‘Is there any reason why you don’t talk about it with your GP?’
M2:‘I’ve got so many other things that need to be checked, there just wouldn’t be time.’
(MOA, aged 61 years, M2)
Furthermore, this could be deepened by sex attitudes to health-seeking more generally:
‘As a male I tend to not go to the GP. It’s kind of being very appreciative of the NHS. I’m not someone to call the GP all the time and kinda go like, oh I wanna tell you this.’
(MOA, aged 60 years, M3)
When offered referrals by GPs, older adults described the support and treatment received consisting of short-term interventions, which left them feeling frustrated and discouraged them from seeking further help:
‘They’ll do something like 6-week counselling. But if at the end of the 6 weeks you still feel you’re struggling, then surely they should do something, have another source of support. I remember being told, well we’ve done the course, there’s nothing else we can do, uhm if you’re not feeling better, that’s your problem.’
(FOA, aged 65 years, F4)
Furthermore, support for self-harm was described as difficult to access as it was not seen as an urgent priority. Although some older adults spoke of an overemphasis on their physical health, some also experienced difficulties in accessing help at crisis points:
‘I cut my stomach and it was really quite bad. I phoned my GP, and nobody would see me, even though I had a priority plan. They said, come here tomorrow. I said, I need to see somebody now and they said, well we’ve got no appointments. So I phoned my CPN [community psychiatric nurse] and she said, well this priority care planning isn’t working, and she phoned them, and they called me straight away.’
(FOA, aged 65 years, F4)
According to older adults, mental health care was only provided for those who were very ill, as opposed to those who were not but were still in need of care:
‘I can’t see the point in it. They turn up and then they don’t do it. They don’t do anything that [it] says on the letter unless you’re absolutely completely and utterly mentally ill. Which is fair enough for those who are like that. Because they’re so stretched, they don’t do much for you unless you’re absolutely crawling up the walls.’
(FOA, aged 62 years, F1)
Finally, older adults described practical barriers such as difficulties in travelling. Where people had mobility difficulties, it was not easy for them to travel independently, particularly in bad weather, which could have cost implications:
‘It costs me 20 pounds [GBP] to get there, which is a lot of money. So yeah, I just have to have to sit tight and wait for the snow to go. And then of course, you’ve got hospital appointments.’
(FOA, aged 62 years, F1)
These barriers to accessing support often resulted in older people seeking support elsewhere:
‘He [older adult] was looking for some support because the GP basically didn’t know what to do, as is the case with many health professionals.’
(MSW, aged 50 years, M5)
Older adults encountered several barriers to obtaining support for managing their self-harm, including feelings of shame, sex and age attitudes, perceptions of competency on the part of GPs, prioritisation of physical over mental health needs, legitimacy in help-seeking, and physical barriers such as transport. Worries about stigma were an overarching barrier to accessing help.
Both participant groups also identified facilitators when receiving self-harm support in primary care. Empathy was one of the most frequently mentioned facilitators as well as reliability and continuity given by healthcare professionals, which could legitimise people’s help-seeking:
‘She [GP] was real for start. I felt as I was gonna see somebody I could talk to, as opposed as to somebody that was going to sit behind a desk and talk to me. As well, I didn’t feel like a burden.’
(FOA, aged 65 years, F4)
Taking the condition seriously conveyed respect:
‘You could see how they treated her, and they were absolutely amazing they just treated her so well. She was treated so respectfully.’
(FSW, aged 49 years, F10)
Linked to this, some older adults described the high impact from positive experiences of support from their GP:
‘I have to say my GP has been fantastic, she’s very good. Very caring, she listens. Which is, you know, some of them don’t, but she’s been fantastic. She’s given me all the literature for [local self-harm support group]. The last time when I went off, that’s when she said we need to change your medication, you’ve been on them too long. She’s very thorough. I couldn’t have asked for anything better.’
(FOA, aged 62 years, F5)
Furthermore, older adults identified the importance of having regular and ongoing support as a facilitator to receiving care:
‘It’s the ongoing support. You’ve always got somebody you can contact. This ongoing support is really, really helpful.’
(FOA, aged 62 years, F5)
Finally, availability of accessible facilities made it easier for older adults to access support for their self-harm. Boxes 1 and 2 summarise the different barriers and facilitators to accessing primary care support for older adults with self-harm behaviour.
External factors |
Healthcare professionals’ attitudes and preconceptions Structure of healthcare system Disparity of care Fragmented care delivery: mind–body dualism and priority to physical health care
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Practical barriers |
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Internal factors |
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Box 1. Barriers to accessing primary care for self-harm in older adults
External factors |
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Structural factors |
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Internal factors |
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Box 2. Facilitators to accessing primary care for self-harm in older adults