Gatekeeping and factors underlying decisions not to refer to mental health services after self-harm: Triangulating video-recordings of consultations, interviews, medical records and discharge letters

When a person attends a UK Emergency Department (ED) for self-harm or suicidal ideation, practitioners may refer to mental health services. While some people ask for and receive support, others ask but do not receive support. We explored requests for support followed by decisions not to refer to mental health services. We analyzed and triangulated evidence from 46 video-recorded psychosocial assessments, one-week and threemonth follow-up interviews with patients and carers, medical records, documentation of the referral proces, and ED discharge letters. We present three detailed cases, revealing four factors underlying these decisions: (1) self-control, self-help, social support, and current treatment as valid treatment plans ("Continue to use my coping strategies and deep breathing. But that ain't working."), (2) narrow referral criteria for services, including exclusion of those 'not ill enough' or 'too risky' ("It's about gathering evidence ... She would monitor you over a period of weeks and then refer."), (3) accessing mental health care while using alcohol ("I'm being told that they can't deal with her mental health issues until she's not an alcoholic."), and (4) accessing more than one service ("Common with most therapeutic services, we would not work in tandem with another therapeutic provider."). These factors lead to people in crisis being excluded from additional professional support, with serious adverse outcomes including suicide attempts. Patients are pressured to align with these decisions as reasonable. Practitioners are required to act as gatekeepers, rationing under-resourced mental health services. This significantly undermines early intervention and patient recovery.Content warning: Detailed descriptions of self-harming thoughts and behaviors including suicide, self-inflicted injuries and disordered eating. Discussions of sexual, physical and psychological abuse. Depictions of discriminatory attitudes and actions.