Challenging questions and ethical obligations: the ethics of everyday practice > 21 January 2015

Sandra Walker


You Don’t Want to Lie But You Can’t Tell the Truth Either.

NICE (2004, 2011) state that all people who self-harm (SH) and attend general hospital should be offered a psychosocial assessment. An ongoing qualitative research study, using Interpretative Phenomenological Analysis to explore the experience people who self-harm of contact with mental health services in a general hospital environment, has indicated that patients may feel unable to tell the truth during this assessment for fear of the consequences, this presentation discusses the psychosocial assessment in light of these findings and questions arising from this situation.

Hunter et al (2013) note that the function of the psychosocial assessment is unclear and it is seen as a routine part of hospital care. This was supported by Sinclair & Green (2005) whose cohort saw assessment as something that had to be agreed to in order to be allowed home. In Eales et al (2006) study the assessment was seen as an opportunity to talk but experienced as negative due to being too short and the mental health practitioners not asking enough questions about background, so not fully understanding the context of the individuals they were assessing. In Taylor et al’s (2009) systematic review the psychosocial assessment was highlighted as something that needed improving and they raised the issue that many individuals who SH are still not receiving psychosocial assessment and when they do it is often superficial and rushed. A good assessment is life affirming, values the person and therapeutic in nature, although there is, generally, no explicit ‘therapy’ element intended. In their study of interventions following SH it is interesting to note that Hume & Platt (2007) did not consider the psychosocial assessment as an intervention after SH completely overlooking the extant evidence that the this assessment itself can have therapeutic effect (Barker, 2004, Walker et al, 2013). The term psychosocial assessment is used extensively throughout research articles and guidance without any clear definition (eg. Hawton et al 2002: Haw et al 2003: Ebbage et al, 1994 and Dennis et al, 2001) but appears to be an umbrella term used to describe an information gathering exercise which may or may not have therapeutic intention and as such has become something of a reified abstraction.

How does the service create an environment that makes this restrictive encounter manifest? How can clinicians create a compassionate space to enable patients to feel safe enough to tell the whole truth? Is truth telling something we really want to happen? Does exploring these questions in the light of different ethical perspectives give us clues to possible solutions for them? This presentation explores the ethical dilemmas that arise in this clinical situation, outlining the barriers that exist in the assessment interaction potentially preventing an honest, open dialogue between patient and clinician and suggests measures that could be taken to maximise the possibility of a therapeutic encounter.


  • Barker PJ. (2004) Assessment in psychiatric and mental health nursing: In search of the whole person. Cheltenham, Nelson-Thornes
  • Dennis M, Evans A, Wakefield P, Chakrabarti S. (2001) The Psychosocial assessment of deliberate Self-Harm: Using Clinical Audit to improve the quality of the service. Emergency Medicine Journal. 18:448-450
  • Eales S. Callaghan P, Johnson B. (2006) Service users and other stakeholders’ evaluation of a liaison mental health service in an accident and emergency department and a general hospital setting. 13: 70-77
  • Ebbage, J., Farr,C., Skinner,D.V., White,P.D. (1994) The psychosocial assessment of patients discharged from accident and emergency departments after deliberate self-poisoning. Journal of the Royal Society of Medicine. 87.pp515-516
  • Haw C, Hawton K, Whitehead L, Houston K, Townsend E. (2003) Assessment and aftercare for Deliberate Self-Harm patients provided by a General Hospital Psychiatric Service. Crisis. Vol. 24(4) 145-150
  • Hawton, K. Rodham,K. Evans, E. Weatherall, R. ( 2002) Deliberate Self Harm In Adolescents: Self Report Survey In Schools In England BMJ: British Medical Journal , Vol. 325(7374): 1207-1211
  • Hume M & Platt S (2007) Appropriate interventions for the prevention and management of self-harm: a qualitative exploration of service-users’ views. BMC Public Health. 7:9
  • Hunter C. Chantler K. Kapur N. Cooper J. (2013) Service users perspectives on psychosocial assessment following self-harm and its impact on further help-seeking: A Qualitative Study. Journal of Affective Disorders. 145 pg:315-323
  • National Institute of Clinical Excellence (2004) Self-harm: the short-term physical and psychological management and secondary prevention of intentional self-harm in primary and secondary care. Guideline. London . NICE.
  • National Institute of Clinical Excellence (2011) Self-harm: longer-term management. Guideline. London. NICE.
  • Sinclair J & Green J (2005) Understanding resolution of deliverate self harm:whalitative interview study of patients’ experience. British Medical Journal Online. doi:10.1136/bmj.38441.503333.8F
  • Taylor TL. Hawton K. Fortune S. Kapur N. (2009) Attitudes towards clinical services among people who self-harm: systematic review. British Journal of Psychiatry. 194:104-110
  • Walker S. Carpenter D. Middlewick Y. (2013) Assessment and Decision Making in Mental Health Nursing. London, SAGE



Sandy Walker is a Senior Teaching Fellow at Southampton University, currently providing teaching, assessment, module planning and delivery and student support at undergraduate and postgraduate level. She is also a PhD student with the university looking at the experience people who self-harm have of contact with mental health services whilst in the general hospital environment. Until 2011 Sandy worked for 20+ years as a Registered Mental Health Nurse, from staff nurse to Clinical Manager/Modern Matron, responsible for management of services and staff.


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