Why Do the Very Old Self-Harm? A Qualitative Study

Objectives: To examine the perspectives of people aged 80 years or older who self-harmed regarding their reasons for self-harm and its consequences, and their perceptions of care. Design: A qualitative study using in-depth interviews. Setting: Participants were recruited from two teaching hospitals and associated community services. Participants: People aged 80 years or older who had self-harmed within the previous month. Methods: Structured psychiatric assessment including cognitive testing, DSM-5 diagnosis, and an in-depth qualitative interview focusing upon the reasons for and consequences of self-harm. Narrative enquiry was used to guide the discussion. All interviews were undertaken by a geriatric psychiatrist, audio recorded, transcribed verbatim, and subjected to thematic analysis using N-VIVO. Results: Themes that emerged for the reasons for self-harm included enough is enough; loneliness; disintegration of self;being a burden;cumulative adversity;hopelessness and endless suffering; helplessness with rejection; and the untenable situation. Themes for the consequences of self-harm were becoming engaged with or distanced from family; the problem was solved;gaining control;I m worse off now;rejection by health professionals; and tension in the role of the inpatient clinical environment. Conclusions: Self-harm may communicate a need that cannot otherwise be expressed. An individualized person-centered approach is required to respond to self-harm, including a combination of practical, medical, and psychological approaches as indicated. Involvement of families in the process of understanding the meaning of and responding to self-harm through education and family therapy, as well as education of health-care professionals beyond risk factor notation may be indicated.