It Doesn’t Look Like Work, but it Works: A Qualitative Study of Staff Experiences with a Self-Harm Strategy in Danish Inpatient Mental Health Services

Abstract

Non-suicidal self-injury (NSSI) is common in inpatient mental health care and poses challenges for staff, patients, and organizations. While training programs can improve knowledge and attitudes, less is known about how staff collectively experience implementing new strategies for managing self-harm and how such strategies influence ward culture and professional practice. This qualitative study was part of a broader evaluation of implementing a regional self-harm strategy in a Danish inpatient mental health service. The strategy included staff training, clinical tools, and supervision. Four focus group interviews with 25 staff members from five inpatient units were conducted in 2024. Data were analyzed using reflexive thematic analysis. The analysis generated four interrelated themes: (1) Relational work as invisible yet essential: Staff valued listening and dialogue as crucial for preventing escalation but described these practices as undervalued and the first to be dropped under pressure. (2) Diagnostic hierarchies: psychosis as the legitimate inpatient diagnosis, self-harm as responsibility: Psychotic patients were viewed as genuinely ill and beyond control, while patients who self-harm were often framed as responsible, sustaining moralized hierarchies of care. (3) Cultural change – from control to dialogue: The strategy disrupted routines of restraint in relation to self-harm. Initially perceived as “doing nothing,” the new strategy was increasingly legitimized as staff witnessed calmer units, reduced coercion, and clearer professional roles grounded in relational practice. (4) Responsibility, guilt, and emotional distance — Staff struggled with the emotional and moral burden of refraining from coercion, negotiating professional boundaries, and managing feelings of guilt and emotional withdrawal. Implementing a self-harm strategy requires more than new clinical tools. It depends on staff integrating the approach into everyday practice, supported by structural and cultural change. Sustainable implementation relies on legitimizing relational care as skilled clinical work, creating space for reflection, and addressing the emotional demands placed on staff. The findings also show that diagnostic hierarchies continue to shape how legitimacy and responsibility are distributed within psychiatric care.