Does changing clinicians' attitudes toward self-harm reduce coercive interventions in mental health inpatient settings? A quasi-experimental study of staff training.

Abstract

Background: Staff education may improve clinicians' attitudes toward self-harm, but whether this translates into reduced coercion is unclear. We evaluated a regional strategy to improve care for self-harming patients and its impact on staff attitudes and coercive interventions across services.

Methods: Quasi-experimental dual design: (a) interrupted time-series of registry data on coercive interventions (Jan 2021-Dec 2024) and (b) three-wave pre-post surveys using the revised 17-item Self-Harm Antipathy Scale (SHAS-DR) at baseline, 2 months, and 8 months post-training. Change points: June 2022 (strategy announcement) and June 2023 (training implementation).

Results: In registry data, coercive interventions declined after the strategy announcement (level IRR 0.39, 95% CI 0.21-0.73) with no subsequent trend change. A temporary increase occurred at the training point (level IRR 2.58, 95% CI 1.57-4.25), consistent with implementation disruption. Reductions were largest for mechanical restraints, particularly among self-harming patients, while rapid tranquillization remained most frequent. Annual coercive episodes fell from 1,280 (2021) to 409 (2024). Staff attitudes improved and were sustained. Mean SHAS-DR decreased from 40.0 (SD 10.8) at baseline to 34.8 (SD 7.4) at 2 months and 35.4 (SD 8.2) at 8 months; baseline-to-follow-up changes were significant (p ≤ 0.001).

Conclusions: The strategy coincided with an immediate reduction in coercion and a transient rise during training, while staff attitudes reflected reduced antipathy toward people who self-harm. Sensitivity analyses suggested changes were not driven by high-frequency patients. Sustained reductions likely require continued organizational and relational supports.

Trial registration: Not applicable.