Quantitative evidence for relational care approaches to assessing and managing self-harm and suicide risk in inpatient mental health and emergency department settings: a scoping review

Quantitative evidence for relational care approaches to assessing and managing self-harm and suicide risk in inpatient mental health and emergency department settings: a scoping review | medRxiv /* */ /* */ <!-- <!-- /*! * yepnope1.5.4 * (c) WTFPL, GPLv2 */ (function(a,b,c){function d(a){return"[object Function]"==o.call(a)}function e(a){return"string"==typeof a}function f(){}function g(a){return!a||"loaded"==a||"complete"==a||"uninitialized"==a}function h(){var a=p.shift();q=1,a?a.t?m(function(){("c"==a.t?B.injectCss:B.injectJs)(a.s,0,a.a,a.x,a.e,1)},0):(a(),h()):q=0}function i(a,c,d,e,f,i,j){function k(b){if(!o&&g(l.readyState)&&(u.r=o=1,!q&&h(),l.onload=l.onreadystatechange=null,b)){"img"!=a&&m(function(){t.removeChild(l)},50);for(var d in y[c])y[c].hasOwnProperty(d)&&y[c][d].onload()}}var j=j||B.errorTimeout,l=b.createElement(a),o=0,r=0,u={t:d,s:c,e:f,a:i,x:j};1===y[c]&&(r=1,y[c]=[]),"object"==a?l.data=c:(l.src=c,l.type=a),l.width=l.height="0",l.onerror=l.onload=l.onreadystatechange=function(){k.call(this,r)},p.splice(e,0,u),"img"!=a&&(r||2===y[c]?(t.insertBefore(l,s?null:n),m(k,j)):y[c].push(l))}function j(a,b,c,d,f){return q=0,b=b||"j",e(a)?i("c"==b?v:u,a,b,this.i++,c,d,f):(p.splice(this.i++,0,a),1==p.length&&h()),this}function k(){var a=B;return a.loader={load:j,i:0},a}var l=b.documentElement,m=a.setTimeout,n=b.getElementsByTagName("script")[0],o={}.toString,p=[],q=0,r="MozAppearance"in l.style,s=r&&!!b.createRange().compareNode,t=s?l:n.parentNode,l=a.opera&&"[object Opera]"==o.call(a.opera),l=!!b.attachEvent&&!l,u=r?"object":l?"script":"img",v=l?"script":u,w=Array.isArray||function(a){return"[object Array]"==o.call(a)},x=[],y={},z={timeout:function(a,b){return b.length&&(a.timeout=b[0]),a}},A,B;B=function(a){function b(a){var a=a.split("!"),b=x.length,c=a.pop(),d=a.length,c={url:c,origUrl:c,prefixes:a},e,f,g;for(f=0;f<d;f++)g=a[f].split("="),(e=z[g.shift()])&&(c=e(c,g));for(f=0;f<b;f++)c=x[f](c);return c}function g(a,e,f,g,h){var i=b(a),j=i.autoCallback;i.url.split(".").pop().split("?").shift(),i.bypass||(e&&(e=d(e)?e:e[a]||e[g]||e[a.split("/").pop().split("?")[0]]),i.instead?i.instead(a,e,f,g,h):(y[i.url]?i.noexec=!0:y[i.url]=1,f.load(i.url,i.forceCSS||!i.forceJS&&"css"==i.url.split(".").pop().split("?").shift()?"c":c,i.noexec,i.attrs,i.timeout),(d(e)||d(j))&&f.load(function(){k(),e&&e(i.origUrl,h,g),j&&j(i.origUrl,h,g),y[i.url]=2})))}function h(a,b){function c(a,c){if(a){if(e(a))c||(j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}),g(a,j,b,0,h);else if(Object(a)===a)for(n in m=function(){var b=0,c;for(c in a)a.hasOwnProperty(c)&&b++;return b}(),a)a.hasOwnProperty(n)&&(!c&&!--m&&(d(j)?j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}:j[n]=function(a){return function(){var b=[].slice.call(arguments);a&&a.apply(this,b),l()}}(k[n])),g(a[n],j,b,n,h))}else!c&&l()}var h=!!a.test,i=a.load||a.both,j=a.callback||f,k=j,l=a.complete||f,m,n;c(h?a.yep:a.nope,!!i),i&&c(i)}var i,j,l=this.yepnope.loader;if(e(a))g(a,0,l,0);else if(w(a))for(i=0;i (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0];var j=d.createElement(s);var dl=l!='dataLayer'?'&l='+l:'';j.src='//www.googletagmanager.com/gtm.js?id='+i+dl;j.type='text/javascript';j.async=true;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-P4HH5NV'); Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search Quantitative evidence for relational care approaches to assessing and managing self-harm and suicide risk in inpatient mental health and emergency department settings: a scoping review View ORCID Profile Jessica L. Griffiths , View ORCID Profile Una Foye , View ORCID Profile Ruth Stuart , Ruby Jarvis , Beverley Chipp , Raza Griffiths , Tamar Jeynes , Lizzie Mitchell , Jennie Parker , Rachel Rowan Olive , Kieran Quirke , View ORCID Profile John Baker , Geoff Brennan , View ORCID Profile Gary Lamph , View ORCID Profile Mick McKeown , View ORCID Profile Brynmor Lloyd-Evans , View ORCID Profile Kylee Trevillion , View ORCID Profile Alan Simpson doi: https://doi.org/10.1101/2024.08.08.24311667 Jessica L. Griffiths 1 NIHR Policy Research Unit in Mental Health (MHPRU), Department of Health Services and Population Research (HSPR), Institute of Psychiatry, Psychology & Neuroscience, King’s College London , London, United Kingdom Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Jessica L. Griffiths For correspondence: jessica.griffiths{at}kcl.ac.uk Una Foye 1 NIHR Policy Research Unit in Mental Health (MHPRU), Department of Health Services and Population Research (HSPR), Institute of Psychiatry, Psychology & Neuroscience, King’s College London , London, United Kingdom Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Una Foye Ruth Stuart 1 NIHR Policy Research Unit in Mental Health (MHPRU), Department of Health Services and Population Research (HSPR), Institute of Psychiatry, Psychology & Neuroscience, King’s College London , London, United Kingdom Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Ruth Stuart Ruby Jarvis 2 NIHR Policy Research Unit in Mental Health (MHPRU), Division of Psychiatry, University College London , London, United Kingdom Find this author on Google Scholar Find this author on PubMed Search for this author on this site Beverley Chipp 3 NIHR Mental Health Policy Research Unit Lived Experience Working Group, NIHR Policy Research Unit in Mental Health (MHPRU), Division of Psychiatry, University College London , London, United Kingdom Find this author on Google Scholar Find this author on PubMed Search for this author on this site Raza Griffiths 3 NIHR Mental Health Policy Research Unit Lived Experience Working Group, NIHR Policy Research Unit in Mental Health (MHPRU), Division of Psychiatry, University College London , London, United Kingdom Find this author on Google Scholar Find this author on PubMed Search for this author on this site Tamar Jeynes 2 NIHR Policy Research Unit in Mental Health (MHPRU), Division of Psychiatry, University College London , London, United Kingdom Find this author on Google Scholar Find this author on PubMed Search for this author on this site Lizzie Mitchell 3 NIHR Mental Health Policy Research Unit Lived Experience Working Group, NIHR Policy Research Unit in Mental Health (MHPRU), Division of Psychiatry, University College London , London, United Kingdom Find this author on Google Scholar Find this author on PubMed Search for this author on this site Jennie Parker 3 NIHR Mental Health Policy Research Unit Lived Experience Working Group, NIHR Policy Research Unit in Mental Health (MHPRU), Division of Psychiatry, University College London , London, United Kingdom 4 Berkshire Healthcare NHS Foundation Trust , Reading, United Kingdom Find this author on Google Scholar Find this author on PubMed Search for this author on this site Rachel Rowan Olive 3 NIHR Mental Health Policy Research Unit Lived Experience Working Group, NIHR Policy Research Unit in Mental Health (MHPRU), Division of Psychiatry, University College London , London, United Kingdom 5 Department of Primary Care & Public Health, Brighton & Sussex Medical School, University of Sussex , Brighton, United Kingdom Find this author on Google Scholar Find this author on PubMed Search for this author on this site Kieran Quirke 6 King’s College Hospital NHS Foundation Trust , London, United Kingdom Find this author on Google Scholar Find this author on PubMed Search for this author on this site John Baker 7 School of Healthcare , Baines Wing, University of Leeds , Leeds, United Kingdom Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for John Baker Geoff Brennan 8 Department of Health Services and Population Research (HSPR), Institute of Psychiatry , Psychology & Neuroscience, King’s College London, London, United Kingdom 9 Florence Nightingale Faculty of Nursing , Midwifery and Palliative Care, King’s College London , London, UK Find this author on Google Scholar Find this author on PubMed Search for this author on this site Gary Lamph 10 School of Nursing and Midwifery, Keele University , Keele, United Kingdom 11 Midlands Partnership University NHS Foundation Trust , United Kingdom Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Gary Lamph Mick McKeown 12 School of Nursing and Midwifery, University of Central Lancashire , Lancashire, United Kingdom Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Mick McKeown Brynmor Lloyd-Evans 2 NIHR Policy Research Unit in Mental Health (MHPRU), Division of Psychiatry, University College London , London, United Kingdom Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Brynmor Lloyd-Evans Kylee Trevillion 1 NIHR Policy Research Unit in Mental Health (MHPRU), Department of Health Services and Population Research (HSPR), Institute of Psychiatry, Psychology & Neuroscience, King’s College London , London, United Kingdom Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Kylee Trevillion Alan Simpson 1 NIHR Policy Research Unit in Mental Health (MHPRU), Department of Health Services and Population Research (HSPR), Institute of Psychiatry, Psychology & Neuroscience, King’s College London , London, United Kingdom Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Alan Simpson Abstract Full Text Info/History Metrics Supplementary material Preview PDF Abstract There is an over-reliance on structured risk assessments and restrictive practices for managing self-harm and suicidality in inpatient mental health and emergency department (ED) settings, despite a lack of supporting evidence. Alternative ‘relational care’ approaches prioritising interpersonal relationships are needed. We present a definition of ‘relational care’, co-produced with academic and lived experience researchers and clinicians, and conducted a scoping review, following PRISMA guidelines. We aimed to examine quantitative evidence for the impact of ‘relational care’ in non-forensic inpatient mental health and ED settings on self-harm and suicide. We identified 29 relevant reviews, covering 62 relational care approaches, reported in 87 primary papers. Evidence suggests some individual-, group-, ward- and organisation-level relational care approaches can reduce self-harm and suicide in inpatient mental health and ED settings, although there is a lack of high-quality research overall. Further co-produced research is needed to clarify the meaning of ‘relational care’, its core components, and develop a clear framework for its application and evaluation. Further high-quality research is needed evaluating its effectiveness, how it is experienced by patients, carers, and staff, and exploring what works best for whom, under what circumstances, and why. Introduction Suicidality and self-harm remain key reasons for inpatient admissions in both acute and mental health hospitals. Therefore, a key purpose of inpatient mental health services and emergency departments (EDs) is to provide a safe environment for people presenting with, and at-risk of, self-harm and/or suicide ( 1 , 2 ). During the years 2011-21, 28% of people in the UK who died by suicide were patients in acute care settings (inpatients, under crisis resolution/home treatment teams, or recently discharged from in-patient care) ( 3 ). Rates of inpatient suicide per 10,000 admissions fell by 33% over this 11-year period. There were on average 31 deaths by suicide on UK wards annually during this period ( 3 ). In England alone, there are approximately 220,000 self-harm presentations to EDs annually ( 4 , 5 ) and such individuals have a 49 times greater relative risk of suicide than that of the general population ( 6 ). Self-harm is the most frequently reported incident in mental health services and rates of self-harm have increased over time ( 7 ). Self-harm rates on inpatient mental health wards vary, with studies reporting between 4% and 70% of patients harming themselves during admission to inpatient services ( 8 ). Self-harm has been found to most often be a private act, which takes place in bedrooms, bathrooms and toilets, and during the evening hours ( 9 ). Given the prevalence of self-harm and suicidality in inpatient mental health and ED settings, these patient groups have been identified as a priority within national suicide prevention strategies ( 10 ). Efforts to enhance their safety have been made, including the implementation of varied interventions, policies and guidelines ( 1 , 3 ). This includes, more recently, the use of surveillance technologies, such as Vision-Based Patient Monitoring and Management, Body Worn Cameras, and closed-circuit television (CCTV). However, there is a lack of evidence for their effectiveness in improving patient safety, and ethical concerns about their potential to negatively impact patients’ human rights, privacy, dignity and recovery ( 11 ). Inpatient and ED settings remain challenging environments in which to deliver appropriate and effective care ( 12 – 15 ). Both inpatient mental health and ED settings are often fast-paced and over-stimulating environments, with high levels of distress, limited therapeutic options, lack of patient choice, inadequate involvement of families and carers, negative staff attitudes towards people who self-harm, and poor continuity of care. The consequences of this include high rates of conflict, coercion and restrictive practices ( 16 – 18 ). Specific challenges faced by emergency departments also include their single-visit nature, heavy footfall, long waiting times, and brief durations of each human encounter ( 19 ). In both settings, these challenges are compounded by systemic issues including rising demands on services, increasing acuity of patients’ presentations, temporary and under-staffing, and inadequate funding and resourcing ( 12 , 13 ). A recent independent rapid review on mental health inpatient care identified key safety issues facing inpatient settings ( 20 ). Those who present to EDs in emotional distress and requiring interventions and treatment for self-harm injuries may be directly or indirectly excluded by services, owing to prioritisation of others with physical health conditions, public discourse about system strain, and efforts to divert mental health cases elsewhere. Although they might be seen initially within an hour, their stay in the ED, or separate decision unit, can be as long as 48-72 hours as they wait for an outcome such as hospital admission. Most ED settings have mental health liaison services attached but these are often underutilised ( 21 , 22 ). Frequent attendance at ED settings is likely driven by limitations within other services in the healthcare system, rejection by other services, lack of clarity of service provisions available, and in some cases convenience. For example, it is often the only local or out-of-hours service accessible to people ( 23 ). These challenges contribute to an over-reliance in inpatient mental health and ED settings on using structured risk assessments and risk stratification to assess self-harm and suicide risk, and the use of restrictive practices, such as physical restraint, seclusion, rapid tranquilisation, and special observations to manage concerns over risk and safety ( 6 , 22 – 24 ). This is despite research consistently demonstrating the ineffectiveness of risk assessment checklists for predicting self-harm and suicide risk and the potential for restrictive practices to undermine therapeutic relationships and cause physical and psychological harm to patients and staff ( 9 , 24 – 26 ). There is, therefore, a growing need for alternative approaches in the assessment and management of self-harm and suicide risk in inpatient mental health and ED settings. Positive relationships between staff and the people they support are fundamental to a person-centred care environment and have been identified as key to a positive culture of care in new guidance for mental health inpatient services ( 27 ). Positive therapeutic relationships between patients and clinicians are central to high-quality mental health care, and strong, consistent predictors of positive outcomes across a range of intervention types and settings ( 28 – 30 ). Therapeutic relationships can underpin interventions and practices and can also be “therapy in and of itself” ( 29 ). Research indicates that patients value genuine listening, validation, warmth and curiosity within therapeutic relationships with clinicians, and that this can help build trust and facilitate disclosures about risk ( 23 , 31 – 34 ). There has, therefore, been an increasing interest in approaches to risk assessment and management which prioritise therapeutic interpersonal relationships – i.e. ‘relational’ approaches to care. What is ‘relational care’? There is no widely agreed definition of ‘relational care’. It has been described across a diverse range of sectors, including health, education, criminal justice and social work ( 35 ). It also forms an integral part of practices and professional identities within professions such as nursing, psychology, social work, criminal justice and medicine, as well as in peer support work ( 36 ). Alongside the lack of an agreed consistent definition is also the challenge that across the sectors there is not a consistent descriptor or term used. Instead, there are many variations that all ultimately describe similar concepts. Furthermore, it is not a new concept – elements of it have been described for centuries. The conceptualisation of ‘relational care’ has therefore varied across time and contexts, and despite this term becoming increasingly used and topical, defining it remains a complex task, especially in the context of mental health care, where many types of relationships are involved (e.g., patient-patient, patient-staff, staff-staff and the overall ward or ED milieu). For this project, a necessary working definition of ‘relational care’ within inpatient mental health and ED settings was coproduced by our working group, comprising academic and lived experience researchers and clinicians, as follows: “ Relational care can be practised at individual, group, organisational or systemic levels. It prioritises interpersonal relationships grounded in values such as respect, trust, humility, compassion, and shared humanity, and involves personalised and holistic care, addressing power imbalances, and promoting effective collaboration between staff, patients and their social networks.” 1 An organisational commitment to relational care, and reducing restrictive practices, is essential to provide the basis for developing and sustaining therapeutic relationships between staff and patients ( 27 ), from first contact (such as with paramedics and ambulance staff), in EDs and on inpatient wards. It is important to acknowledge the tensions between practising relational care in a setting that most patients experience as initially coercive and restrictive. In inpatient mental health services, there are pronounced power imbalances between staff and patients, and patients have limited choice and agency. Democratisation of care in these services may, therefore, be considered aspirational at present. In striving for relational care, it is important to both acknowledge and take active steps towards addressing these power imbalances ( 26 ). The environments in which relational interactions take place are important to consider as they need to be conducive to impact positively upon relational care experience, and we can conceive of configurations of space and place that are systemically more likely to support relational practice ( 35 ). For example, ward designs that maximise shared spaces, rather than demarcate space into designated staff and patient areas, or ward and ED layouts featuring outside areas and few confined spaces ( 45 – 47 ). Though not their only defining characteristic, ‘relational care’ is a fundamental part of other approaches to care, such as trauma-informed, person-centred, or recovery-focused care. It is also integral to psychological therapies, encompassing the soft skills needed to foster the therapeutic relationships between staff and patients that are fundamental to effective therapy. In this paper, psychological therapies are therefore included as relational care. Review objective This scoping review aimed to answer the following research question: What is the quantitative evidence for the impact of ‘relational care’ in non-forensic inpatient mental health and ED settings on self-harm and suicide-related outcomes? A scoping review methodology was deemed most appropriate due to the lack of a consistent definition of ‘relational care’, its conceptual complexity, and the limited research on this emerging topic. This approach allows us to broadly and systematically map relevant existing literature, and to identify gaps, key issues and themes. Materials and methods This scoping review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) ( 48 ). The PRISMA-ScR checklist can be seen in Appendix C . The review was conducted by the National Institute for Health and Care Research (NIHR) Policy Research Unit in Mental Health (MHPRU) based at King’s College London and University College London. The MHPRU conducts research in response to policymaker need (e.g., in the Department for Health and Social Care or NHS England). A working group comprising academic and lived experience researchers, and clinicians met regularly throughout the course of the project. Eligibility criteria Our review’s inclusion and exclusion criteria are described below. A table summary is available in Appendix D . Population Patients of any age, gender and ethnicity were included. Staff, family members/carers or non-mental health patients were excluded. Setting We included reviews that focused on care delivered within non-forensic inpatient mental health settings, including acute and longer-term inpatient services, and emergency departments. We excluded reviews focused on forensic inpatient mental health services, non-psychiatric medical inpatient services, services specifically for people with intellectual disabilities or autistic people, neurorehabilitation services, services specifically for people living with dementia, and community-based services. Intervention We included relational care approaches to assessing and managing self-harm and suicide risk in inpatient mental health and emergency department settings. These approaches must include a focus on interpersonal relationships and involve at least some of the values and/or principles described in our co-produced definition of ‘relational care’, provided above. We excluded pharmacological interventions, surveillance technologies, restrictive interventions (e.g., physical restraint, seclusion room use, rapid tranquilisation), structured risk assessment checklists and risk stratification, approaches focused only on the physical design of the environment, and standard aspects of inpatient mental health and ED care (e.g., psychosocial assessments, ward rounds). Outcomes We included reviews that examined self-harm and/or suicide-related outcomes, such as measures of suicidal ideation, frequency of self-harm or suicide attempts, time to next self-harm or suicide attempt, and rates of completed suicides. We excluded reviews that focused solely on risks to or from others, other patient outcomes, or staff or carer outcomes. Types of studies We opted to scope published reviews rather than primary research studies, due to preliminary literature searches revealing numerous existing reviews on the effectiveness of interventions for assessing and managing self-harm and suicide in inpatient mental health and ED settings. Quantitative and mixed-methods reviews were eligible for inclusion, including systematic, scoping, integrative, rapid, and narrative reviews. Both peer-reviewed and non-peer-reviewed sources were eligible for inclusion. We excluded primary research studies, books, commentaries, editorials, PhD/MSc/BSc theses, opinion pieces, blog posts and social media content. We applied no date restrictions but only included studies published in English. These restrictions were applied to narrow our scope, ensuring this review could be completed within the required timescales. Literature searching We searched three academic databases (Medline, PsycINFO and CINAHL) for reviews examining the impact of relational care approaches on self-harm and suicide-related outcomes in inpatient mental health and ED settings. Database searches were conducted on 11/06/24 and were limited to review articles. No date or language search restrictions were applied. Our search strategy included key terms relating to ‘relational care’ and ‘relational practice’ as well as terms to search more generally for approaches to assessing and managing self-harm or suicide risk in inpatient mental health and ED settings. The search terms were drafted by JG and further refined through consultation with the working group. The full search terms used can be seen in Appendix E . The results of the database searches were exported into Endnote and duplicates were removed. Additional relevant literature was also identified through searching Google Scholar, the National Institute for Health and Care Excellence (NICE) website, reference and citation lists of included reviews, and recommendations from members of our working group. Selection of sources of evidence All studies identified through database searches were independently double screened at title and abstract (JG, UF, RS). 10% of full texts were independently double screened (JG, UF). Any disagreements during screening were resolved through discussion. Screening was conducted in Rayyan ( 49 ). Studies identified through searching Google Scholar, the NICE website, expert recommendations and forwards and backwards citation searching were screened by JG and RS. Data charting and data items Two data extraction forms were developed in Microsoft Word and collaboratively revised with the working group. The first form summarised the eligible reviews, including their design, aims, search strategies, eligibility criteria, identified relational care approaches, and overall conclusions. The second form summarised each of the relevant primary studies in these reviews, including information about their designs, locations, samples, interventions, any control/comparison groups, and reported quantitative evidence for the impact of the relational care intervention on self-harm and suicide-related outcomes. Data were extracted into these forms by two researchers (JG, RS), and all entries were double-checked for accuracy. Disagreements were resolved through discussion. No systematic quality appraisal of the included reviews or primary studies was conducted. Synthesis Synthesis was led by two researchers (JG, RS), with input from the working group. The characteristics and findings of the included reviews were tabulated ( Appendix G ) and summarised narratively. Similarly, the characteristics and results of relevant primary studies within these reviews were tabulated and narratively described, grouped by setting and relational care approach. Only quantitative evidence for the impact of relational care approaches on self-harm or suicide-related outcomes was synthesised. More detailed tables and narrative descriptions summarising evidence from primary studies are provided in the appendices (see Supplementary File 1 for relational care approaches in inpatient mental health settings, and Supplementary File 2 for ED settings). Results Database searches returned 2,424 studies. After removing duplicates, 2,118 records remained for title and abstract screening. 2,064 studies were excluded, leaving 52 studies for full-text screening. Additional search methods identified 18 studies. Overall, 29 reviews met our inclusion criteria and were included in this scoping review. A list of studies excluded at full-text screening, with reasons for their exclusion, are provided in Appendix F . Figure 1 presents the PRISMA flow diagram ( 50 ). A table of included review characteristics is available in Appendix G . Download figure Open in new tab Figure 1. PRISMA flow diagram Characteristics of included reviews All reviews identified studies by searching academic databases. Thirteen reviews also searched grey literature sources (e.g., clinical trial registries, Google Scholar, ResearchGate, relevant governmental and non-governmental websites, contacted authors for unpublished research) ( 51 – 63 ). Search strategies and eligibility criteria were not clearly stated in one review ( 64 ). Out of the 29 included reviews, there was one systematic review with meta-analysis ( 51 ), 14 systematic reviews without meta-analyses ( 52 – 57 , 65 – 72 ), two rapid reviews ( 58 , 73 ), one integrative review ( 74 ), two scoping reviews ( 59 , 60 ), and nine non-systematic narrative reviews ( 61 – 64 , 75 – 79 ). Eighteen of the reviews focused on inpatient mental health settings only ( 51 , 52 , 55 – 58 , 62 – 68 , 74 – 77 , 79 ), six focused on emergency department settings only ( 53 , 59 , 60 , 69 , 71 , 73 ), and five included inpatient and ED settings ( 54 , 61 , 70 , 72 , 78 ). Eighteen reviews included self-harm and suicide as outcomes of interest ( 51 – 56 , 60 – 62 , 65 , 67 , 68 , 70 , 71 , 74 – 76 , 80 ), three reviews included self-harm only ( 59 , 66 , 77 ), and eight reviews included suicide only ( 58 , 63 , 64 , 69 , 73 , 78 , 79 ). None of the included reviews used the term ‘relational’ to describe the interventions they examined. They captured ‘relational’ approaches by either searching broadly for any intervention for assessing and/or managing self-harm or suicide risk, or by specifically investigating ‘non-pharmacological’, ‘non-restrictive’, ‘psychological’, or ‘psychosocial’ interventions. There was considerable overlap in the primary studies included in the reviews. Characteristics of primary papers In the 29 included reviews, 87 relevant primary papers were identified, reporting on 82 primary studies. 32 (39.0%) primary studies were conducted in the USA ( 81 – 114 ), 22 (26.8%) in the UK ( 80 , 115 – 136 ), 4 (4.9%) in Ireland ( 137 – 140 ), 4 (4.9%) in Germany ( 141 – 144 ), 4 (4.9%) in France ( 145 – 148 ), 3 (3.7%) in Canada ( 149 – 151 ), 3 (3.7%) in Switzerland ( 152 – 154 ), 2 (2.4%) in Australia ( 155 , 156 ), and 1 (1.2%) each in New Zealand ( 157 ), French Polynesia ( 158 ), Japan ( 159 ), Taiwan ( 160 ), South Korea ( 161 ), Spain ( 162 , 163 ), and Italy ( 164 ). One study (1.2%) had sites in Brazil, India, Sri Lanka, Iran and China ( 165 , 166 ). This shows that most of the included primary studies on relational care approaches were conducted in high-income countries, the majority in the USA and UK. Overall, 49 primary papers reported on adult samples, 20 on CYP samples, 12 on adult and CYP samples, and six did not specify the age of participants. More detailed breakdowns of sample ages by primary study are provided in Table 1 and Table 2 . View this table: View inline View popup Table 1. Overview of relational care approaches identified and their impact on self-harm and suicide-related outcomes in non-forensic inpatient mental health settings . View this table: View inline View popup Table 2. Overview of relational care approaches identified and their impact on self-harm and suicide-related outcomes in emergency department settings . Sixty-two relevant relational care approaches were identified which had been evaluated in terms of their impact on self-harm and/or suicide risk in inpatient or ED settings, across the 87 primary papers. Many of these were psychological interventions delivered at individual or group levels. However, some ward- and organisation-level approaches were also identified. The primary studies reporting on them varied in design, from RCTs and controlled studies, to pre-post and cross-sectional studies. Thirty different relational care approaches were identified from the included reviews which had been quantitatively examined in terms of their impact on self-harm and/or suicide-related outcomes in inpatient mental health settings , in 46 primary papers (see Table 1 for an overview). Thirty-two different relational care approaches were identified from the included reviews which had been quantitatively examined in terms of their impact on self-harm and/or suicide-related outcomes in ED settings , in 41 primary papers (see Table 2 for an overview). Overall conclusions of the reviews Overall, recurrent themes in the conclusions of the reviews included: a lack of high-quality evidence for the impact of these interventions on self-harm and suicide in inpatient mental health and ED settings; some interventions and their underlying theoretical assumptions and mechanisms of change are poorly described; a lack of consistency in methods and outcomes measured across studies; and a lack of lived experience involvement in the research. None of the reviews addressed how good relational care may be provided for neurodivergent individuals. This is important given that they often face barriers in accessing and benefiting from mental health care which can be mitigated with simple, reasonable adjustments ( 167 , 168 ). Nevertheless, the reviews did highlight some approaches with some supporting evidence for a positive change in key outcomes, summarised below. Inpatient settings We identified a systematic review and meta-analysis by Yiu et al. (2021) which included 10 RCTs evaluating psychosocial interventions in inpatient settings (including CBT, DBT and gratitude journalling) ( 51 ). It concluded that psychosocial interventions did not significantly reduce suicidal ideation or suicide attempts compared to controls post-intervention (95% CI = -0.38 to 0.10; p = 0.26) or at follow-up (95% CI = -0.15 to 0.59; p = 0.24) ( 51 ). However, it only included some of the primary studies identified in this scoping review, in part due to only including RCTs, whereas we included primary studies of any quantitative design. Other reviews we identified in this setting provide some evidence suggesting that the following approaches can have a significant positive effect on self-harm: adapted inpatient DBT (in 9/11 studies) ( 82 – 84 , 137 , 138 , 141 – 143 , 149 ), combined DBT and MBT (in 1/1 studies) ( 144 ), STEPPS therapy (in 1/1 studies) ( 164 ), psychodynamic-oriented crisis assessment and treatment (in 1/1 studies) ( 149 ), city nurses (in 1/2 studies) ( 116 , 134 ), collaborative problem-solving training for nurses (in 1/1 studies) ( 94 ), intermittent observation (in 2/2 studies) ( 119 , 120 ), and twilight nursing shifts with an evening activities programme (in 1/1 studies) ( 80 ). Evidence also suggests that Safewards significantly reduces ‘conflict’ events (including self-harm and suicide attempts amongst other conflict events) (in 2/2 studies) ( 123 , 156 ). There was also some evidence for a significant positive effect on suicide-related outcomes for adapted inpatient DBT (in 4/5 studies) ( 81 , 84 , 138 , 149 ), CAMS (in 2/2 studies) ( 91 , 92 ), STEPs (in 1/1 studies) ( 93 ), psychodynamic-oriented crisis assessment and treatment (in 1/1 studies) ( 149 ), insight-oriented psychotherapy (in 1/1 studies) ( 88 ), a wellness and lifestyle discussion group (in 1/1 studies) ( 81 ), a brief admission crisis program (in 1/1 studies) ( 152 ), intermittent observation (in 1/2 studies) ( 121 ), and post-discharge caring letters (in 1/2 studies) ( 96 ). Only 2/7 studies of CBT-based approaches in inpatient settings, investigating STEPPS ( 164 ) and behavioural therapy ( 88 ), showed a significant positive impact on suicide-related outcomes, the remaining studies either found no significant effect ( 85 , 87 , 89 , 115 ) or a significant negative effect ( 86 ). There was some evidence that no-suicide contracts (in 1/1 studies) ( 98 ), constant observation (in 1/4 studies) ( 118 ), and post-admission cognitive therapy (in 1/2 studies) ( 86 ) can have a significant negative impact on self-harm and/or suicide-related outcomes in inpatient settings. Emergency department settings In ED settings, there was some evidence that brief psychodynamic interpersonal therapy initiated after ED discharge (in 1/1 studies) ( 130 ) and assertive case management initiated in the ED and continued post-ED discharge (in 1/1 studies) ( 159 ) significantly reduced self-harm. Other relational care approaches either had no significant impact on self-harm ( 128 , 129 , 131 – 133 , 139 , 157 ) or their impact on self-harm was not investigated or not significance tested. There was evidence that some approaches initiated in the ED and continued post-ED discharge can significantly improve suicide-related outcomes, including: Safety Assessment and Follow-up Telephone Intervention (SAFTI) (in 1/1 studies) ( 101 ), Safety Panning Intervention with follow-up (SPI+) (in 1/1 studies) ( 102 ), brief intervention and contact (BIC) (in 1/2 studies) ( 165 , 166 ), a rapid response outpatient team (in 1/1 studies) ( 150 ) and assertive case management (in 1/1 studies) ( 159 ). There was also some evidence suggesting that the following relational care approaches initiated post-ED discharge significantly improve suicide-related outcomes: CBT-based interventions (in 2/5 studies) ( 108 , 114 ), non-directive supportive relationship treatment (in 1/1 studies) ( 108 ), brief psychodynamic interpersonal therapy (in 1/1 studies) ( 130 ), abandonment psychotherapy (in 1/1 studies) ( 154 ), Attachment-Based Family Therapy (ABFT) (in 1/1 studies) ( 109 ), the Attempted Suicide Short Intervention Program (ASSIP) (in 1/1 studies) ( 153 ), case management (in 1/1 studies) ( 161 ), and telephone follow-up contacts (in 4/6 studies) ( 145 , 146 , 151 , 162 , 163 ). The remaining relational care approaches were either found to have no significant effect on suicide-related outcomes ( 100 , 103 – 107 , 110 , 113 , 128 , 148 ) or their impact on them was not investigated or not significance tested. One study found that combined letter and telephone follow-up contacts were associated with significantly worse suicide-related outcomes compared to usual care ( 136 ). For a more detailed breakdown of primary study results for each relational care approach in inpatient mental health settings, see Supplementary File 1. For a more detailed breakdown of primary study results for each relational care approach in ED settings, see Supplementary File 2. Discussion Key findings Our scoping review outlines a proposed universal definition of ‘relational care’ and synthesises quantitative evidence for relational care approaches to assessing and managing self-harm and suicide risk in non-forensic inpatient mental health and ED settings. Twenty-nine relevant reviews were identified reporting on 62 relevant relational care approaches. Many of these were psychological interventions delivered at individual or group levels. However, some ward- and organisation-level approaches were also identified. For most of the relational care approaches included, only one primary study was identified assessing its impact on self-harm and/or suicide in inpatient or ED settings. It is important to acknowledge that none of the included reviews’ research questions explicitly used the term ‘relational care’ and they, therefore, included some primary studies that did and did not meet our eligibility criteria for relational care. Instead, the reviews within this report constructed research questions which used the terms ‘psychosocial’, ‘psychological’, ‘non-restrictive’, and ‘non-pharmacological’ approaches, with the ‘relational care’ aspects of these interventions being implicit, rather than the stated primary focus of the studies. In inpatient settings, supporting evidence was identified from controlled studies for some psychological interventions, including adapted inpatient DBT, combined DBT and MBT, CAMS, psychodynamic-oriented crisis assessment and treatment, behavioural therapy, insight-oriented psychotherapy, a wellness and lifestyle discussion group, and a brief admission crisis program. Additionally, controlled studies suggest that Safewards and post-discharge ‘caring letters’ can reduce self-harm and/or suicide. Uncontrolled studies provide some evidence for STEPPs therapy, STEPs, intermittent observation, twilight nursing shifts with evening activities, and certain staff training approaches such as ‘city nurses’ and ‘collaborative problem-solving training for nurses’. There was a lack of evidence, or mixed evidence, regarding the impact of other relational care interventions on self-harm and suicide-related outcomes in inpatient settings. Evidence from a controlled study of no-suicide contracts and an uncontrolled study of constant observation suggests that they can have a significant negative impact on self-harm and/or suicide related outcomes. In EDs, relational care approaches demonstrated mixed effectiveness. Evidence was identified from controlled studies suggesting that some psychological approaches (e.g., brief psychodynamic interpersonal therapy, abandonment psychotherapy, SAFTI, SPI+, BIC, ABFT, ASSIP, some CBT-based approaches, and non-directive supportive relationship treatment), rapid response outpatient teams, assertive case management, and post-discharge telephone contacts can have a significant positive impact on self-harm and/or suicide-related outcomes. An uncontrolled cross-sectional study provided evidence supporting a post-discharge case management intervention. Evidence from controlled studies indicated that therapeutic assessments, other psychological approaches, on-demand crisis support (e.g., crisis cards, green cards), a specialist direct service for youths, mobile crisis teams, postcard follow-up contacts, and combined crisis card and telephone follow-up contacts, do not have a significant effect on self-harm or suicide-related outcomes. Evidence from one controlled study suggested that combined telephone and letter follow-up contacts can significantly worsen self-harm and suicide-related outcomes. Overall, the identified reviews highlighted a lack of high-quality research in this area, noting poorly described interventions and mechanisms of change and inconsistent methodologies and outcome measures in primary studies. However, it is essential to consider that absence of evidence is not evidence of a lack of value in these approaches. It may instead reflect some of the challenges in researching ‘relational care’ and its impact on self-harm and suicide in inpatient and ED settings, explored below. Challenges defining ‘relational care’ As identified earlier in this report, the term ‘relational care’ is not widely used within inpatient mental health academic research. This is despite the concept having a longstanding history and underpinning many clinical approaches in mental health, including in inpatient and ED settings ( 29 , 169 , 170 ). Reviews on ‘relational care’ in a mental health context are only just beginning to emerge. For example, Lamph et al. (in prep) are conducting a conceptual analysis of ‘relational practice’, drawing upon global, cross-sector papers to report some of its key components. The concept of ‘relational care’ also extends beyond mental healthcare; it has been described and applied across a range of other contexts, including education, criminal justice, and social work. For example, in social work, ‘relational-based practice’ is seen as core to social workers’ interactions and roles, and it is also cited within a variety of mental health nursing education texts ( 171 – 173 ). Whilst the concept of relational care exists across different sectors, there is variation in how it is defined and understood by clinicians and service users. For example, different professions have different perspectives on what ‘relational care’ means and how it can be applied in their work, shaped by their professional identities and philosophical and training backgrounds. ‘Relational care’ can be understood and applied differently depending on cultural, contextual, and individual factors. This variability makes it difficult to define, operationalise and research. Challenges in defining and assessing fidelity to relational care values and principles Another challenge is to evaluate fidelity to ‘relational care’. Some fundamental components such as respect, authenticity, and shared humanity, can be difficult to measure and depend on the personal qualities of individual health professionals. It is possible that a ‘relational care’ intervention could be delivered in a way that is perfunctory and inconsistent with the values and principles that underpin it. For example, verbal de-escalation encourages staff to validate patients’ emotional responses while empathising calmly and is a part of some relational care approaches. While intended to be supportive and comforting, there is a risk that it could be experienced as invalidating or a means of “providing a kinder façade to oppressive practice” ( 26 ). This complexity can make it difficult to operationalise and evaluate adherence to relational care approaches in research. Difficulties in measuring self-harm and suicide outcomes Evaluating the impact of any intervention on self-harm and suicide rates in inpatient and ED settings is a challenge. While highly important, it must be considered that the numbers of suicides on inpatient wards remains, thankfully, a relatively rare occurrence ( 3 ). As a result, it is difficult to evaluate the impact of any intervention on preventing suicides without conducting large-scale studies on multiple wards (e.g., Bowers et al. (2008) ( 119 )). Furthermore, the nature of suicidality and reasons people may engage in self-harming behaviours, as well as self-harm methods, are vast, variable, and may change drastically over time, making them difficult to measure. It can also be challenging to distinguish suicidal and non-suicidal self-injury ( 174 ). Whilst frequency of self-injury is a crude outcome measure, accounting for self-injury severity risks creating a problematic and potentially invalidating hierarchy of methods. The private nature of self-harm also means it is unlikely to be accurately measured. More restrictive approaches may keep people safer in the short term but cause long-term harm, such as physical and psychological injury, dehumanisation, erosion of trust between patients and staff, and (re)traumatisation ( 25 , 175 ). There is a need to be person-centred when approaching these topics, as what works to help keep some patients safe may be problematic for others. There is no standard ‘one size fits all’ approach for everyone and all services. The impact of many relational care approaches on self-harm and suicide has not been researched There are many other relational care approaches used in inpatient and ED settings which were not captured by these reviews, and thus within this report, because they were not quantitatively evaluated in the academic literature in terms of their impact on self-harm or suicide. There is likely a bias in the research towards approaches such as DBT which were developed with an explicit and direct focus on reducing self-harm and suicide. It is notable that this review identified evidence supporting relational care interventions which take a less behavioural approach, for example, brief psychodynamic interpersonal therapy ( 130 ). Other therapies and approaches that also have positive effects in the long- or short-term are likely to exist, though their direct impact on self-harm and suicide may not have been evaluated in research and so they will not have been identified in this scoping paper. Approaches that have an indirect impact on self-harm and suicide, including interventions aimed at changing ward cultures and environment may, therefore, be overlooked within these reviews. Such approaches include evidence-based approaches such as Safewards ( 56 , 156 , 176 ) and the Assured intervention ( 33 ). Other approaches include Open Dialogue ( 177 , 178 ), therapeutic communities ( 179 , 180 ), and Enabling Environments ( 181 ). These examples offer valuable insights into the potential benefits of relational care interventions, values, and practices which address systemic and cultural factors affecting self-harm and suicide risk management. Barriers and facilitators to implementing relational care approaches in these settings While this scoping review found evidence for the use of some relational care approaches within inpatient and ED settings to reduce suicide and self-harm, it is important to acknowledge that consistently and effectively implementing relational care in these contexts is difficult. Whilst implementing complex interventions in any real-world setting is inherently challenging and requires careful consideration of active and dynamic factors that either facilitate or hinder implementation ( 182 , 183 ), these specialist settings introduce additional unique barriers. Firstly, inpatient mental health and ED environments are dynamic with a diverse mix of different staff, patients, and visitors, each with their unique backgrounds and personalities. There are therefore many different relationships at play, between patients, between staff and patients, and between different staff. There may naturally be variability in the provision of relational care between services, wards, staff teams, and people on different shifts. Individuals with certain personal qualities (e.g., people who are caring, kind and empathetic) may provide relational care more naturally, whereas others may struggle to engage relationally. Furthermore, an individual’s capacity to provide relational care may vary over time, for example, depending on their personal circumstances and other factors such as stress levels, burnout, and other stressors ( 184 ). Navigating the boundary between demonstrating these qualities and maintaining safe boundaries and professional limitations also needs to be considered. Secondly, providing relational care consistently in an inpatient or ED context is further complicated by the changing composition of staff and patients in these settings. Inconsistent shift patterns, high levels of unfilled vacancies (especially for registered nurses), reliance on bank and agency staff, and utilisation of more peripheral team members introduces variability. Patients themselves often have transient experiences in EDs and short stays in inpatient settings, and the NHS Mental Health Implementation Plan is aiming to reduce the length of inpatient psychiatric stays further, to a maximum of 32 days ( 185 ). These factors require careful consideration as they will impact both implementation of relational care at a personal level and influence the broader ward milieu and culture at a more ecological level. Thirdly, inpatient mental health and ED settings are complex and coercive environments. Many patients – often the majority – are compulsorily detained and may experience interventions and restrictive practices against their will, leading to diminished autonomy and limited choices. There are therefore significant power imbalances between patients and staff, which no doubt create considerable barriers to implementing an intervention based on relationship equality, particularly within a hierarchical, authoritarian system ( 26 ). Finally, it is crucial to remember that these are contexts where there are significant risks. Getting things wrong can have severe consequences, including physical and psychological harm to patients, devastation to families, and severe distress to staff. In ED settings, there is often a disproportionate focus on mental health presentations as the cause of violence and aggression. This can contribute to staff difficulty distinguishing clinical distress and agitation from actual violence and aggression, increasing staff anxiety and leading to a reliance on restrictive interventions to manage risk, thereby hindering the implementation of relational care. Front-facing staff in ED and inpatient settings who spend the most time with patients often receive the least training, are the lowest paid, and receive the least supervisory support (e.g., supervision and reflective practice). This can result in high levels of burnout and moral injury amongst staff ( 186 ). Furthermore, staff face pressure from hospital management, external regulatory agencies, and coroners to document risk assessments. This is in addition to the already substantial burden of administrative tasks, monitoring and reporting required of staff, which reduces time available for direct clinical care. These pressures faced by staff can hinder their ability to effectively implement person-centred, relational care and drive an over-reliance on risk assessment tools and restrictive practices, despite their ineffectiveness in managing risk ( 187 ). Strengths and limitations This paper offers a broad overview of the quantitative evidence for relational care approaches to assessing and managing self-harm and suicide risk in inpatient mental health and ED settings. We have presented a coproduced comprehensive definition of ‘relational care’, laying the groundwork for future research in this area. This review is the result of a collaboration of academic and lived experience researchers and clinicians with expertise in the topic of relational care, ensuring representation of diverse expert perspectives. However, this report also has some limitations. Firstly, we did not register a protocol a priori for this review. Future studies should consider protocol registration to enhance transparency and reproducibility. Secondly, due to time constraints, we did not systematically search grey literature. This may have limited the scope of the literature identified. However, many of the reviews that we identified did search grey literature (e.g., pre-print servers, Google Scholar, relevant websites, policy documents) more comprehensively. Thirdly, in line with PRISMA guidelines ( 48 ), we did not conduct any formal quality appraisal, limiting the certainty of conclusions about the strength of the evidence identified. Fourthly, although we conducted independent double screening of all sources at title/abstract and a subsample of full-texts, we did not perform formal double independent data extraction. However, all extracted data were double-checked for accuracy. Finally, qualitative evidence was not included in our synthesis due to time limitations. Further research incorporating it could provide insight into patient, staff and family/carer experiences and views of relational care approaches and, subjectively, what makes a positive difference ( 188 , 189 ). Implications for research, policy and practice The current lack of a consistent definition of ‘relational care’ poses a significant challenge for both research and practice. Future research could aim to clarify the meaning of ‘relational care’, its core components, and develop a clear framework for its consistent application and evaluation. Conceptualisations of ‘relational care’ should consider the influence of culture and context, including how it intersects with the needs of marginalised groups, such Black and ethnic minority groups, those facing language barriers, autistic individuals, and people with intellectual disabilities. This is crucial given the inequities that these groups experience in terms of access, experiences, and outcomes in acute mental healthcare ( 30 , 190 – 196 ). However, the consideration of culture and context should not be limited to marginalised groups; it should be a universal consideration for all patients, staff, services, and healthcare systems. Further research is needed to evaluate the impact of relational care approaches on quality and safety in inpatient mental health and ED settings, including more large-scale RCTs and studies evaluating long-term outcomes ( 30 ). This includes research examining the impact of relational care on self-harm and suicide, as well as on other important outcomes such as psychological safety, self-neglect, physical health, iatrogenic harms, staff safety and wellbeing, therapeutic alliance, engagement with services (e.g., length of stay, readmission rates, other service use), and treatment satisfaction. Economic evaluations taking these broader outcomes into account are also needed; cost-effectiveness evidence is important for shaping policy and practice. Further research co-produced with patients, families/carers, staff, policymakers, and commissioners is needed to ensure research addresses the priorities of these key stakeholders. Future research should also focus on understanding the barriers and facilitators of successfully implementing relational care approaches to assessing and managing self-harm and suicide risk in these settings, including consideration of training and support needs for staff. Furthermore, realist approaches could help to determine what works for whom, in what circumstances, and why ( 197 ). This could enable relational care approaches to be more effectively adapted and tailored to different contexts and populations, including those underrepresented in research studies ( 30 ). Given the complexity of research in this area there is a considerable need for qualitative studies to explore patient, staff, and family/carer experiences of relational care approaches. Personal stories from qualitative studies could help to understand how relational care can be provided authentically, rather than performatively. Whilst some primary qualitative studies were identified in this scoping exercise, synthesising their findings was beyond our scope. Synthesis of this qualitative literature, and further qualitative research, would help to understand the nuances in both the delivery and experience of these interventions. While this scoping exercise highlighted a general lack of high-quality evidence for relational care approaches, research has shown that many common practices in inpatient mental health and ED settings are not supported by the evidence, for example, structured risk assessments, no-suicide contracts, and constant observations. It can be argued that it is preferable to implement approaches based on the principles of relational care whilst continuing to develop its evidence base than continue to use approaches with evidence of harm. Conclusion This scoping review proposes a co-produced definition of ‘relational care’ and identifies supporting evidence for some relational care approaches to assessing and managing self-harm and suicide risk in inpatient mental health and ED settings, including a variety of individual-, group-, and organisation-level approaches. However, further high-quality research, including larger-scale RCTs, is required to evaluate their effectiveness and long-term impact. Co-produced research is needed to clarify the definition, core components, and develop a framework for applying and evaluating ‘relational care’. Future studies should also focus on understanding barriers and facilitators to implementing relational care and incorporate qualitative methods to capture the perspectives of patients, staff, and carers. Lived experience commentary by Raza Griffiths, Tamar Jeynes and Lizzie Mitchell This Lived Experience Commentary comes from the perspective of wanting to strengthen lived experience voices in policy research and positively impacting practice, by ensuring that research reflects the priorities service users themselves have highlighted. In this regard we would like to highlight the following points about this paper. The paper concentrates on developing the idea of ‘relational care’ and using it to assess and manage suicidality and self-harm. But the impetus for developing the idea of “relational care” does not seem to have come from people with lived experience. The idea itself is innocuous, encapsulating standard tropes about how workers should ideally relate to service users. This semantic repackaging suggests some exciting new developments, whereas in all probability, it may simply become another ‘buzzword’ to mask a lack of real change, as happened with earlier concepts like “recovery” and “trauma informed”. On a practical level, there were difficulties in reviewing literature defining ‘relational care’ differently, and using various methods of measuring, recording and evaluating services. How are staff and services meant to adhere to a standard where there isn’t a set definition? Moreover, the studies reviewed self-defined how ‘relational’ their services were, based on their own definition of services, rather than asking how we as service users rated them in terms of relational care. Even more than this: shouldn’t we as service users, be defining what the ideal characteristics of the way staff relate to us should be, rather than using a rubric on what is important which has been developed by someone else? Reviews should not be reinforcing knowledge from research studies which exclude Lived Experience voices. In its definition of relational care, the paper foregrounds interpersonal relationships, which are crucial and can be therapeutic in themselves. However, relationships exist within powerful political, systemic and cultural constraints and unequal power dynamics, which the paper does not focus on. The bigger picture needs to be addressed, including the impact of severe understaffing and long waiting lists. A key cultural challenge to relational ways of working, is the reliance on coercive practices, which sits diametrically opposite relational ways of working. Widespread and controversial use of control and restraint in inpatient services is a point of ongoing debate and campaigning within mental health, with the United Nations Convention on the Rights of Persons with Disabilities being an important rallying point for us and our allies. It argues for a move away from biomedical coercive approaches to ones which could be broadly defined as ‘relational’. But will it be possible to mainstream a relational approach in the current system, or can it only ever be tokenistic, given the nature of the mental health system? Finally, the review highlights a reduction in suicides in inpatient care between 2010 – 2020. The broader context outside wards, however, was of a steep rise in suicide, which was correlated with the financial squeeze, a more onerous benefits regime and cutbacks to mental health services. This highlights the need to focus on the wider social context, entailing joined up action from diverse organisations and central government addressing wider social determinants of self-harm and suicide. Funding details This project was funded by the National Institute for Health and Care Research (NIHR) Policy Research Programme (grant no. PR-PRU-0916-22003). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. The funders had no role in project design, data collection and analysis, or preparation of this report. Disclosure statement The authors report there are no competing interests to declare. Data availability statement All data used is publicly available in the published papers included in this study. Ethics approval and consent to participate Not applicable. Consent for publication Not applicable. Appendices Appendix A: Definitions drawn upon in coproducing a working definition of ‘relational care’ View this table: View inline View popup Appendix B: Expanded definition of ‘relational care’ co-produced by our working group of academic and lived experience researchers and clinicians Relational care can be practised at individual, group, organisational or systemic levels. It relates to how care is delivered, rather than the specific content or format of interventions. Relational care prioritises interpersonal relationships, acknowledging their central role in effective treatment and recovery. It is grounded in values such as respect, dignity, empathy, humility, authenticity, compassion, empowerment, trust, and shared humanity. Relational care is guided by principles that include: understanding individuals within the context of their lives, providing personalised and holistic care, promoting cultural safety, fostering effective communication, believing in patients and inspiring hope. It is also guided by the principle of democratisation – actively involving patients and the people close to them (e.g., family, friends, partners) in decisions about their care and the functioning of the care environment. This requires power imbalances to be acknowledged and addressed. Appendix C: Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist View this table: View inline View popup Appendix D: Inclusion and exclusion criteria for reviews in this report View this table: View inline View popup Download powerpoint Appendix E: Search strings (Psychiatri* or “mental health”).mp. (inpatient or hospital* or ward* or facility* or unit* or PICU or “136-suite” or “136 suite” or “place* of safety” or emergency department* or A&E).mp. (Intervention* or approach* or strateg* or program* or manag* or protocol* or therap* or initiative* or mileu* or environment* or anti* or prevent* or improv* or trauma-informed or trauma informed or safeguard* or protect* or precaution* or reduc* or mitigat* or secur* or risk assessment* or model* or train* or policy* or policies* or leadership* or activit* or group* or session* or practice* or treatment* or QI or project* or peer or counselling* or de-escalat* or skill* or technique* or implement* or meeting* or communit* or scheme*).mp. (Suicid* or ligature* or ligation or hang* or strangle* or strangulation* or asphyxi* or parasuicid* or self-harm* or self harm* or self-injur* or self injur* or self-mutilat* or self mutilat* or DSH or NSSI or self-poison* or self poison* or incident* or safety).mp. 1 and 2 and 3 and 4 limit 5 to “review articles” Appendix F: Excluded full texts and reasons for exclusion View this table: View inline View popup Appendix G: Table of review characteristics View this table: View inline View popup Footnotes ↵ 1 When referencing this definition, please cite this paper as follows: [add citation]. Our definition draws upon existing definitions and descriptions of ‘relational care’ in the literature ( 35 , 37 – 44 ) (see Appendix A ). An expanded definition is provided in Appendix B . Acronyms A&E Accident and Emergency ABFT Attachment-Based Family Therapy ASSIP The Attempted Suicide Short Intervention Program BPD Borderline Personality Disorder BIC Brief Intervention and Contact CAMS Collaborative Assessment and Management of Suicidality CBSP Cognitive-Behavioural Suicide Prevention Therapy CBT Cognitive Behaviour Therapy CCTV Closed-Circuit Television CYP Children and Young People DBT Dialectical Behaviour Therapy ED Emergency Department FBCI Family-Based Crisis Intervention FISP Family Intervention for Suicide Prevention HCP Healthcare Professional IISPT Interpersonal Problem-Solving Skills Training ISRCTN International Standard Randomised Controlled Trial Number LGBTIQ Lesbian, Gay, Bisexual, Transgender, Intersex, Queer or Questioning MACT Manual-Assisted Cognitive Behaviour Therapy MBT Mentalisation-Based Therapy MHPRU Policy Research Unit in Mental Health NHS National Health Service NIHR National Institute for Health and Care Research NICE National Institute for Health and Care Excellence NSSI Non-Suicidal Self Injury RCT Randomised Controlled Trial SAFTI Safety Assessment and Follow-Up Telephone Intervention SNAP Successful Negotiation Acting Positively therapy SPI+ Safety Planning Intervention with follow-up STAT-ED Suicidal Teens Accessing Treatment After an Emergency Department Visit STEPPS Systems Training for Emotional Predictability and Problem Solving therapy STEPS Steps to Enhance Positivity therapy TOC Teen Options for Change UK United Kingdom USA United States of America References 1. ↵ The Royal College of Emergency Medicine. 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