In total, 34 participants completed the interview, consisting of 9 psychiatrists (3 females and 6 males), 10 psychiatric nurses (9 females and 1 male), and 15 parents (11 mothers and 4 fathers).
The professional experience of the psychiatrists ranges from 11 months to 8 years. Psychiatric nurses included qualified nurses (n=9) and an advanced practice nurse (n=1). The professional experience of nurses in the mental health setting ranges from 1 month to 15 years. Most of the psychiatrists (55.6%) and psychiatric nurses (60%) hold bachelor’s degrees.
About 50% of parents have a high school education or above, and 73.3% of families live in cities and towns. Four participants were divorced, and 1 participant was widowed. Regarding the children, it was found that 12 adolescents had been diagnosed with non-psychotic major depression and 3 adolescents with non-psychotic bipolar disorder according to the International Classification of Diseases 10th Revision (ICD-10). They came to the hospital for treatment due to suicide attempts/behaviors or repeated self-harm. Among them, 10 adolescents had self-harm behaviors and 5 adolescents had suicidal behaviors or suicidal attempts.
Theme one: staff perceive patients with SRBs as difficult to engage
Feelings of helplessness
Many participants reported that they feel powerless, mainly because everyone's disease is heterogeneous and the treatment is not effective for everyone. At times they feel that some of the treatments they do are futile. In addition, patients are not cooperative enough.
“It's when you want to help a patient, but it feels like sometimes you can't help her, there is a feeling of powerlessness…” (Nurse, p11)
“…But sometimes they may have many strange reasons to hurt themselves. I don't know how to help him…” (Nurse, p10)
Other participants mentioned that their sense of achievement feels exceptionally low. Unlike patients with physical illness, some patients do not feel sick and therefore think they do not need treatment. Moreover, some treatments do not have an immediate effect on them, and their hospitalization is long but ineffective.
"The patient doesn't understand and doesn't think he is sick, so his desire for treatment is not high, and then the doctor's sense of accomplishment is relatively low." (Psychiatrist, p5)
“…I sometimes go to speak with patients, but there is no obvious effect for many times, and the patient's condition is not good. Then he couldn't understand what you were saying and couldn't follow your instructions, so I felt frustrated…” (Nurse, p10)
A few participants felt distrustful, making it difficult for them to communicate effectively with patients and gain a deeper understanding of what parents really think.
“…They don't want to communicate with people he doesn't trust, so they don't tell us exactly what he thinks. We can't collect all the information, and what we know is one-sided…” (Psychiatrist, p1)
“…Mistrust, especially at the beginning of hospitalization, because the effect of the drug has not yet been achieved, they think that the treatment may not be effective, so they will not trust us at that time…” (Psychiatrist, p2)
The need for compassion
Most participants mentioned that medical staff with patience, love, a calm personality, and a certain degree of discrimination and empathy are more qualified for working with SRBs adolescents.
“…I think this job requires a well-balanced personality, otherwise the problem will not be solved, and it will be more serious…” (Nurse, p13)
“…should be stronger inside and have the ability to distinguish, otherwise you will be led by the patient. Love and empathy are also required.” (Nurse, p11)
Challenges of professional self-efficacy
Many participants said that working with teenagers who display SRBs requires strong communication and professional skills, and mastering these skills is a challenge.
“…We have to learn communication skills, and then learn some psychological counseling methods to empathize with patients, which is very difficult to learn…” (Nurse, p16)
“…I don't think I have enough ability. I have too much professional knowledge to learn…” (p10)
In addition, due to the recurrence of diseases, getting along with patients will encounter some challenges. There are many uncertain factors and the risk of accidents is high.
“…Compared with other patients, these patients have a higher risk of suiciding…” (Psychiatrist, p4)
“…For some patients, they don't want to talk to us at all, and they even don’t want to nod and shake head. I just feel like I can't get into his heart…” (Nurse, p11)
“…The patient may feel that I do not understand him or that the age gap is large…” (Nurse, p12)
A few participants mentioned that the lack of social recognition and acceptance of psychiatric patients is a major challenge. It is difficult for these patients to return to society after discharged.
“…The whole society still has a certain prejudice against mental illness. They cannot get social approval and support…” (Psychiatrist, p3, p4)
The recommendations to the health care service
Many participants mentioned that the department is understaffed, so there is less time to communicate with patients and their families, and the attention to patients may not be timely enough. They suggested increasing staffing and optimizing the division of labor.
“…There are too many patients in the department and too few medical staff. When a patient appear s suicide or injures himself, we sometimes fail to detect it in time….” (Psychiatrist, p6)
“…We do not have much time to communicate with patients and solve some of their psychological problems. Understaffing is a factor, and the second may be the division of labor is not optimized…” (Nurse, p14)
In terms of treatment, it is recommended that a complete set of treatment modes specifically for SRBs be developed with individualized treatment methods. In addition, at present, psychiatrists and nurses are mainly responsible for treatment tasks, and psychotherapists are in great need.
“…For self-harm and suicide, there is currently no perfect system of treatment mode. The main treatment now is drug treatment and communication, etc. It still has a lot of room for development…” (Psychiatrist, p1)
“…I think there is a need for personalized treatment plans because the group therapy we are doing now is similar to health education…” (Nurse, p10)
“... Our hospital also has psychotherapy, but it is usually implemented by nurses rather than professional psychotherapists. Some nurses also do well, but there is still a mixture of the good and the bad in the area of psychotherapy…” (Psychiatrist, p1)
Some participants believed that supervision and training on SRBs are also needed. Communication skills and psychological intervention methods could be taught more professionally, which could help to dispel their negative emotions.
“…I think we need a professional psychotherapist to supervise us. Now we are just exploring some communication skills and psychological intervention methods ourselves…” (Nurse, p12)
“…I think more training on self-harm can be carried out in the future…” (Nurse, p13)
Theme two: parents not satisfied with the existing hospital services
Doubt the hospitalization treatment
Most participants reported that medical staff were busy and communicated little with them and their children; therefore, their understanding of childhood mental health diseases and the treatment mechanisms were limited. Furthermore, it was felt that the medical staff focused on patients with more severe illnesses, and patients with mild illnesses were not treated equally.
“…I feel like they just come in the morning and ask if they have any questions. No one went to chat with my child or to communicate with her…” (Mother, p23)
“…Psychiatrists and nurses don't make enough rounds and careless. I think they can communicate more with patients and enlighten their minds…” (Mother, p24)
Some participants doubt the intervention due to the severe side effects of the drug. Furthermore, a few participants believed that their children's behavior is not a natural manifestation but a response after treatment.
“...After taking this medicine, she has obvious symptoms of nausea and vomiting...” (Mother, p38)
“...I feel like she's a little more excited now. Because she wouldn't do that kind of intimate behavior to me before, but she would do it deliberately now...” (Mother, p34)
Other participants mentioned that there are limited treatments administered in hospitals, including drugs, physiotherapy, and group therapy. Moreover, children are not willing to do physiotherapy and group therapy because these treatments are uncomfortable and ineffective for them.
“…A treatment that shook her ears, she didn't want to do it and said it was uncomfortable…” (Mother, p20)
The advice to the health care service
In terms of treatment, many parents mentioned that the existing treatment is relatively simple and hoped to increase psychotherapy.
“…At present, it is mainly medication, and I think it still needs spiritual communication. At the psychological level, it is necessary to do some intervention and guidance…” (Mother, p25)
In addition, parents hoped that psychiatrists and nurses could communicate more effectively with their children in order to better understand their ideas. Many parents expressed concerns regarding how to get along with their children in the future, hoping that psychiatrists or nurses would give them guidance on parenting.
“…I think they need to communicate more with the kids. Psychiatrists and nurses may be more likely to communicate with my daughter than we are. After they know it, they can teach me how to communicate with her…” (Mother, p23)
“…For example, when you encounter such a situation, how do I communicate with her because she has to go to school and she is not willing to go to school?...”(Mother, p38)
Some participants said that they did not have a professional mental health care institution in their place of residence, so it was difficult to register and hospitalize their child.
“…I tried to register from August 27, and I couldn't register in the hospital until September 18. Then, we have been waiting for a bed from September 18 to October 9th…” (Mother, p32)