Self-Harm and Medical Treatment

The National Institute for Clinical Excellence (NICE), in 2004 issued some guidelines on

The short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care

These include instructions such as,

People who have self-harmed should be treated with the
same care, respect and privacy as any patient. In addition,
healthcare professionals should take full account of the
likely distress associated with self-harm.
[...]
•
If a person who has self-harmed has to wait for treatment,
he or she should be offered an environment that is safe,
supportive and minimises any distress. For many patients,
this may be a separate, quiet room with supervision and
regular contact with a named member of staff to ensure
safety.
[...]
•
Always treat people with care and respect.
[...]
•
Take full account of the likely distress associated with
self-harm.
•
Offer the choice of male or female staff for assessment and
treatment. If it is not possible to give people a choice, explain
why and write it in their notes.
•
Always ask the service user to explain in their own words why
they have self-harmed. Remember, when people
self-harm often, the reason for each act may be different on
each occasion; don’t assume it’s done for the same reasons.
•
Involve the service user in clinical decision-making and provide
information about treatment options.
[...]
•
Always offer necessary physical treatments even if the person
doesn’t want psychosocial or psychiatric assessment.
•
Always use proper anaesthesia and/or analgesia if treatment
for self-injury is painful.
•
Offer sedation if treatment may evoke distressing memories
of previous sexual abuse, such as when repairing harm to the
genital area.
[...]
• Don’t delay treatment because it is self-inflicted.

There is an awful lot of info in the report, but some of the pertinent points I have listed above.

I have heard endless stories of people in A&E being refused stitches to a self-injury cut, on the basis that 'You've got so many scars already, one more won't make a difference', or 'There's no point - you'll only do it again'. Similarly with people who have been refused anaesthetic before being stitched or having other painful treatments.

These situations appall me. People who have caused their own injuries deserve just as good (physical and psychological) care as those whose injuries were accidental or caused by others. People do not self-harm for no reason - it almost always occurs within a context of intense distress and desperation, and can frequently prevent the person from further harm (for example, suicide attempts) by releasing some of the pressure before it boils over.

People who need treatment for self-harm injuries are likely to be feeling dreadful, full of their own inner guilt for needing treatment, and very possibly feeling quite vulnerable. They do not need doctors or nurses or ambulance staff to reinforce their own feelings of self-hatred or to imply that they are wasting people's time.

I cannot talk for everyone who self-harms, and I also do not want to downplay the incredible sensitive and appropriate treatment offered by many medical staff. There are people who self-harm who won't relate at all to what I say, and there are doctors, nurses and ambulance staff who do brilliant work. There's no doubt about that.

However some people are treated appallingly, and this only leads to the person who has self-harmed to feel even worse about themselves, and further self-harm feels more appealing because they have had all their worst fears and feelings confirmed.

So, where am I going with this?

Well, there are cases of blatantly bad treatment (being refused stitches when they are needed, not using local anaesthetic where it normally would be used, derogatory comments by staff etc.), and these are easy to criticise. But there are also many, many occasions when someone who has self-harmed gets bad-mediocre treatment, but it is hard to know what the motivation behind the not-really-caring is.

I needed treatment the last couple of weeks for a burn. I went to a GP, who asked the Practice Nurse to dress it. The nurse's treatment was, well, lukewarm to say the least. She dressed the burn very badly - using inadequate dressings and suggested no follow-up at all. I needed to go back 2 days later because of the state of the dressing and the injury and although she dressed the injury better than the first time, it was still very careless, unnecessarily painful and there was no plan for follow-up again.

I came out of both of these encounters very upset, especially the second one. I was spinning between 'I deserve better treatment than this' and 'Why on earth should I expect decent treatment? It's my own stupid fault anyway'. On top of that, I really didn't know whether the nurse didn't treat me well because my injury was self-inflicted, or whether she was actually just quite incompetent and not very interested in general.

I still don't know the answer to that, but the following week I saw a different nurse at the practice, who dealt with my injury competently, and was actually nice to me. It made a huge difference to how I felt when I left the surgery. I didn't feel full of self-hatred, full of self-loathing, full of self-directed anger.

I have that age-old double standard. I believe, without a doubt, that people who have self-harmed deserve and require treatment which is as good as people who have injuries which were accidental or caused by someone else. However, when it's *me*, I of course don't deserve a single nice word or a dressing which actually deals adequately with the wound. I am stupid and a waste of time, though noone else is!

I really don't know if I got sub-standard treatment because the nurse wasn't up to speed on burn dressings, or on 'bedside' manner, or whether it was because she didn't want to deal with a self-inflicted injury, or didn't think it deserved time and treatment, or indeed deal with someone who could self-injure.

All I know is that I came out of the appointment with the second nurse feeling much more positive and capable and listened to. I'm no expert on dressings, but even I knew that the first two were inadequate. I came out of those appointments feeling disgusting and loathsome.

I do believe that in terms of avoiding future self-harm, feeling positive and capable and listened to is certainly a better place to start!

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