Saturday, February 25, 2006

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

Always treat people with care and respect.

Take full account of the likely distress associated with

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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L said...

Hey Hippie,

This was a really interesting and sensitive post. I used to self harm, but never badly enough to need medical attention, and I hadn't realised that it often wasn't taken seriously by medical staff - how appalling. It's not as if the self harmer thinks 'hmmm, how can I waste some valuable hospital time today - I know, I'll cut my arm up for no reason whatsoever other than to get their attention' - as you say, there are deep underlying reasons why people self harm, and injuries should be taken just as seriously as 'accidental' ones. The guidelines look good, though, let's hope they become more thoroughly adhered too.

And I know it prob won't make any difference me saying this, but I'll say it anyway: you're not stupid, not a waste of time, and deserve oober wonderful treatment and lots of tender care :-)


Laura xx

The Goldfish said...

In a sense I can sympathise with medical staff who spend a lot of time dealing with the aftermath of indiscriminate accidents or illness, then having a problem with those who they imagine had a clear choice in the matter. For example, if I was a nurse, I would be far less sympathetic with the patient who broke his arm in a drunken brawl than the patient who was knocked off his bike.

However, the care that is currently given to people who self-harm or even attempt suicide is completely counter-productive. These are manifestations of illness; in the same way that my poor co-ordination means I sometimes walk into walls. And if I ran the world and someone came into an A&E with self-inflicted injuries, I would be looking not only to treat those injuries to the best possible standard, but also to start putting in place mechanisms to stop it happening again; providing counselling and psychiatric referrals if need be.

The absolute last thing you do is give such a person more ammunition to fire at themselves and yet that is exactly what folks all too often receive.

I reiterate Laura's comments about the quality of this post; well done. I also wish you all the best in getting through all this crap. If it is any help, I wrote something about dealing with episodes of anger and frustration here.

Take care of yourself.

Anonymous said...

It seems totally hypocritical that medical staff respond this way to self-harmers, but are presumably ok with people who come in with sports injuries. After all the people who hurt themselves playing football or skiing or whatever were doing it just for fun, whereas if you self harm, it's very unlikely you're doing it for enjoyment, rather than because they are coping with their situation the best way they can.

In any case, surely it's the responsibility of doctors and nurses to provide appropriate care to all patients, regardless of how they feel towards the person, or who's fault the injuries were. Also how do they imagine that treating an already vulnerable person so badly is going to help them in any way?

Lucy said...

hey hippie,

i agree with you. having self harmed for masny reasons and many times needing medical attention i am completely with you for how the difference of how you are treated can make a big impact on how you feel afterwards.

strangely with m its the same nurses that have changed, but insstead of getting annoyed that i keep coming back time after time. originally when i started they were horrible, and couldn't understand why i kept doing it, now i think after talking to me, being in on some psych assesments they seem to understand.

thinking of you

Anonymous said...

"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."

Which sort of figures - i tend to think that anyone who has that attitude to themselves wouldn't be self-harming in the first place.
Also, i agree with Goldfish's point on sports injuries.

TP said...

I support what others have said in that people who self harm deserve as much can and compassion as everyone else, perhaps more because if additional support is available it should be offered.

I hope your burn heals ok.

vapid ness said...

Hi folks,
I work in the health service in a non-clinical post- my job is to direct patients to the appropriate nursing staff who triage and arrange clinical help for the patient if it's needed.

Since I started this job in November, I have to say, as an ex- self harmer (for the minute, anyway, 24 years and counting) that I have been hugely impressed by the way that people who self harm are treated.

Clinical supervisors have always been very helpful when a nurse is not available right at that minute, and all the policies and procedures direct us to treat all patients with the dignity and courtesy they deserve, regardless of their current problem.

I'm not saying that there might not be exceptions that I'm not aware of (particularly in branches of the service in other cities), but they would be the exception, and they would get a hard time from colleagues, not just supervisors.

I'm not just saying this to rave about how wonderful the place I work is- (although I came here because it has a really good reputation for the way it treats staff, and I'm really pleased to see that the reason it does so is to ensure good service to patients/clients)- I'm saying it because it is unacceptable for anyone to be treated in the way hippie has described, and I hope to encourage anyone who is treated like that not to believe that it reflects on them personally. It reflects on the health professional treating them- if they behave like that, they are out of order, they know they are out of order, and should be prepared to face the consequences of their actions.

Understandably, anyone treated like this is not going to be at their most confident. But if anyone does feel up to it, I would strongly recommend recording as many details as possible of what happened, and pass the information on either to the relevant health board, community health council, patient advocate, or whoever they feel comfortable with. Maybe other readers could come up with suggestions relevant to their particular area- not all health authorities are arranged in the same way- but most have some department or allocated person to act as patient advocate, who is meant to be neutral and will help you go over any problems you have had with treatment or staff, and advise you on what can be done.

Shitty attitudes are being got rid of, slowly but surely- not fast enough, i know, but anyone who feels up to helping by reporting how they've been treated would be helping out other people as well as themselves. Just do a bit of reasearch first and make sure the person you speak to is reliable and neutral- there are a few patients rights groups out there who should be able to help you decide who to go to.

Unfortunately there are still a few people in management positions in some organisations who are less than sympathetic, and you don't want to make yourself feel worse by speaking to one of them.

All the best to everyone, virtual hugs to everyone who needs 'em, and I hope if you're needing help, you come through to someone I work with rather than a bastard like those described above.