Self harm and the emergency department
BMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i1150 (Published 13 April 2016) Cite this as: BMJ 2016;353:i1150
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The anonymous contributor suggests small things that may help, and of course it is often a collection of small acts or comments that flavour the experience of the individual seeking healthcare. We make no assumption about the diagnosis of the contributor but have a suggestion from our own clinical experience. It might be easier for health care staff to make a difference to those who repeatedly self-harm if they could consider the possibility that a person may act with one aim (i.e., self-injures) in a particular self-state while being remorseful or even horrified about the consequences of that action when in another self-state. When a person has had severe trauma in early life self-states can be relatively independent in their functioning and there may even be amnesia for aspects of self-harm and suicidality. Suicidal thinking, suicide attempts, and recurrent non-suicidal self-injury (NSSI) are frequently associated with Dissociative Disorders (Webermann et al, 2016), but these conditions are often not recognised by psychiatrists so it is no surprise if they are not understood or identified by non-psychiatric health care staff.
The anonymous contributor is accurate in saying that many people who engage in NSSI have experienced trauma; the more severe the trauma in early life the more likely it is to lead to dissociative symptoms and indeed to a condition such as a dissociative disorder; treatable if recognised but often missed. Dissociative disorders are the result of early life attachment disruption and later childhood sexual, physical and emotional abuse, with childhood sexual abuse being a particularly strong predictor of pathological dissociation (Dorahy et al, 2016). A compassionate response to individuals using high risk and intensely harmful methods of regulating their distress would include not just the A&E staff, but assessment from mental health services that recognise the complexity of response to early life adversity (ISSTD, 2011). This issue is neither new nor rare and sensitive services should be able to respond both acutely and also, over the longer term, offer appropriate treatment. The hope would be that people such as the anonymous contributor are helped to clear the pain trapped inside them from their early days rather than to continue indefinitely to struggle with ways of attenuating it, often with very temporary psychological benefits, and often markedly adverse physical effects.
References
Dorahy, M.J., Middleton, W., Seager, L., Williams, M., Chambers, R. (2016). Child abuse and neglect in complex dissociative disorder, abuse-related chronic PTSD, and mixed psychiatric samples. Journal of Trauma & Dissociation, 17, 223-236.
International Society for the Study of Trauma and Dissociation (2011). Guidelines for treating dissociative identity disorder in adults, third revision. Journal of Trauma & Dissociation, 12, 115-87.
Webermann, A.R., Myrick, A.C., Taylor, C.L., Chasson, G.S., Brand, B.L. (2016). Dissociative, depressive, and PTSD symptom severity as correlates of nonsuicidal self-injury and suicidality in dissociative disorder patients. Journal of Trauma and Dissociation, 17, 67-80.
Competing interests: No competing interests
This courageous and timely article serves to remind all health care professionals of their duty to treat the whole person and not the diagnostic label attached to that individual. Hope is a central plank in the journey into recovery from illness, and this is particularly true of service users with mental health needs. Where prejudicial, stigmatising care is experienced, trust in that health professional service is highly unlikely . Without that vital trust, it is so much harder for the service user to generate and maintain hope for a healthier future. All health professionals exhibit cognitive biases of one sort or another and as part of their training must actively reflect on how the resulting professional behaviour may impact positively or negatively on those they seek to treat for the better. By so doing, the outcome for their patients will improve, personal/ professional work satisfaction will be enhanced and the effectiveness and efficiency of the health care service will be greater. What's not to like?
Competing interests: No competing interests
Thankyou for this article. I have supported young people at A&E to get treatment for self harm injuries. The attitude of so many staff has been apalling and the examples quoted here ring true to my own observations in Bristol over the last 25 years.
I recently attended a Mental Health First Aid course. Some nurses on the course resisted hearing these exact same examples and displayed these same negative and punishment driven attitudes.
I came to the conclusion that training to change health workers' attitudes so that people with mental health needs can access care, must incorporate self awareness and behaviour change elements to change staff attitudes to mental health care.
Competing interests: No competing interests
I found it incredibly sad but also unsurprising to read about the author’s awful experiences of attending A+E with self-inflicted injuries. As stated, self-harm is an incredibly private affair yet when attending hospital everyone from the receptionist onwards enquires (sometimes unnecessarily) about how an injury happened. Repeatedly stating that one has self-harmed can be difficult and demoralising, especially when faced with the reactions described.
I would have very much liked to keep my self-harm private but working as a junior doctor with the ‘bare below the elbow’ rules in hospital means that this has not been possible. Since medical school I have endured members of hospital staff pointing at or touching my scarred arms and saying ‘what happened?’ or ‘looks like you’ve been scratched by a cat’. During a particularly bad relapse as an FY1 I had a surgical registrar point at my arms and laughingly ask if I cut myself in front of the rest of our surgical team. The most insulting encounter was with a midwife I hadn’t previously met who pulled down my sleeve and said ‘you should keep your arms covered.’
I hope that medical schools are changing their attitudes because an enduring memory I have is of meeting my supervisor for the first time only to be told that he didn’t think I could do medicine. I have to assume this was based purely on his knowledge of my medical problems as he had never seen any of my clinical or written work. Needless to say this was quite demoralizing, further reducing the little self-confidence I retained at that time.
The silver lining of that experience was that it spurred my determination to finish my medical studies and, despite some time out, I did. Some, more sympathetic, supervisors comment that my personal battles with depression and self-harm probably make me a better physician, enhancing my sensitivity to patients’ suffering. I hope this is true and certainly strive to make sure that patients I encounter do not have experiences such as those of the article’s author.
Mental health problems are common amongst medical students and doctors are yet my personal experiences demonstrate that there is a lack of sensitivity to this with stigma and ignorance widespread even within the healthcare system. Organisations such as the charity ‘Blurt’ are trying to change attitudes towards mental health problems but if we, the people who are meant to help those suffering, can’t even demonstrate understanding and compassion towards our colleagues and patients how can we expect the wider public to do so?
It wouldn’t be fair to imply that everyone has been unsympathetic, some colleagues have supported me through some very dark periods. Being told that it’s ok to sit down for 10 minutes in a busy shift and to have a cry on a sympathetic shoulder can make all the difference on a particularly bad day. With the pressure on NHS staff it is easy to overlook opportunities to provide this relief but the time taken to do so will not be wasted. It is the consultants and fellow junior doctors who have offered listening ears and hugs to whom I am particularly grateful.
We need to educate those treating patients with self-harm, not just about the facts and figures of the problem, but to acknowledge the distress behind these acts. Individuals seeking help must not be labelled with the stereotype of attention seekers or be treated as ‘time wasters’ or of lower priority than other patients. Although it may be frustrating to repeatedly ‘patch up’ a person only to have them return with fresh injuries days later a professional, compassionate manner is something all patients deserve from their doctors and nurses.
Competing interests: No competing interests
As the joint chair of a self harm support charity which has been working closely with local A&E departments and psychiatric liaison teams to improve the experiences of self harm treatment in A&E this article is a breath of fresh air.
Our survey of self harm treatment experiences in local A&Es in 2013 showed exactly what the author describes - that caring and compassion and appropriate physical treatment are the main things people need in this situation. A&E departments understandably have a focus on solving acute issues and frequent self harm can challenge this and feel frustrating for people who attend and staff alike.
As a result of our work we have been able to focus on small changes in local A&Es such as concrete signposting written by and for people who self harm, centralised personalised care plans and self advocacy forms at triage, as well as rolling training for A&E staff where we focus on compassion for patients and staff.
Self harm in A&E is sometimes seen as a huge challenge, but as this piece and our work show small changes can go a long way and we welcome more discussion and action in this area.
Our report and follow up survey can be found here:
https://www.sishbristol.org.uk/get-involved/improving-local-services
https://www.sishbristol.org.uk/get-involved/survey
I would also like to acknowledge our partners in both Bristol Royal Infirmary and Southmead Hospital Psychiatric Liaison Teams in supporting this work.
Naomi Salisbury
Joint Chair
Self injury Self Help
Competing interests: No competing interests
Rasamund Snow provides a frank and useful reminder about the judgements made when some health care staff meet people who self harm. I suspect that withholding analgesia is an all to common experience for this group and is more than a passive act. In effect it is a way of punishing the person for 'deliberately' inflicting a wound.
These attitudes and the sub standard care they produce are not a new revelation, Friedman and colleagues alerted us to this practice a decade ago (1).
Clearly not all wounds are equal, that needs to change. On the surface this appears a straightforward ambition but the underlying attitudes and values that underpin these judgments of those deserving and undeserving of compassionate care are likely to be a challenge to change. Quick fix remedies such as training can merely leave some staff adopting the 'correct language and approach without changing their core beliefs and approach to patient care.
1. Friedman, Trevor, Charles Newton, Christine Coggan, Samantha Hooley, Rekha Patel, Matthew Pickard, and Alex J. Mitchell. "Predictors of A&E staff attitudes to self-harm patients who use self-laceration: Influence of previous training and experience." Journal of psychosomatic research 60, no. 3 (2006): 273-277.
Competing interests: No competing interests
Re: Self harm and the emergency department
Dear Editor,
RE: Self harm and the emergency department
The stigma faced by persons diagnosed with mental disorders remains a challenge to their recovery. Too often it is recognised that the support needed from family, friends and the community is lacking in the health maintenance of these patients. Many persons turn to the healthcare system and its workers to find that needed support. But alas, here we find an account which mirrors the experience of many patients facing mental health challenges while accessing the healthcare system. Not only does the identified behaviours display unprofessionalism, it helps to highlight the deeper issue of stigma by healthcare workers.
Self-harm in itself is not considered a mental disorder (National Alliance on Mental Illness [NAMI], 2017) but has been generally classified under Non-suicidal Self-injury (NSSI). However, it is accepted that persons who self-harm are indeed facing mental health challenges and it has been associated with diagnosed mental disorders and an increased risk for suicide (Hawthorn et al, 2015; Weberman et al , 2016). The author of the article has several suggestions that would demonstrate caring and professionalism from the healthcare team. These suggestions are however expected behaviours based on the code of ethics for the health care clinicians, which makes the article quite sad.
While additional training aids in the demonstration of expected professional behaviour, what is really needed is an understanding by the healthcare workers of what these patients are actually facing. Thereby effecting change internally (which is what is needed), reflecting a more caring and professional manner. Perhaps consideration needs to be given to mandatory training in mental health care for all healthcare workers in the emergency department. But as I always tell my students there are two main considerations that we should all have in the delivery of care to our patients; our professional code of ethics and putting ourselves in the patient’s shoe. What care would I expect if I or any of my family members were this patient?
2017 March 4
Sheryl Garriques-Lloyd
sheryl.garriqueslloyd@uwimona.edu.jm
Nurse Educator
The UWI School of Nursing
University of the West Indies, Mona,
Kingston, Jamaica
References
Hawthorn, K., Bergen, H., Cooper, J., Turnbull, P., Waters K., Ness, J. & Kapur, N. (2015). Suicide following self-harm: Findings from the Multicentre Study of self-harm in England, 2000–2012. Journal of Addictive Disorders, 147, 147-151. DOI: http://dx.doi.org/10.1016/j.jad.2014.12.062
National Alliance on Mental Illness. (2017). Retrieved from https://www.nami.org/Learn- More/Mental-Health-Conditions/Related-Conditions/Self-harm
Webermann, A.R., Myrick, A.C., Taylor, C.L., Chasson, G.S., Brand, B.L. (2016). Dissociative, depressive, and PTSD symptom severity as correlates of nonsuicidal self-injury and suicidality in dissociative disorder patients. Journal of Trauma and Dissociation, 17(1), 67-80. doi: 10.1080/15299732.2015.1067941
Competing interests: No competing interests