Intended for healthcare professionals

Practice What Your Patient is Thinking

I am more than a body to stitch up and label

BMJ 2021; 373 doi: https://doi.org/10.1136/bmj.n1003 (Published 12 May 2021) Cite this as: BMJ 2021;373:n1003
  1. Anonymous

This author describes the impact of self-harm and how support services have left her feeling rejected and dismissed.

I live with scars that are both highly visible and largely unseen. At the age of 16 I went on a diet so that I would feel less noticeable. I was diagnosed with anorexia nervosa and spent the next three years being re-fed as an inpatient. Since losing control of my weight, I started another secretive and self-destructive action.

Painful treatments

I started cutting my skin with a razor blade 20 years ago, at the age of 22. I did experience six years free from self-harm, during which I saw a compassionate psychiatric nurse who was consistent, listened to my story, and didn’t see me as just a label. But I still go through cycles of self-harm driven by obsessive thoughts and extreme distress.

Self-cutting is excruciatingly painful. I only attend the emergency department when cuts are bleeding uncontrollably or are very deep. I have needed many blood transfusions and iron infusions because of the resulting anaemia. The treatment for my injuries can often be worse than the pain of the original cuts, especially the local anaesthetic injections. I feel deeply ashamed and desperate, since the impact on my life is irreversible.

A lack of help

Unlike eating disorders or alcohol and substance misuse, very few dedicated services are available for self-harm, and no long term support. In my experience, non-suicidal self-injury is usually dismissed. The only healthcare intervention I can access is enduring the painful treatment for new wounds. I don’t want to consume time receiving treatment from a busy emergency department, but I also worry about infections or dying from blood loss.

Medical professionals sometimes show me concern, but there is no follow-up care or support. I cannot access any mental health services other than the one-off chats in the emergency department. It sometimes feels like they don’t want to “reward” me by showing me attention. I have been told by a psychiatrist that they cannot make it too comfortable for me to go to the emergency department or they are “enabling” me. I am made to feel that I am responsible for bad behaviour and not worth treating.

The repeated discharges are dismissive, traumatising, and rejecting. I have now asked not to be referred to mental health teams as I do not want to be subjected to brief chats covering a tick list “action plan” signposting to local helplines, which result in a dead end.

Carrying the stigma

I previously received a diagnosis of emotionally unstable personality disorder (EUPD), which I feel has invalidated my history of distress. Self-harm and EUPD both carry a high level of stigma. This diagnosis is impossible to discard or challenge and is never reviewed.

I wish there was no judgment or stigma and more concern shown towards people who self-harm, whose distress is too extreme for them to contain. The view that people cut themselves for attention should be dismissed entirely. Self-harm should instead be seen as a flag for someone needing more support. I do not expect long term input from NHS mental health services anymore, but there should at least be crisis input available for self-harm. This would then avoid further harm, and would save lives and emergency resources.

What you need to know

  • Patients may self-harm for many different reasons and the underlying distress needs careful and professional assessment

  • Self-harm requires long term support given its complexity. Knowledge of local mental health services and charities can help in decision making with patients

  • Patients who self-harm will bring expertise into how best to support them

Education into practice

  • What support could you give someone who is self-harming to help to reduce their distress?

  • How could you ensure a patient’s expertise is included when drawing up a meaningful plan together to support them?

  • How can you help someone who is stigmatised owing to their diagnosis?

Additional information

Footnotes

  • Competing interests: none.

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