Dealing with the hurt

There
are thousands of people who deliberately harm themselves every year. But
because of the stigma surrounding self-harm, its underlying causes are often
left untreated. Anabel Unity Sale reports.

Angela
Smith was 16 years old when she first used a razor to cut her arm. She is one
of many thousands of women and men who regularly hurt themselves, but receive
little understanding or help from health and social care agencies.

Angela
continued to self-harm until she was 22, then stopped for 12 years before
starting again in her thirties. Now aged 42, Smith admits self-harming is
something that will always be part of her life regardless of whether she
actively does it or not.

She
explains: "I self-harm to deal with my intolerable distress and because I
am unable to articulate my inner pain." After she cuts herself she
immediately feels relief. "I have a completely overwhelming, desperate
urge to hurt myself. Once I have done it I feel much calmer and because I have
been hurt I can then comfort myself."

Deliberate
self-harm takes many forms. It includes cutting, piercing, burning, bruising,
breaking bones, hair pulling and swallowing medicines and poisons. While it can
sometimes be a prelude to suicide, there is no direct link between self-harming
behaviour and suicidal behaviour.

Each
year an estimated 100,000 people are referred to hospitals in England and Wales
for self-harm, mainly because of drug overdose or physical injury;¹ and
it is one of the top five causes of acute medical admissions in the UK.²
Shocking as these figures are, what they do not reveal is the number of people
who self-harm without seeking hospital treatment.

So
why would someone want to harm himself or herself? Jan Sutton, a counsellor,
trainer and author on the subject, says the reasons are complex and diverse.
"Self-harm is fundamentally a coping mechanism, much like excessive
consumption of alcohol or drugs, and incredible as it seems it makes people
feel better," she says.

Angela
Smith, who is also chairperson of self-help and campaigning organisation the
National Self-harm Network, agrees that self-harming is a coping mechanism. She
says: "It is about making yourself feel better, it is not about affecting
others."

Head
of service users’ initiatives at the Mental Health Foundation Alison Faulkner
believes a person’s decision to self-harm is related to "a deep sense of
worthlessness".

She
says: "It is about individuals’ inability to express their feelings and
emotions. They drive them inside until they are forced out and expressed
through self-harm."

Faulkner,
too, self-harms. She first cut herself when she was 19. Although she avoided
self-harming for 15 years until a few years ago, she admits it is a strategy
she may use again. "I will never rule it out. I think I understand myself
now to be vulnerable to major life events."

It
is fair to expect that staff dealing with self-harmers to do so in a
professional and understanding manner. Unfortunately this is not always the
case, according to Faulkner. "Some hospital staff think because you did
this to yourself you are wasting health service time and money."

Sutton
too has come across cases where practitioners have responded to people seeking
treatment for self-inflicted wounds insensitively. She alleges that there has
been an instance of a self-harmer’s wounds being stitched without anaesthetic
as a form of punishment.

She
says: "Some professionals mistake self-harm for a failed suicide attempt
or label self-harmers as attention seekers, time wasters, manipulators or as
untreatable."

David
Owens was working as a psychiatrist in an accident and emergency department
when he heard anecdotal evidence about staff treating self-harmers "rather
shabbily". Now a senior lecturer in psychiatry at the University of Leeds,
he explains: "There was some kind of resentment from staff about the
things people did to themselves when there seemed to be other patients with
illness that were not self-inflicted."

He
says the arrangements for psychiatric assessments and the follow-ups of people
admitted to hospital for self-harming were also poor. Junior psychiatrists were
assigned consultations with people who self-harmed without adequate training
and were expected to squeeze them into their demanding schedules.

Owens
has just completed the first part of a research project on behalf of Leeds Mind
into the experience of people who visited hospital after self-harming. The
research was in part promoted by his earlier experiences and its final report
is due out in a year’s time.

Last
year, Mark Johnstone developed and facilitated a self-harm group for men in
Liverpool for the Young Persons Advisory Service. Staff he met through the
project were unaware of constructive practice on the subject. "The word I
have often encountered when discussing self-harm with professionals is
helplessness," he says.

So
what is appropriate good practice for health and care workers dealing with
people who self-harm?

Owens
believes social care professionals can encourage their colleagues in the NHS to
develop more effective ways of dealing with people who self-harm. He says:
"They can push the NHS to be more careful in working with self-harmers who
go to hospital. Just physically patching people up is not good enough. Patients
need an assessment so they can be pointed towards the appropriate help they
need."

Smith
says it is important that health and care staff listen to people who self-harm
and accept it is something they feel they need to do. She says: "Do not
condone it but accept that people are going to do it and don’t be too alarmed
by it. Staff are sometimes frightened that someone is going to cut an artery
but they are not likely to." She recommends additional training for
practitioners on how to work more effectively with people who self-harm.

Johnstone
believes the stigma attached to self-harm prevents people from disclosing it to
professionals and hinders attempts to address the problems that may have given
rise to self-harming.

And
not pre-judging someone who self-harms is essential. Sutton says: "They
deserve to be treated with the same care, sensitivity, and respect as people
who present with accidental injuries or who have experienced a traumatic
experience."

Sutton,
who also runs a website dedicated to self-injury and related issues, argues it
is essential professionals build a trusting and equal relationship with someone
who self-harms. They need to establish a safe and therapeutic environment so
the individual can feel comfortable about discussing their self-harming.

Coercing
a person who self-harms into stopping will not work. "It should be a
personal choice and alternative coping strategies need to be firmly in place
before a reduction in self-injury can be hoped for. Any attempt to take control
may drive the client away," she says.

Unless
an alternative strategy can replace self-harming it is pointless trying to stop
people deliberately hurting themselves, Faulkner says. "Saying a person
has to stop self-harming before they get treatment makes them feels worse if
they self-harm again. The situation can get out of control."

As
self-harm is a form of control, she says it is about finding ways for the
individual to feel more in control. Enabling a person to find ways of dealing
with their feelings, which could include counselling and therapy, helps to
achieve this.

Helping
an individual to manage their self-harm, she says, is vital, and the National
Self-Harm Network has produced a workbook for self-harmers to help them
minimise damage.³

Although
most people cannot imagine deliberately harming themselves, health and care
workers must accept that for some this is a frequent occurrence and the
services they provide do not always help self-harmers address this. 

–
The National Self-Harm Network can be contacted at PO Box 16190, London NW1 3WW
or at www.nshn.co.uk  Jan Sutton’s website for people who
self-harm is www.siari.co.uk 

¹
Lisa Bird and Alison Faulkner, Suicide and Self-Harm, The Mental Health
Foundation, 2000

²
NHS Centre for Reviews and Dissemination, "Deliberate Self-Harm" in Effective
Health Care, University of York, December 1998

³
E Dace, A Faulkner et al, Hurt Yourself, National Self-Harm Network,
1998