I have only been to A&E once because of self-harm and would not bother to go again unless I was seriously dying – and then not from self-harm

The desperate words in the headline come from Maria Johnson*, one of the 170,000 people each year who go to hospital because of injuries sustained in a self-harming episode.

The UK has one of the highest rates of self-harm in Europe yet many people who attend accident and emergency departments complain of victimisation, including abrupt and patronising attitudes from staff and cuts being sewn up without anaesthetic.

Johnson continues: “The one time I did go was because I had been self-harming all evening and had scared myself by cutting more and deeper than ever before.

“At A&E I was taken to a relatives’ room. A doctor came and asked to see the cuts which were about a quarter of an inch deep on my upper arm. They were gaping but had stopped bleeding. He poked and prodded them and said they did not need stitches but would leave scars. And boy did they – huge keloids all over my arm. I’m sure that if the cuts hadn’t been self-inflicted they would have been stitched. I was given nothing for the pain, and not even an antiseptic wipe for the cuts. I was then left alone until the crisis intervention team could see me. That wasn’t until 7am, even though I had arrived at A&E at 3am, and in the end no help was offered because I am a university student and do not live in the right area.

“When I was finally let go at 10.15am I was exhausted. I had not been offered any water – I had to ask twice and all I got in seven hours was two half cups – I was dehydrated. I had been left alone for hours and was not given a bed. Instead I had to sit in an uncomfortable seat despite it being the middle of the night and A&E not being busy.

“I felt judged and dismissed, like I was a nuisance, pathetic, a liar and totally worthless – someone who wasn’t even worth a bed. When I got back to my university room I called in sick and self-harmed again because I felt so useless and such a waste of space. I felt guilty for going to hospital, as if I had wasted their time.”

Despite guidance from the National Institute for Health and Clinical Excellence1 stating that people who have self-harmed “should be treated with the same care, respect and privacy as any patient”, service users say they are still maltreated.

Social worker Robin Spencer knows the score only too well. He has worked with clients – mainly young people – who self-harm for the past 15 years, and has often accompanied them to A&E.

He says: “I’ve been shocked by the coldness of the people who have dealt with them. It’s like they’re hardened to it and feel that the person has brought it on themselves and doesn’t deserve sympathy or nice treatment. They take the attitude that the person is an inconvenience who is taking away resources from people who really need help.”

Long waits for treatment are the norm, he says, recalling how he once sat with a client for three and a half hours. “By then the blood was starting to congeal and the wound was healing on its own,” he says.

Some people become so exasperated they give up and go home without treatment.

Although Spencer has heard medical staff make flippant comments, he can understand why some have negative attitudes.

Spencer, who now works for a housing project in Bristol run by children’s charity NCH, says: “Professionals aren’t exempt from stereotypes. People live in the real world and come into a profession with a whole load of baggage. Those who deal with people cutting their wrists time after time form an opinion about what it’s about and spend less time trying to find the causes.”

Inadequate training
What many staff may not realise, however, is that the way they interact with people who self-harm could help sustain the problem. Research has shown that patients who are treated in a hostile and uncaring way are more likely to self-harm again.2 Sometimes they pull out their stitches before they have even reached the hospital exit.

This, combined with the fact that one in 100 people who attends hospital because of self-harm commits suicide within a year, begs the question as to why medical staff are not better equipped to manage these patients.

Mike Hayward, the Royal College of Nursing’s professional adviser for acute and emergency care, says that for nurses the problem is inadequate training. “Self-harm is touched upon but it is vying for its place in general courses,” he says. “They get an overview but not the level of education that is helpful and appropriate for front-line clinicians. The whole area of mental health, suicide and self-harm is not as well understood as it should be.”

Hayward worked in A&E for several years, and still spends time on the front line once a month. He has seen colleagues behave unsympathetically to people who self-harm, but is adamant that only a minority have negative views.

Yet in a busy inner city A&E department it is perhaps understandable why regular self-harmers can become labelled as attention-seeking timewasters. From a nursing perspective, however, everyone’s needs are as important, says Hayward. “Someone who self-harms who is presenting for the fourth time in a week is as important as someone who cuts themselves with a Stanley knife when laying a carpet.”

And, as he points out, negative attitudes are not just the preserve of nurses. “This is not just a nursing thing. It goes across all health care professions. Also, your average Joe public in the waiting room sees people who self-harm and is intolerant.”

To challenge the stereotypes may be a job for social care. After all, the sector does have a wealth of experience in dealing with the issue.

Cath Holmstrom, who teaches social work students at the University of Sussex, and has fostered young people, suggests inter-professional training where social workers can showcase the views of service users. But she warns: “Trying to teach medics might not go down that well. In inter-professional practice there’s often a hierarchy of whose views are listened to more, and often medical views are accepted more. Social workers being actively involved in local workshops incorporating service user perspectives is a more effective and creative way forward.”

Social workers must also speak up in multidisciplinary settings, she says. “Social workers need to have confidence in their own perspective and be clear that theirs is valid, which can be difficult in medical-based settings.”

This is something social worker Lucy Titheridge tries to do daily. She is a children’s services assistant team manager employed by the London Borough of Sutton but based in a nearby hospital.

Her team talks to the medical staff to help them understand young people and at least once a day she visits the wards where she initiates conversations about self-harm and challenges staff assumptions.

Reciprocal education
Alongside this daily face-to-face approach, Titheridge also sees the potential in more formal training arrangements. All the hospital staff have child protection training and she feels there is an opportunity in those sessions to talk about self-harm. However, she feels that educating other professionals would have mutual benefits.

“Social workers do have a part to play in educating other professionals but, equally, other professionals need to educate social workers. Social workers have an understanding of self-harm because they come across and deal with it, but at the same time there are youth workers who are educated about it.”

Who does the educating or how it is carried out is irrelevant; what matters is that attitudes are changed. People who self-harm often feel ashamed about what they are doing to their bodies; the last thing they need is for their feelings of worthlessness to be multiplied by the very people they go to for help. CC

* Not her real name.

(1) Self Harm, Clinical Guideline 16, National Institute for Clinical Excellence, 2004
(2) “Self harm: cutting the bad out of me”, Qualitative Health Research, Vol 10, No 2, March 2000

Treated differently