Harming the self-harmed

Photo by Reza Hasannia on Unsplash

(Un)professional treatment of self-harming patients is a sad reality

It is almost always an unnecessarily complicated experience for psychiatric patients to interact with non-psychiatric departments - especially the ER - when the underlying reason for the visit or consult is a psychiatric condition. And it’s my own colleagues, the medical community, who are to blame. We are harming the self-harmed.

(note: all patients mentioned have given consent to share their stories and are anonymized)

The pandemic hit us all hard. Personally, I had the somewhat fortunate experience of being admitted to a psychiatric ward. Fortunate, because as a medical professional myself, this was a unique opportunity to witness the system from the inside. Most importantly I got the opportunity of talking with fellow patients, not in the setting of a medical interview as I usually do, but as a conversation between individuals. Naturally, it was near impossible to close down the ‘medical student’-part of my brain, so admittedly I used this opportunity to gain insights into how patients with varying degrees of illness, from nearly the whole psychiatric spectrum of conditions, experience and interact with the healthcare system and the people who are there to help them get better.

This piece is not about the psychiatric departments. That is a topic for another day, although I will mention, at least where I was admitted I met some of the most caring and dedicated nurses and doctors. (and I’ve met quite a few!)

No, this piece is all about what mental health patients experience when they are forced to interact with all the other hospital departments as a result of their psychiatric condition(s). After witnessing multiple dramatic and literally traumatic episodes, I began talking with the people who lived through it all, to understand their points of view. In the following text, I will share the experiences of three patients (A, B & C), in their interactions with non-psychiatric healthcare personnel following episodes of self-harm where emergency treatment was a necessity. I do this in the hopes of giving everyone, and first and foremost my medical colleagues, an insight into the world of the self-harming patient, as well a list of advice on what MUST happen, what SHOULD happen, and perhaps most importantly what should NOT happen when interacting with psychiatric patients who are self-harming.

Understanding the setting

Doctors and nurses working in the ER will often encounter patients, who for some reason have been self-harming on such a level that it requires medical attention. This is something I experienced first hand as a second-year medical student. During a single week of evening/night shifts at the ER of a small town remote hospital, I basically learned how to become an expert in suturing superficial wounds thanks to two patients who I came to see every single night of that week (and one of them, multiple times in the same shifts due to her cutting open the sutured wounds). Therefore it was no surprise when B told:

By now I know the color schemes and paintings at every single ER in the city. (…) I felt… I feel, it’s incredibly difficult to show up in the ER with self-harm. I always think that the nurses are staring at me like: “Oh, there she is again”. It was… it is humiliating and shameful. I always feel ‘in the way of the other patients’.

Likewise, A explains:

I always feel inferior. My self-esteem is already low, but it hits rock-bottom. It’s at an absolute zero. It’s not even by my own choice. I didn’t ask for the treatment, but it’s not my decision, not under my control. Just like I can’t control my self-harming.

Hearing and rereading these anecdotes gave me the chills. Seeking medical attention, or getting medical attention, should never be something that worsens someone's condition. Physically or mentally. We are not here to kick people while they are down, we are here to reach out and help them back up on their feet.

Here is, based on the conversations with A, B & C and my own experience in the clinic, a list of advice for non-psychiatric medical professionals on what MUST be done, what SHOULD be done, and what NOT to do, when dealing with cases of self-harm:

The ‘MUST’ be done

· Speak with the patient
The emphasis here is on the word speaking with, not speaking to. Make it a conversation. Ask the patient about the circumstances, although not in a clinical matter only regarding the self-harm incident. Meet the patient at eye level and with a non-disease focus (move the focus from the physical injury, in a caring manner).

· Show compassion

· Treat the patient no differently from you would treat a patient with a similar injury from a non-self-harm related incident
As A recalls:

The classic case is the doctor chooses to skip the local anaesthetic, even for larger wounds. “If I can cut myself, then getting some stiches shouldn’t be problem” or “This ought to teach me a lesson for cutting myself”.
Well I might had been able to cut lots of deep cuts on my arm, but it occurred in relation with the toxic redemptionary satisfaction that self-harm provides. That was an hour ago, now I’m sitting in front of you embarrased, in pain, oversensitive and in total regret. And you choose to punish me for my own mental disease. Guess what, it didn’t help. I didn’t, or rather, I couldn’t just stop self-harming just because you caused me more pain.

B shared an interesting anecdote:

Once I had come to the ER for the sixth time in two days. My foster parents were fighting and yelling, yet again, and everytime it got out of hand, I would cut myself and they had to stop fighting to drive me to the ER. It was my way of breaking it apart before it got violent. On the sixth visit the young doctor got creative and asked the nurse to put a plaster cast on my left arm, so I couldn’t cut myself again. The fighting continued at home, so I had to smack my head in the wall instead. And so I was back at the ER, with much more pain and problems, than simple cuts on my arm. It was a deeply misunderstood help from the doctor.

B is partially aware that self-harm was and is the wrong way of crying for help. As she puts it:

At times I have a hard time believing that anybody would believe me or think I am in need of help, and not just calling for attention, unless I prove it of course.

There are clearly multiple underlying causes for the B’s self-harm. As is the case for almost, if not all, who practice self-harm. We must understand that self-harm related injuries are the result of mental distress that have at least psychiatric and environmental underpinnings. It’s not solved by punishing such patients, by treating them any differently or with a simple ‘one-time lesson’.

The ‘SHOULD’ be done

While in my opinion the ‘MUST be done’ are essentials for not being a bad doctor or caregiver, the ‘SHOULD be done’ points are the ones that will make one good if not great.

When I had to be hospitalized in connection with prolonged treatment of self-a harm incident, it was really lonely and difficult. The doctors were busy and often had difficulty understanding (…)

C recalling the first time she was admitted to the hospital.

· Understand the circumstances
If you’re a medical professional, working at an ER at a big city hospital, chances are that you are probably quite busy and overwhelmed with a long queue of people in need of your medical care. This can make it difficult to allocate time to speak with the patient in detail to create an environment in which the patient is emotionally comfortable enough to share their actual inner thoughts and potential motives without the fear of being judged.

Despite that in detail conversation is a necessary step to understand the circumstances behind the actions of the self-harming patient.

This can also be the case when self-harming patients are admitted to non-psychiatric wards or without psychiatric consultation and care. We have to understand that when we treat the injury or incident (which we must do), we are only treating the symptoms of the actual underlying cause. And unless we take time to listen and speak with the patient, we will have a hard time figuring out how to refer them to the right colleagues in the system, who can help them with that underlying problem.

While we all wish we had unlimited time to allocate to each patient that is simply not the world we live in. Therefore we have to compromise with solutions that can fix this issue.

One solution I have come to learn is to ask with sincere and personal curiosity, without being snarky, focusing not on the injury or incident, but the patient and their inner thoughts behind the action. E.g.: “I have never understood how (…) Can you explain?” or “I really want to understand what’s happening, so I can better help you and/or others in the same situation.”

Another solution is to utilize our wonderful colleagues (nurses, caregivers, physiotherapists, etc.), who in their often amazingly compassionate manner can create a safe environment in which sharing personal and inner thoughts become much easier. Making it possible for our team members to understand the inner motives of the self-harming patient, thereby receiving a summary and insight into not only the injury but also the patient and their motives.

· Ask about their needs
Ask how we can make it better. If they feel the treatment is sufficient. What solutions can the patient see themselves in regards to improving their condition? Especially if it's a patient that you have seen multiple times. Make them understand that you would like to help them in the right direction, recognizing that this is much more complex than to be solved right here, right now.

The ‘NOT’ to do

I would like to address four ‘NOT to do’ points, which echoed among almost all self-harm patients I have spoken with:

· Don’t be condescending
Understand that the patient probably already finds the situation humiliating, and the tone that they are met with will define how they will be cooperating and whether they will open up to you or not. Also, it’s never nice to be condescending to anyone, a psychiatric patient or not. Neither speaking in a predetermined decisive manner or “I-Know-Better”-attitude, nor in an overly pitiful tone. These are misunderstood ways of help.

· Don’t be angry
Yes, we can be stressed or agitated, but as doctors and nurses, this must never be deflected towards the patient. Even though it might be frustrating seeing the same patient for the fifth time this week, with yet another two cuts to suture (and a smile on their face), while we still haven’t processed having dealt with an 8 yo child who had lost half her right pinky, just half an hour ago…

Understand that our natural frustration is the result of our lack of understanding. After all, nobody in their right mind would find it amusing to self-harm.

A explains:

I always notice the rolling eyes and scolding tone. All it did was increase my hatred towards myself. Worst case it leads to even more serious self-harm. My self-harm was, partly, because I hated myself.

I can’t put a number on how many times I have been in a humiliating position, where I as a grown-up have to sit and listen to the admonitions of some physician, on how stupid my actions are and how I am stealing time from patients who are ‘actually sick’ and things like ‘if you had been my daughter, then…”

· Don’t discriminate
… just because the injury is self-inflicted. Obviously, we have to triage patients, prioritizing the acutely ill and seriously injured. But don’t discriminate psychiatric/self-harm patients from those who are mentally stable, by pushing them back in the queue, not offering a blanket, water, and all the other things normally offered to everyone else.

· Don’t take the role of a therapist
Hopefully, the patient is already receiving treatment in psychiatric care with a focus on the mental problems. If not, then it’s the perfect opportunity to refer the patient to begin psychiatric treatment. We have to know and respect our limitations as caregivers in a non-psychiatric setting. Do not expect to be able to fix/safe/cure the patient with a single conversation in ER.

Although, your approach to the patient, through actions and compassionate talking, can make a difference — of significant character, which might be the turning point for the patient.

Unfortunately, psychiatric conditions are often so complex, also those regarding self-harm, that they simply cannot be fixed with a philosophical rant while putting five stitches on a limb.

If only…

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Neural-engineer 🧑🏻‍💻 soon to be MD 🩺 Neuro-curious 🧠 everything brains, neurotechnology, transhumanism, psychiatry and philosophy.

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Younes Subhi

Younes Subhi

Neural-engineer 🧑🏻‍💻 soon to be MD 🩺 Neuro-curious 🧠 everything brains, neurotechnology, transhumanism, psychiatry and philosophy.

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