The NHS and self-harm – a gap in care

Rita Binns

Signposts pointing in different directions. Text on each sign: There, Away, Anywhere But Here, Somewhere Else, Anywhere, Just get on and do it, We don’t give a ****

The Covid-19 outbreak has changed all health services. The changes have been far reaching and stretch beyond the pandemic. The pandemic has also highlighted pre-existing inequalities in the NHS – this blog is based on one person’s experience of accessing care and treatment for self-harm. From what other people have told us, they are not the only ones dealing with the same problems.

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While emergency treatment has remained available, going to Accident and Emergency (A&E) is a changed experience. Now you have your temperature taken on arrival and are placed in a different waiting area depending on ‘Covid status.’ Staff who greet and treat you are wearing personal protective equipment. At present there are plans, drawn up by the Royal College of Emergency Medicine, to try to limit attendances to those who are referred by 111, their GP or are brought in by ambulance. This change, if introduced, could have a profound impact on people with mental distress, who already feel they are actively discouraged from attending A&E even when they feel at risk of completing suicide.
I self-injure by cutting at times of extreme distress. My self-harm is acutely painful, cyclical and compulsive in response to a number of events which become a personal crisis. The pandemic has made me avoid hospital services through fear of disapproval, shaming, concern about unknowingly infecting others or being infected, and taking up scarce resources.
I know that NHS services may see any temporary cessation of self-harm as a success. In reality, it is still a daily battle to stave off self-harm when I am alone and in difficult circumstances. Because of the lock-down, I have had no video or face to face contact with my two family members for four months. I am forced to work from home in a housing association flat that has no garden or balcony. I have lost the pastimes that served as a distraction and reason to live. I have needed to switch to Skype with my private psychologist, though I am getting used to this. I feel incredibly lonely and have suicidal thoughts at times given the way we now must live for a long time yet.

In truth I felt abandoned by NHS services long before the outbreak changed the services available. Mental health services view my self-harm as ‘impulsive’, ‘longstanding’ and due to Borderline Personality Disorder (BPD). These ‘specialist’ services, provided by a single mental health trust, avoid getting involved at all costs. It feels as though I have been blacklisted and that this status, along with the wretched diagnosis, will never be reviewed.

My experience has been primarily one of signposting and aborted referrals. I’ve had one off assessments that lead to nothing more than more signposting and ‘action plans’ that act as service back-covering tick-lists. All this leaves me feeling worse than ever.
There are misconceptions about those who self-harm feeling some high or adrenaline rush. My experience is that there is no high, pay off, or euphoria. There is only torture which is heightened by the response from NHS mental health services. I do feel the re-emergence of my self-harm in ‘later life’ can be partly attributed to iatrogenic damage.
There is no NHS service help for people who self-harm. It is a service gap which no-one talks about, including the NICE guidelines, NHS providers or Clinical Commissioning Groups. The only way of accessing a chat is to injure, get wound closure by A&E and then see a Psychiatric Liaison practitioner as a one off. Liaison and CMHTs will always assess and discharge someone back to the GP, no matter how serious the recent injury or risk of either accidental death or disability. I was seen by the CMHT in February and told: “you have capacity to make bad decisions and that is the law.”

There is a slightly different approach to suicidal intentions expressed, but still the response to those is that it is our ‘choice’ if we want to kill ourselves as we have ‘capacity’ to do so. This is especially true for people who have been given the diagnosis of BPD where suicidality is seen as a trait rather than a concern.

Self-harm deserves the same level of concern as physical ill health, attempted suicide, eating disorders or addictions. I appreciate there are shortcomings in all mental health services due to historic underinvestment, but eating disorders and addiction services do still exist in principle. Instead self-harm is seen as ‘longstanding’ and not an ‘acute mental health need’, for which someone needs therapies designed for those with ‘dysfunctional behaviours’ which come under PD. There is no crisis care as Crisis and Home Treatment Teams tend to say that they can’t make any difference to ‘chronic difficulties.’ People who self-harm may indeed feel in crisis, as I often do, but they are treated as though doing what they always do, as if it was a hobby rather than a sign of immense inner distress. I sometimes feel I could suffer amputation and still the non-response would be unchanged.

The lack of secondary care help for self-harm, apart from basic medical care, could be understood if there were primary care mental health services. I do believe that GPs and practice nurses are often dedicated and excellent, as my GP surgery has been. But still I now have the third named GP in one year due to GPs leaving the practice. During the Coronavirus pandemic, it has been more difficult to see a GP or practice nurse, phone 111 or access care for injuries. People with mental health issues have mostly all been left to fend for themselves unless they become very ill with the virus.

I have tried to raise with clinicians and commissioners how lacking the response is to self-harm but am just told that “services are not set up in the way that they used to be.” It is as though the reduction in mental health services over the years (due to demand, underfunding, imposed boundaries for BPD, staff shortage and raised thresholds) justifies the worsening of attitudes. The message seems to be that we just have to get used to this basic level of endless signposting service, with any actual intervention aimed at younger people or florid psychoses. It is signposting with no existing service for most of us, just an endless frustrating hunt with advertised crisis text lines along the way. Charity helplines will never replace consistent low- level support that would help people with long-term distress to survive and avoid crises.

I don’t think the lack of resources can be used as an excuse for the current treatment of self-harm in the mental health sector. Using more compassionate and sensitive language doesn’t cost any money. Health professionals should stop using insulting language immediately, and this should be part of any training programme. I could come up with a long list of clinical insults to exclude for starters; Impulsive, PD, chronic, behaviour, neurotic, enabling, and emotional regulation. Liaison teams are making matters worse when they advise medical staff on self-harm by saying not to show emotion or give attention. The doctors and nurses I have met in A&E have often been far more professional, thorough and caring than any of their mental health colleagues.

The NHS front line has deservedly been praised for the heroism and dedication shown during the pandemic. I share that admiration and gratitude to medics who have put their lives at risk because they care as a vocation. But care still needs to be extended to people who self-harm. If the aim is to keep mental health patients out of A&E to help with infection control, then we need alternatives including physical wound care, crisis support and access to a service rather than another plan that isn’t really a plan. All mental health professionals should try to grasp that those who self-harm are not one homogenous PD group. Individuals are not harming to present a problem to the service, but because inner pain has become too much to deal with in any other way. It is an opportunity to listen and avoid further harm.

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recoveryinthebin

A critical theorist and activist collective.