“Having recovered from self-harm, I can now look back on my experiences with health professionals and reflect on what advice helped and encouraged me. I went to see one GP with an infected cut on my arm, a wound I had inflicted and then not properly cared for. This particular doctor after cleaning the wound and prescribing antibiotics for the infection asked me how this had happened. After noticing my silence and embarrassment they said, ‘I’m here to listen to anything you want to talk about and anything you tell me will stay within this room.’ This immediately reassured me and encouraged me to open up to them and we talked about some of the emotions behind the self-harm and how some practical solutions could help me to move forward. I felt like a person and not a ‘case’ or vulnerable patient. Building a relationship of trust and equality with a sufferer is essential and often encourages discussion, which is a first step towards achieving recovery.”
My Suggested Action Plan: the information in the section is provided by Dr Becky Steed, a GP based in Nottingham with an interest in young people’s mental health
Look out for signs and symptoms, an infected cut or something less obvious such as a scratch or burn.
Talk to the sufferer with positive unconditional regard and treat them as an individual and not a series of symptoms.
Speak to the sufferer without judgement, shock or a lecturing tone. Remember that if they have come to you it has taken them a lot of courage and your response to this is critical in gaining their trust.
Avoid bombarding the sufferer with information that isn’t directly relevant to their situation or current state of emotions as this can come across as impersonal and unsympathetic.
Professional doesn’t always mean a medical approach – holding back with a diagnosis or list of treatment options before taking time to listen is often more beneficial for the sufferer.
“I think that it is useful to remember that knowing what to say or how to raise the subject can be difficult. Asking with curiosity rather than judgement is an approach which I have found useful and being prepared for someone to be unwilling to discuss in depth at the first consultation.”
Dr Becky Steed answers some frequently asked questions regarding treatment and after-care
“A non-judgemental approach is so important. It is important to understand why someone is self harming rather than just focussing on the self harm behaviour itself-seeing it as a symptom/expression of distress which someone needs support to deal with. I definitely agree that it is important to highlight that if someone has actually presented to discuss their self harm this will have taken a huge amount of courage and responding sensitively is vital to gain their trust and move things forwards for them.
I think that it is important to explain that self-harm is a different phenomenon to suicide although this can of course be a consequence if self-harm escalates (often unintentionally). I do feel that a lot of people still struggle to understand this. I also think it is important to emphasise that it is not something which is done as attention seeking or deliberate troublesome behaviour rather it is often the only way that someone can find to cope with their emotions. I know that one of my patients on her many trips to A+E having self- harmed encountered these attitudes from doctors.”
How do you deal with an emotional parent who is forcing their child to talk about it with a doctor?
“It can be a very challenging situation, which often takes time and multiple meetings to resolve. It is important to listen to the parent and allow them to explain/express what they need to but being mindful of how the child is behaving/reacting whilst things are being discussed. I often prefer to speak to parents prior to the consultation about their concerns but if it just comes out at a consultation without prior preparation/warning then I will often get the basic facts and then suggest that the child has a couple of minutes to talk to me without the parent being there. I will then ask them if they feel that they can talk to me about what is happening and also ask how they feel about their parent raising the issue. Depending on how closed the child is/whether they will speak to me I will then book a follow-up appointment having emphasised that it is good that the issue has been raised and that it has only been done because the parent cares (trying to minimise arguments when they get home) and that there is a lot of support that we can give when they are ready for it. I do emphasise to parents that no one can be forced to tackle an issue before they are ready and that we need to take things at the child’s pace.”
If a patient goes to A&E with a self-harm injury, how does the GP get notified? What’s the follow-up procedure?
“There is an electronic summary, which comes through to a GP the day after a patient has been to A+E with self-harm or an overdose that briefly outlines what has happened. Often, anyone under 16 with overdose are admitted overnight to paediatrics and seen by the local liaison CAMHS team before they are allowed home again. Usually adult patients will be seen by the DPM (department of psychological medicine) team before discharge to assess their safety to return home and this assessment will also be forwarded to the GP. The follow-up plan may request GP involvement or explain that the DPM/CAMHS team are following things up. I don’t think that many practices will contact every patient who has presented with self harm although if it is happening repeatedly then they are likely to be invited in for a review and certainly if a review has been requested by the hospital at discharge this will be suggested and the patient contacted.”
How and when would a GP refer to specialist services? What resources do GPs have?
“Specialist self harm support can be difficult to access; for children it would need to be a referral to CAMHS which can cause a lot of fear and anxiety and for adults it would be through the IAPT team (improving access to psychological therapy -essentially counselling). In many areas there are support groups which GPs can signpost to but resources are often lacking and having advice/basic measures to offer within general practice would be really useful.”
When would a GP prescribe antidepressants?
“GPs are generally discouraged from prescribing them. The brain of an under 18 year old doesn’t respond in the same way as an adult and some impulsive behaviour can be made worse by antidepressants. For these reasons it tends to be sometime which is left to CAMHS. Sometimes if someone is close to age 18 I will consider prescribing but generally it’s not something which I will do. CAMHS are also quite reluctant to prescribe and so things generally tend to have to be quite severe before they will prescribe.”
Any other vital points you think should be highlighted?
“I think that it would be useful to cover the range of ways that self harm can present and occur aside from cutting. Most GPs are not going to have a great deal of understanding of the different forms and also won’t always consider that overdoses can be a form of self harm rather than suicide attempts.
I often ask people when I’m worried about hopelessness about what plans they have e.g. for later in the week/month or where they see themselves in perhaps a few years time/after they have completed their course to give me a bit more insight into how deep that hopelessness goes- I sometimes find that someone can present quite negatively but actually longer term has hopes for the future. I certainly agree that extreme hopelessness is a significant cause for concern, close follow-up and earlier referral on.”