29 Mar, 13 | by BMJ
Guest Post by Kerry Gutridge* and A.M. Calladine
Imagine you are a doctor, nurse or teacher and someone in your care asks for a razor. The person you look after wants to slice into their own skin and draw blood. They are compelled to hurt themselves. They have an overwhelming urge to feel a momentary visceral sense of pain. Would you provide them with a blade? Is it ever right to enable people in your care to harm themselves?
At first glance such questions may appear shocking and seem likely to elicit a strong gut reaction. Surely it can’t be right for people in a position of authority, with a duty of care to be seen to apparently condone or provide a means for vulnerable people to engage in such self-destructive behaviour?
Yet recent media reports (such as this and this) suggest that such a choice has already been made. Teachers at Unsted Park gave a “special needs” pupil sterile Bic safety blades so they could injure themselves in the privacy of the school bathroom. According to reports, staff checked in on the pupil every two minutes. After the pupil had finished cutting teachers cleaned and dressed their wounds.
The news story attracted a predictable sense of outrage. Readers commenting on newspaper message boards found the school’s decision at best incomprehensible and often disgusting and immoral. According to the top-rated comments on the Daily Mail website:
That’s Nuts! What’s wrong with these people??!!!
Absolutely shocking, I am by far an expert in the field but that sounds ridiculous to me
Unfortunately such feelings of revulsion and disgust are not limited to the comment boards of the Mail. One of the authors of this blog was told by another academic that their doctoral abstract on the subject of self-harm made them feel physically sick.
The news reports on the case at Unsted School are vague. The nature and severity of the pupil’s injuries are unclear and the age of the pupil is put between seven and nineteen. Without more detailed information it would be disingenuous to comment at length on this specific case. The Unsted Park School policy of allowing the pupil to self-harm has since been abandoned after some of the teachers complained to the local authority.
It is not the first time that the issue of institutional enablement or allowance of self-harm has been subject to scrutiny. In 2006, the subject was debated by the Royal College of Nursing Congress in relation to patients. And in 2005, a prisoner with a history of self-harm brought a case to the High Court claiming that his human rights were being infringed by the prison authorities refusing to provide him with access to razor blades. The case led Lord Justice Newman to proclaim in rather Devlinesque terms that the prisoner’s proposal
… is offensive to the individual, it is offensive to the staff and the prison service and it flies in the face of what we regard as civilised standards.
While such concerns for the moral fabric of society and the sense of deep unease and disgust at the idea of allowing people to self-harm is understandable, these sorts of emotive disgust based responses are rather unhelpful. They fail to provide any sort of solution for people who self-harm.
Indeed disgust-based responses often simply serve to maintain the status quo and obscure or hide both the complex moral issues and the vulnerable people concerned. In order to make some sort of progress it is important that we recognise that revulsion and gut reactions alone do not provide sufficient reasons to dismiss alternative strategies for dealing with self-harm. We need to start thinking about self-harm in a clearer more rational way that takes account of the perspectives of people who injure themselves rather than simply flinching, looking away or trying to prohibit their behaviour because we find the issue upsetting.
Underlying the issue of self-harm and how we ought to approach it are difficult questions to do with autonomy and harm (amongst other things). We think the crucial questions are: should we be more concerned about physical harm or mental well-being? Should we try to minimise the potential physical harms in the short-term in order to alleviate suffering and potentially work towards recovery in the long-term?
We should begin with a sense of compassion by trying to understand what self-harm is and why people do it. People self-harm for a number of reasons. They carry out a range of actions with a variety of motives and intentions and these may be different at different times. It is important that we do not view self-harm as a homogenous problem and instead focus on the individual. However, the most common reason for self-injury is to cope with overwhelming emotional distress. Louise Pembroke describes self-harming as
a silent scream. It’s about trying to create a sense of order out of chaos. It’s a visual manifestation of extreme distress. Those of us who self-injure carry our emotional scars on our bodies. (p 16)
Of course self-harming is a dangerous activity. Cutting is commonplace. Individuals who injure themselves often cut their arms but also their legs, abdomen, breasts, genitals or other areas. This can carries substantial risks. Muscles, tendons and blood vessels can be severed causing long-term physical damage. Wounds can become infected. Obviously this is both undesirable and traumatic. Moreover, self-harming can lead to guilt and reinforces feelings of shame and distress. For many people it perpetuates a low sense of self-worth. Individuals can become trapped in a miserable cycle of anguish and injury.
So how should we treat people – in both senses of the word – who self-injure? It is unlikely that there is a “one size fits all” solution. It is doubtful that simply trying to prohibit self-harm is adequate. Indeed, attempting to do this may cause more emotional distress and be unfeasible. Trying to prevent some people from self-harming increases feelings of powerlessness and the risk of suicidal thoughts. While tolerating injury might initially seem incomprehensible or wrong, allowing a degree of self-harm may be beneficial for some people in both the short and the long-term.
In the short term, allowing people access to blades, understanding and after-care can minimise the risks of serious physical damage. It is also less harmful in terms of well-being. It doesn’t take away an individual’s familiar coping strategy or cause the related feelings of distress, anger or frustration that this entails. Allowing a degree of injury can also create an environment in which trust and honesty flourish between the institutional authority and the individual who self-harms. By imposing an outright ban on self-harm the professional and person who self-harms may become embroiled in a relationship of power and resistance fostering an atmosphere of antagonism and mutual distrust. It is a relationship which has the potential to reduce the self-harmer to a state of passivity, incapable of making choices or exerting any sense of control. The need to feel a sense of control is important to many people who self-harm. Prohibiting their behaviour and making them feel like a victim often leads to an increased desire to injure.
The notions of choice and control in terms of self-injury are of course problematic. People use self-injury to cope. They do so because they are distressed rather than because they genuinely want to injure themselves.
They want to feel better. Injury provides a temporary sense of relief and in some cases also establishes a sense of control – which people who self-harm often feel they lack – over themselves and their own bodies. Providing people with the opportunity to have a sense of control over their own bodies and lives has value. This isn’t to say that professionals should condone the choice to self-harm but perhaps it should be tolerated. Providing a space in which individuals who self-harm are, at least partially, responsible for their actions and able to explore and question their decisions is important. As the first author has previously argued, the question of autonomy and self-harm is complex. However, this sort of environment can help people who self-harm to develop the ability to autonomously choose whether or not to injure.
The issue of allowing people to self-harm in institutions is controversial. As the newspaper message boards and professional responses demonstrate it is a subject that provokes a sense of unease, occasionally bordering on disgust and revulsion. These feelings are understandable and are sometimes motivated by the best of intentions. However, they often obscure the complex moral issues and the voices of the vulnerable people that lie at the heart of the debate over how to treat people who self-harm. If we are to make any progress on this issue we need to start thinking about it in a clear way which takes into consideration the multiple perspectives of people who self-harm. While people causing harm to themselves is a bad thing, surely it is better that they are provided with an environment in which they are listened to and the risks minimised. This may ultimately lead to less suffering and a situation where people who self-injure are able to manage their condition better and feel that their autonomy is enhanced.
* Dr Kerry Gutridge is a Lecturer in Biomedical Ethics and Law at the Centre for Ethics in Medicine. This post is based on her doctoral research on self-harm which was funded by the Wellcome Trust. Please contact her at her website contact page on psychiatricethics.com. If you have been personally affected by self-harm please contact the National Self Harm Network.