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Cutting Class: Thinking about Self-Harm without Disgust

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??!!!

And

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.

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  • http://www.facebook.com/john.mcmillan.10485 John McMillan

    Hi Kerry, I remember hearing a talk at a philosophy of psychiatry conference by two women who self harmed. One of them might even have been Louise, but I can’t recall now. Anyway, they were talking about the intensity of self harming and how it oriented them. Most of us can relate to the way in which a self inflicted pain can give us focus: make us feel engaged. I can’t help thinking it was a shame that Unsted park had to stop this. The risks that you mention are real, but again I wonder if the reasons why people self harm were better understood, there might be ways to help people get what they need from this while minimizing the risk.

    • Kerry Gutridge

      Hi John

      Thank you for your comment. I agree that we need to understand better why people self harm and that increased understanding may lead to other strategies that may help people who engage in self-harm. As the post suggests, people self harm for a variety of reasons and it is unlikely that there is a “one size fits all” solution. I also have a great deal of sympathy with the idea that it was a shame that the school’s policy was stopped.

      However, I think it is worth noting that the case at Unsted School may have an added level of complexity. The news reports suggest that the pupil had “special needs”, and the age of the pupil isn’t clear (put between 7 and 19). While questions of autonomy and responsibility (etc) in terms of self harm are complicated in respect to adults, perhaps we should question whether they are even more problematic in terms of children or people with “special needs”.

  • MaryB435

    What if one of my patients wanted to self-harm? Could I tell her that that wasn’t right? No. In our culture of death, we refuse to acknowledge right or wrong. It’s all relative. Could I tell her to stop because God loves her, and wants the very best for her? No. I’d be “imposing” my morality on her. Could I tell her ANY truth; could I give her any hope? No. Hope is a virtue. We can’t have any of that.

    Today, we are seriously considering things that any sane person would have rejected as evil just a generation ago. We haven’t lost our moral compass; we’ve killed it. Oh, wait, we’ve got to deny the existence of evil, too. Wouldn’t want to damage Adolf’s self-esteem.

    A culture that denies God, the source of goodness, truth, and beauty, ends up hopeless, destroying itself and losing its collective mind in the process.

    • http://www.law.manchester.ac.uk/aboutus/staff/iain_brassington Iain Brassington

      Wow. You seriously think that the best way to talk about mental health and distress is in terms of right and wrong, and good and evil?
      You’re willing to throw to one side attempts by people who know what they’re talking about to get to grips with a difficult situation, and replace those attempts with a claim about Hitler? And you think that that’s a legitimate move because of God?

      When you talk about your patients, are they real, or are you talking metaphorically? For their sake, I hope it’s the latter.

      • MaryB435

        “…attempts by people who know what they’re talking about…” Apparently people who know what they are talking about have completely opposite opinions about this.

        Obviously, what Hitler did was unspeakably evil. No question about that. I will call it evil, and reject any philosophy that says that there is no such thing as evil. My point in using that example is to point out that relativism is fundamentally incoherent.

        • http://www.law.manchester.ac.uk/aboutus/staff/iain_brassington Iain Brassington

          Well, I’m with you in being suspicious of relativism (though for different reasons). But since this isn’t a question where relativism is relevant, I’m struggling to see why you raised it.

          Once again, questions of mental health and self-harm are not questions of good and evil.

        • MaryB435

          But they are. It is a sin to harm oneself or another. God created us in His image and likeness. Because He loves us and has created us, HE has the ultimate authority to decide what is right and what is wrong. When we disobey God, that is sin, and that is wrong.
          When society takes God out of the equation, we lose our ability to make any sense at all.

        • http://www.law.manchester.ac.uk/aboutus/staff/iain_brassington Iain Brassington

          You’re just trolling now, aren’t you?

        • MaryB435

          Not at all. It becomes nearly impossible to have a serious discussion when people refuse to recognize that every moral decision one makes necessarily involves a choice between right and wrong.

          I have read (and yes, did understand) the above article regarding “safe” self-harm, along with the various links and comments. There is a pattern to the thought processes of those commenting.

          People note that we must understand the CAUSES of self-destructive behavior. (but they never seem to want to get around to treating the cause in any specific person) Various theories are that these actions indicate: a desire for attention, a way to release tension, a way to cope with pain, obsessive-compulsive behavior, a way to feel as if one has some measure of control in an otherwise chaotic world, etc.

          Those who support the notion of “safe”, supervised self-harm typically point to the various possible causes and immediately make the false assumption that our options are limited to two false choices.

          a. Let them do it, because they’ll do it anyway, and we can’t stop them. Might as well have sterile blades. And this MUST be a good idea. We are, after all, professionals. If you disagree, you must not have enough letters behind your name.
          b. Force them to stop. But if we do that, we will only serve to increase their stress level, thereby causing them to harm themselves much more severely.

          That is a false choice. What these people never address is what is causing the person’s emotional distress in the first place. Until that is taken care of, we are only (no pun intended) putting a band-aid on the problem.

          Our modern world is capable of a remarkable amount of self-deception. There are problems–moral problems–that we are afraid to acknowledge because we know that we can’t fix them. If we don’t acknowledge God, we not only reject the One Who can help us, we prevent ourselves from seeing much of reality. C.S. Lewis once said that a major problem of society is that: “…we REFUSE to call things by their proper names.”

          There is also another author, Mark Twain, I think, I’m not sure, who said that: “There are some ideas so foolish that only the very educated can believe them.”

        • MaryB435

          You say you’re suspicious of relativism, but for different reasons. Just curious; What reasons? I know why I’m suspicious of relativism.

          In the United States, there is a murder trial going on concerning an abortionist named Kermit Gosnell. He is accused of negligently overdosing a woman who died as a result, and he also systematically executed babies who were born alive after abortions, by slitting their necks after birth. If you’re not too squeamish, the details can be found at LifeNews.com.

          With what Pope emeritus Benedict called the “dictatorship of moral relativism” we have no grounds for determining that what Gosnell is accused of doing–delivering live babies, then stabbing their throats–is actually wrong. Without solid moral standards, we are left with ever-shifting public opinion. That inevitably leads to “might makes right” which inevitably leads to anarchy.

        • http://www.law.manchester.ac.uk/aboutus/staff/iain_brassington Iain Brassington

          The Gosnell case is genuinely awful. It tells us nothing about the truth or otherwise of a relativistic claim, though. If it turns out that there is no overarching standard by which we can assess moral actions, then that’s a fact about the world, and its being unpleasant wouldn’t help us: we’d just have to bite the bullet. By the same token, whether or not moral statements can be true won’t help us much when it comes to identifying what those statements actually are. (By analogy, a mathematician may be able to demonstrate that some x has a definite value in a set of equations – but you need much more than that to identify what x actually is.)

          I’m still struggling to see what any of this has to do with the case in hand, though.

        • MaryB435

          But WHY is the Gosnell case genuinely awful? I’m not being sarcastic, just pointing to the fact that there must be a reason behind it. As a matter of fact, Gosnell and his attorney don’t think that it was awful at all.

          Contrary to popular misconception, abortions are often done in the third trimester, when the fetus (the Latin term for “young one”) is very well-developed. The techniques for aborting (killing) these young ones are just as gruesome as everything Gosnell ever did. Abortions are done under the cover of the darkness of the womb, where we can preserve the illusion that we are not really committing murder, even though that is precisely what is going on.

          According to that line of thought, what Gosnell did was logical: It’s that “darkness of the womb” part that’s the problem. If you can’t see what you’re doing, it’s so much harder to avoid perforating the mother’s uterus while you’re trying to slice the baby to death. Therefore, it’s so much safer for the mother if she is ‘heavily drugged”, labor is induced, and the baby is actually born. If, as often happens, the baby is born alive, (Remember, they were HOPING that the baby would be born dead) then they can just slit the babies’ throats, or “snip” their spinal cords with complete visual access. Mom’s so drugged-up; she’ll never know the difference.

          Of course, that’s awful! But no more awful than abortion. It’s just a logical consequence of the mentality of the Culture of Death.

          What does all this have to do with relativism, and what does our culture’s uncritical acceptance of relativism have to do with inflicting harm?

          You understand that ideas have consequences, but say that “IF (emphasis mine) it turns out that there is no overarching standard by which we can assess moral actions, then that’s a fact about the world, and its being unpleasant wouldn’t help us; we’d just have to bite the bullet.” You do not consider the alternative. What if there IS an overarching standard? From whence does that standard come? Many in our society immediately dismiss that possibility without consideration. When I struggle with an idea, I need to examine the evidence, not dismiss it.

          If there IS an overarching standard to determine what is moral behavior, and I believe that there is, then part of the evidence would be in the lives of people who claim to hold that standard. Briefly, Mother Teresa is evidence that there is such a thing as good, while Hitler is evidence that there is such a thing as evil.

          Not proof, but certainly evidence. Mother Teresa’s life was enough evidence to lead journalist Malcolm Muggeridge to become Catholic. I found that fact interesting, but what I found very curious was the effect Mother Teresa had on the late atheist Christopher Hitchens. While an intelligent man, he went absolutely ballistic, HATING her! He also hated Pope Benedict, saying that the WORST thing about having cancer was that he (Hitchens) wouldn’t be able to “dance on Benedict’s grave”. (I could think of worse things about having cancer.) I wonder what HE struggled with. Why did it bother him so much that Mother Teresa was so good? It’s something to think about.

          If there is no absolute Truth, there is no ultimate moral authority, no right or wrong, it just changes with the styles. (I’m reminded that we used to have slavery in this country. How could they NOT know that that was so wrong?)

          If there is no ultimate moral authority, then all of us can do whatever we think is “right”, and we can see where that leads. It also makes being an expert in ethics an exercise in futility. . Whose ethics, Yours or mine?

          It’s important to critically examine, not just dismiss, the idea of whether or not there is an overarching moral standard. You may want to read anything written by G.K. Chesterton. His writing is brilliant, full of wisdom, and very enjoyable. (Certainly more enjoyable than reading my replies. By the way, sorry it took so long to reply. I’ve been ill. Please pray for me. I’ll pray for you, too.)

    • Kerry Gutridge

      Dear Mary,

      Thank you for your comment. We were in two minds about
      replying but thought you deserved a response. We question whether you have read and understood the post. Rather than being relativists, we clearly state that “people causing harm to themselves is a bad thing” and that “This isn’t to say that professionals should condone the choice to self-harm but perhaps it should be tolerated [in some circumstances].” We also say that “We should begin with a sense of compassion by trying to understand what self-harm is and why people do it.”

      You claim that “Hope is a virtue”. We think that compassion, tolerance and seeking to understand before rushing to judgement are also virtues – do you disagree?

      Kerry Gutridge & A.M. Calladine

      • MaryB435

        Compassion and tolerance are wonderful…depending on what it is that you’re tolerating. I’m old enough to remember when self-harm was not a trendy disorder. It was also considered scandalous to cover yourself with tattoos, pierce every square inch of your body, not to mention abort your babies. God created us for something better. Our culture is rapidly disintegrating. Common sense isn’t common.
        Often, when people harm themselves, there is a self-loathing that needs to be healed. Psychological problems frequently have a spiritual component that we are unwilling to address. The West has been saturated in what Blessed John Paul II aptly called the “culture of death”. Providing razors is not the answer.
        You say that: “We should begin with a sense of compassion by trying to understand what self-harm is and why people do it.”
        Of course we should try to understand. That does not mean we accept or approve of self-destructive behavior. Giving razors to already-wounded people is in effect telling them that we really don’t care about them or mind if they harm themselves. Genuine concern, compassion, and authentic love wants the best for the other.
        Hope is a virtue,one of the theological virtues given to us by God, but I’m not the one to make that claim: “There are in the end three things that last: faith, hope, and love, and the greatest of these is love.” St. Paul’s first letter to the Corinthians 13:13
        Technology changes; human nature doesn’t.

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