You're relaxing on the couch while watching an episode of ER entitled "If I Should Fall From Grace." One of your favorite characters, Dr. John Carter, and his colleague, Dr. Susan Lewis, find a patient named Grace collapsed on the floor. As Dr. Lewis helps Grace up, she asks about the scars on Grace's arm. She admits that she used to be a "cutter," but insists that she has stopped. Dr. Lewis flips up Grace's skirt and finds fresh cuts. The clinicians want her to see a psychiatrist, but Grace refuses. Dr. Carter tells her that they're going to put her on "psych hold" on the grounds of "danger to self." Dr. Lewis sends another staff member for droperidol. Grace resists injection but is overpowered, and sinks to the floor in tears.
This episode would probably make any viewer uncomfortable, but imagine how frightening it must have been for the estimated 1% of the U.S. population who regularly harm themselves. And that estimate, reported by CNN in 2000, may be low.
The threat of being "locked up," medicated, or virtually ostracized can discourage people who self-injure from seeking professional help, especially someone like the Grace character, an aspiring law and medical student with much to lose. By forcibly exposing her wounds and hospitalizing her against her will, the TV clinicians transformed an intelligent, if troubled, young woman into a sobbing mess. These actions are in direct contravention to ideas outlined in the Bill of Rights for Those Who Self-Harm by Debra Martinson, BS, an advocate for people who self-injure and founder of the Web site Secret Shame (http://www.palace.net/~llama/psych/injury.html). The rights set forth by Martinson include
* caring, humane medical treatment.
* bodily privacy.
* full participation in decisions about emergency psychiatric treatment (as long as no lives are endangered).
Some of the images of self-injury-blood, wounds, sharp blades-are associated with danger and confrontation. It's obvious that the act of injuring oneself is taboo, alluding to suicidal tendencies. But for many sufferers, the secrecy surrounding self-injury is at least as harmful as the behavior, and deepens their sense of isolation. How caregivers react to these patients is crucial.
Let me be clear: self-injury is not a healthy behavior, but neither is it inherently suicidal. For many, it is primarily a coping method used to deal with disturbing thoughts or emotions. Indeed, the most current clinical definitions explicitly distinguish self-injury from suicidal behavior and factitious disorders such as Munchausen syndrome, in which the sufferer feigns an illness.
People who intentionally harm themselves are generally very clear on whether or not they are trying to die, as an article in the April 1996 issue of the Journal of Adolescence noted. Furthermore, being treated as suicidal when one isn't may lead to a downward spiral of repeated self-harm (and increased caregiver frustration). This is particularly true if patients face the contempt of clinicians who believe that they were making a "half-hearted" suicide attempt or that they could stop if sufficiently motivated.
People who harm themselves but aren't suicidal have the right to refuse psychiatric treatment, even if it seems obvious that it would help. After all, many "normal" people feel uncomfortable seeing a physician about sensitive topics. For people who self-injure, many of whom also have maladaptive social and coping skills, seeking professional care can be terrifying.
During their careers most clinicians will eventually treat patients who have intentionally harmed themselves. Because evidence of self-injury alone doesn't necessarily indicate suicidal intent, when patients present with self-inflicted wounds, it's vital that caregivers assess their patients' feelings and thoughts about living. It's often neither appropriate nor possible for nurses to counsel such patients at length. But a thorough initial assessment of and response to self-injury reduces the risk of recurrence and makes a patient's long-term recovery more likely.