Psychiatrists have criticised colleagues who described self harming patients as "wilfully immature", who "displace more needy patients" and who "seem to thrive on the chaos they cause and attention they receive."

The rebukes were posted on the discussion board of doctors.net.uk, an online resource for psychiatrists and other doctors.

The lively exchange of opinions at the discussion board had followed remarks by a GP, Rachel James. Writing at societyguardian.co.uk she had urged people who self harm: "Please don't lacerate yourself, come to hospital and then complain about it [the service]."

Dr James (a pseudonym) was responding to a National Institute for Clinical Excellence guideline on how accident and emergency (A&E) staff should treat people who self harm. The guideline urged A&E staff - including psychiatrists and mental health nurses - to handle people who self harm with the same respect as they would any other patient.

More than 50 comments to Dr James's article were posted on the discussion board of doctors.net.uk, which more than 103,000 doctors have registered with.

One doctors.net.uk contributor, consultant psychiatrist Dr David Bramble, wrote: "I think she [Rachel James] speaks for many of us who have spent years dealing with these people and, from a psychiatric point of view, getting metaphorically regularly pissed upon by those serial offenders who are not mentally ill but seem to thrive on the chaos they cause and attention they receive.

"In my humble opinion unless there is a robust clinical reason for not doing so. They should be encouraged to apologise for and, perhaps even, pay towards the costs of their wilfully immature behaviour."

Another contributor, Dr Robert Davies, also a consultant psychiatrist, said that most self harming patients "will merely be displacing more needy but less dramatic patients."

Such consultants' views, which appear to contradict NICE's message, may be viewed with concern by many other mental health professionals.

In fact, other psychiatrists on the discussion board voiced disapproval for their colleague's remarks.

A senior house officer, Dr Carolyn Nahman, wrote: "I don't approve of antagonising/being rude/unhelpful to self-harmers - it doesn't help them or the staff dealing with them."

A staff grade psychiatrist, Dr Silke-Yvonne Habel, added: "It's not the patient who is chaotic, but the service. If the service isn't chaotic, then the patient doesn't need to seek attention by creating more chaos. You need to offer separate services and dedicate time."

Dr Robert Davies suggested the guideline increases "the influence of the nanny state, while totally ignoring a fundamental breakdown in the fabric of society."

He said: "They [self-harmers] are an heterogeneous group of patients…This is a fundamental point, and to focus the guideline on a symptom or feature is, to put it bluntly, incompetent. These days, when something goes amiss, it is always the services which have "failed" the individual. The individual is never considered to have "failed" society.

"Until we get shot of this ludicrous notion, our A&E departments, and wards and clinics will be full of these characters [people who self harm], some of whom have a legitimate place, but most of whom will merely be displacing more needy but less dramatic patients."

Dr Davies went on to suggest that self harming patients be charged £50 for attendance at an A&E ward.

"This could be deductable direct, where necessary, from benefits. I certainly think it would be worth a trial," said Dr Davies.

A third consultant psychiatrist, Dr Robert Gray, said: "Don`t forget these patients are not children and at some point they must take some personal responsibility for their multiple social/relationship/drug/lifestyle/illness problems.

"For many of these patients the solution does not lie with health service professionals but a lot closer to home."

See also:
July 29, 2004: Treat people who self harm with respect, new guideline urges professionals - A&E staff should also receive specialist training, NICE recommends

Treating self harmers like lepers will create more suicides

Comment by: Shaun Williams, vocational worker, Lambeth, London
Date: August 28, 2004

"As an individual who self harmed in the past but overcame this, I find it amazing that certain psychiatrists suggest self harmers should pay in A&E wards. I only self harmed because I felt suicidal, and did not want to die. The act of harming myself prevented my death.

"I would suggest far more time is taken up in A&E wards by people drunk, using drugs etc than people self harming. It is true that indivduals need to control their harming behaviours but treating them like lepers will mean more suicides. I for one have burnt and cut my arms, but never show these off to anyone, so I am certainly not seeking attention and am ashamed I harmed myself in the past, but not ashamed I turned up in hospital for help.

.....

Outrageous comments...but understandable

Comment by: Wedge Black, director, LifeSIGNS
Date: October 15, 2004

"Such extreme comments are indeed outrageous, but understandable considering the personal confusion and frustration of health care workers who do not understand the syndrome of self injury.

"With awareness training, and a little empathy, health care workers can choose to respond to self harm in a professional manner; considering the whole person, and not simply the ‘damaged tissue’ presented. LifeSIGNS offers free training to health care workers and can be contacted on training@lifesigns.org.uk

"But why did Robert Davies bring up the issue of benefits? There is no rule that people suffering from emotional distress can’t hold professional positions; 1 in 4 people will suffer from some kind of mental distress during their life."

.....

Training blickers staff to reality of depression

Comment by: Lacuna Lamb (pseudonym), consultant doctor at Lambeth Hospital, Landor Road, London
Date: October 21, 2004

"I have deliberately used a false name to hide my identity. I am not a self-harmer but my husband currently is.

"After over 40 years of mental illness he found that his thoughts drove him to start doing this early this year. He has done, and is doing, everything in his power to try and stop doing it.

"He knows how much distress it causes me and his young son who, although living with his mother, has become aware that his dad is ill and sometimes hurts himself.

"He cannot say why he does it other than that his thoughts make him do it.

"So far he has not succeeded in getting the help he needs.

"We recognise that this behaviour is a symptom of a problem with very deep roots. He knows that he needs to sort those roots out but also that he is extremely resistant and very untrusting so he has no hope.

"What would the learned Robert Davies suggest for someone in his position?

"My husband is far from immature, not just in age. He is also highly intelligent and very deep thinking. At the moment I consider him to be deeply depressed.

"Regarding depression, I remember a young man who had travelled through the South China Sea by boat to escape an oppressive regime. He was asked which was worse, to be in the boat not knowing what might happen, or depression. He said that the depression was worse because there is no hope. It is a justified truism that no experience is as valid as first hand experience.

" I cannot suggest strongly enough that psychiatric staff spend as much informal time with their patients as possible, among them on the wards, where they still exist. They would learn a lot that their training blinkers them to."

.....

Doctors should be trained in psychotherapy

Comment by: Michael Russon, GP, Hillswick Health Centre, Shetland
Date: November 17, 2004

"Until psychotherapy becomes a required part of doctors' training, we will continue to have inane comments from colleagues who clearly have no insight into the familial nature of psycopathy and its development."

.....

Adding psychology to medical science training might help

Comment by: Mustapha Otuyo, staff nurse, Lynfield Mount Hospital, Bradford
Date: April 4, 2005

The unfeeling comments made by some of our eminent psychiatrists towards self harmers further show the bizarre dichotomy between “pure” psychiatry and “pragmatic” psychology.

It is rather sad that the over reliance in medicational therapy as often employed by the psychiatrists would never seem to solve the problems of self-harming. I believe it will be an immature optimism to hope that we can solve the problems of self-harming without demonstrating a little emphathy towards the patient.

My suggestion is that psychology should be added to anatomy, physiology and biochemistry to form the basic medical sciences and clinical psychology to be taught and examined in the final MB.

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