Psychiatrists rebuke colleagues over remarks on self harming patients
August 26, 2004
by Adam James
Psychiatrists have criticized colleagues who described self harming patients as "willfully 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 asked people who self harm: "Please don't lacerate yourself, come to hospital and then complain about it."
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 professionals - 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 apologize for and, perhaps even, pay towards the costs of their willfully immature behavior."
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 antagonizing/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 deductible 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."