It is sobering to consider the reasons why someone who is programmed from birth to avoid pain and to flee danger would purposefully inflict harm on themselves; to act in this way requires the need to override the basic instincts which exist not just as individual self-protection but also protect us as a human species.
It is relatively common for a person to come to the attention of mental health services following an act of self-harm. A proportion of these individuals will then be diagnosed as having a mental illness. The converse is also true: being given a psychiatric diagnosis can also lead to self-harm. This is in addition to the fact that certain psychiatric drugs have been found to be associated with an increase in thoughts of suicide and self-harm.
The observations below are made with the intention of provoking a creative response by both individuals and healthcare systems as to how they can help combat the growing use of self-harm as a means by which people try to get their needs met.
The History of Self-Harm
The complex questions around self-harm have always existed, and yet it’s mainly over the last 20 years that attention has been given to exploring the factors that lead up to such behaviours. At one time, self-flagellation was thought to be a higher calling associated with spiritual gain, and there are historical records of self-harm being used during distress, including a biblical reference to people cutting themselves with stones in response to bereavement.
I had not heard of ‘self-harm’ when I was growing up, either in childhood or as an adolescent in high school. The whole concept of ‘mental illness’, was not discussed and there were only occasional whispers of people having ‘breakdowns’.
At medical school, I enjoyed the few weeks I spent as a student attached to the inpatient psychiatric wards and I accepted what I was taught by the ‘expert’ senior doctors without question. I was given a list of diagnostic categories and I had to interview enough patients from the local mental hospital, to tick all the boxes. It was a fearsome place where the patients were incarcerated and there was little hope of recovery.
Once I started work in Emergency Departments (A&E) several years later, I came across patients who overdosed or self-harmed, often by cutting. The medical culture had for decades suggested that the vast majority who did such things were weak characters, attention seekers and timewasters. They felt that if those who had not made a ‘serious’ attempt on their lives were treated kindly, they would just ‘do it again’.
At the same time, there was also a prevailing belief that if someone really wanted to die by suicide, they would do it ‘properly’ and therefore not ‘bother’ healthcare services. This sort of attitude was commonplace and led to a punitive culture, with the result that patients who self-harmed were treated very badly. It was thought that they ‘deserved’ such ghastly ordeals as having their stomachs ‘pumped out’ or being stitched without local anaesthetic. It was hard for me as a junior doctor to challenge the established culture.
Over recent years there has been wider recognition of the role self-harm plays as an outward response to emotional distress and a simultaneous decrease in the pejorative and often punitive attitudes shown by healthcare professionals towards their patients who self- harm. While self-harm is now talked about and acknowledged in society, perhaps seen as more acceptable, it is also on the increase. I have personally witnessed an exponential rise in the number of cases coming to the Emergency Department following self-injury or self-poisoning. This more or less parallels the lessening of the stigma of psychiatric ‘diagnoses’ and the simultaneous reliance on the medical model of psychiatry, which propagates the belief that emotional distress is a sign that people are mentally ill and in need of treatment.
Why People Self-Harm
I have seen self-harm from many different perspectives and I have learned a lot during my work as a doctor in the Emergency Department, yet nothing quite compares to my own lived experience. It has taken me a long time to really understand what happened during the period that I was labelled as mentally ill. It was then that I learned to use self-harm as a coping mechanism. Something that only ever happened after I began taking psychotropic medication. The relevance of this fact should not be underestimated.
I had an emotional crisis a few years into my work as a junior doctor. Events occurred that triggered memories of my troubled childhood—this compounded the exhaustion I felt from working an 80-100 hour week, whilst simultaneously trying to be a good mother to my four young children during my limited time off. I took myself to see my GP, believing that this was the ‘right thing to do’. I received a diagnosis of depression and a prescription for antidepressant drugs.
My self-esteem took a huge dip. As a doctor myself, I was well aware of the fact that my profession thought those with psychiatric diagnoses were weak characters with only themselves to blame. It was very unusual for any doctor to admit to any symptoms that could indicate ‘mental illness’ and if they did, it was hushed up immediately.
Soon, I decided that I needed to take sick leave. I was very tired, but could not sleep, was feeling unbelievably sad as I constantly ruminated over the past. I thought of myself as a terrible failure. The diagnosis had not helped at all, even though I was now convinced that I was sick and that the medication I had been prescribed was going to make me well again.
However, after a few weeks of religiously complying with the treatment regime, I didn’t feel any better and now had to contend with side effects. I was feeling nauseous, I was shaky, my mouth was dry, I was constipated and I felt dizzy every time I stood up too quickly. Not only that, neither friends nor family understood what was going on in my life and started to distance themselves from me; I felt like a leper, as if I was contagious. This compounded my sense of isolation. I had become subject to the very real and damaging stigma that was prevalent at that time.
The downward spiral had begun. When I was in such despair that I thought my life was not worth living, I asked for help again; the subsequent admission marked the start of the next seven years as a revolving door patient. I was in and out of psychiatric hospitals, treated with different combinations of over 30 psychotropic drugs and given more than 100 ECT treatments. I was given the revised diagnosis of treatment-resistant depression (which I now believe to be erroneous.)
I have never seen myself as needing to be particularly brave when I have written or spoken of my own diagnosis and treatment within the psychiatric system. Yet, when it comes to my personal experience with self-harm, I am much more afraid of being judged than before.
Despite the reduction in stigma of ‘mental health problems’, there continues to be an underlying belief held by some of my fellow health professionals that individuals who self-harm repeatedly are fundamentally flawed in character. Simplistic answers over why people self-harm can fail to consider the root causes for deep-seated and severe mental torment experienced by some of these people. I was one such person and it led me into vicious cycles of repetitive self-harm, akin to Russian roulette; I became locked into harmful behaviours and I knew there was a risk of death, even though each particular act of self-harm may have been carried out without specific suicidal intent.
Even though my first admission to hospital was for pervasive suicidal ideation, I did not act out on any thoughts of self-harm until several years and multiple admissions later. When I first started to self-harm, I didn’t tell anyone what was happening. I was using physical pain as a source of distraction, to displace the mental torment that seemed so unbearable. But after a while, it wasn’t enough. It didn’t reduce the distress I was feeling. It was then that I started to injure myself in a more visible way.
By then I had a very low self-esteem, and I thought of myself not just as unworthy or ‘bad’, but positively wicked. Therefore, subjecting myself to punishment did not seem a difficult thing to do, but rather a natural sequalae. This resulted in some terrible acts of self-directed violence. During the final period of the seven-year ordeal, I was permanently hospitalised and became obsessed with thoughts of self-harm, which took over my mind until I had injured myself. It became another source of torment.
Often these injuries required treatment that could not be managed on the psychiatric ward. It meant I was taken to the very same Emergency Department where I had worked. My dysfunctional beliefs about myself were further reinforced, not just by staff in the psychiatric hospital, but also by some of the medical and nursing staff I came across during in the ED. Those in supposedly caring roles could be very unkind or judgemental and sometimes they were cruel. This only confirmed to me that my pre-existing self-denigrating beliefs were correct. I felt humiliated when they treated me like I was an unworthy and bad person, which created a breeding ground for the same thoughts to flourish in me, until I no longer cared about myself or my well-being.
Despite this, I still cared very deeply for my husband and children, although I began to believe that they would all be better off without me.
I know I also felt as though my caregivers, the unresponsive staff within the psychiatric system did not listen and I did not feel heard. I believe that part of my self-harm was an attempt to show them just how bad I felt inside. It back-fired, of course, because rather than lead to empathy, it led to increasing amount of judgement and a deliberate disregard for what had happened. No-one would talk about it with me. I was not asked why I had done such a thing and nobody seemed to care that I had almost lost my life. After my recovery, it was confirmed that some staff were angry and frustrated with me.
I must have been angry myself but the numbing effect of the medication meant that I had no awareness of such feelings. I cannot help wondering whether the aggression I meted out on myself was also directed at them.
I was not able to trust anybody in the hospital where I was detained. I was so lost within my head and in terrible torment.
Does Psychiatry Help or Harm?
There are many kind and compassionate people who work in psychiatric care, who are dedicated and well intentioned.
But personally, I do not see psychiatry as being a solution on the wider scale. There are far too many patients trapped within the system who are desperately in need of help and understanding. An equilibrium must be restored for such patients to be able to re-enter life away from the negative influences of psychiatry, which have been unwittingly imposed on them.
My first admission to hospital was ‘voluntary’ and I was told it was to keep me safe and I believed that it would get me better. I soon found that whether voluntary or not, hospitalisation was akin to imprisonment and little else. It was an environment used to contain patients in one place, with the stated aim to prevent them from harming themselves or in certain cases, harming others.
So here we all were, the unsafe people, all housed together in a locked ward with nothing to do except take the medication that we were told would make us feel better. The day room was the only place we had away from our bed, and here we sat for most of the day, men and women and a TV. The nurses were those tasked with keeping us safe, keeping control, and doling out the drugs. Nobody talked to us and there was nothing therapeutic about our stay in hospital.
We, the patients, watched the staff, watched each other, and soon learned the rules of survival in such an environment. I remember feeling horrified and terrified the first time I witnessed another patient use the most effective way of getting the nursing staff out of their office: throwing furniture or various objects or even attacking someone else guaranteed a response.
It was extremely stressful and unpleasant for all of us. I hated it, as did most of my fellow patients. Yet I saw some of the most unlikely people engaging in such violent outbursts just to get the attention they so desperately desired. Some even considered it lucky to get jabbed with a tranquiliser. It gave them relief from the torment of being left in enormous distress, without hope, for days on end.
Self-harm was also widely practiced on these psychiatric wards, long before it became commonplace in the wider community. I could see how it served a similar purpose to other forms of violence, in that it ensured that healthcare staff gave some time to the patient concerned. Some would say that this confirms their belief that such behaviour is purely motivated by attention seeking. I see this not just as pejorative, but also as a wholly inadequate explanation for why patients on psychiatric wards often resort to self-harm. Yet it was clear that there were times when patients really did use such behaviours to get the attention required, just to get their needs met. This way nobody else got hurt.
Once a patient is admitted to a psychiatric ward, feeling suicidal is considered very low key. There is a ladder of ‘risk’, a symptom hierarchy which healthcare professionals used to assess their patients. It seems that they were blind to the fact that patients quickly cottoned on to this.
Even today, psychiatrists, psychiatric nurses, and psychologists may believe that they are uniquely trained and talented in being able to determine how serious the risk of completed suicide is, but they admit that they cannot predict who will or will not go on to take their lives. They make superficial judgements based on a range of factors which nowadays is a variation of what is called the ‘SADPERSONS’ score. For instance, a declaration of feeling suicidal is one thing, while having a plan for suicide puts you further up the ‘risk’ ladder.
For the residents of psychiatric wards, who have become very familiar with the staff responses to those who have self-harmed, they soon see that, without exception, it does bring a measure of extra attention; even when such attention is punitive or judgmental. For those who are desperate for interaction with the staff, negative attention may seem better than no attention at all.
Most of these patients believe what they have been told by the psychiatric profession—that the answer lies in hospitalisation or in treatments that mental health services offer. I was one of them. I believed that if I did what was advised—took all the medications they prescribed, agreed to all the treatments they offered—I would get better. I can speak from experience when I say that nobody ‘in their right mind’ would want to be locked on a psychiatric ward. Yet, once embedded in a coercive system and heavily medicated, it can be hard to break away and resume your independence.
SO, readers may be wondering, are patients playing the system? The answer is that it is no different from any other aspect of life, where we all learn what works for us as individuals and what does not.
Those who are deemed mentally ill, as I was and want to get better, will do all that we can in our attempts to find the solution to our problems. No one wants to feel sad or hopeless or anxious or frightened. I suspect that most patients who engage in self-harm and are labelled as attention seekers, as was my experience, do so in the subconscious belief that it will help them to be better understood by their psychiatric team—i.e., they do so for good reason, as a valid means to an end, to obtain the help they so desperately need. I believed that if I was really listened to, my concerns would be taken seriously.
In retrospect, I suspect that the nursing staff on the psychiatric ward thought that I was already being taken seriously. The psychiatrists and the psychotherapists thought that they listened. But I did not feel heard. They did not ask the right questions and they did not understand. I remember being subject to logical, rational answers which only served to isolate me further.
Imagine telling an addict that ‘all they need to do is stop taking the drug’ or someone in an abusive relationship, ‘all you need to do is leave’. I was told ‘all I need to do is stop self-harming.’ I was repeatedly told that the reason I didn’t get better was because I didn’t want to get better.
The worst thing about this situation is that, as a patient trapped in the system, it is easy to think that your caregivers will help you to find a way to resolve your difficulties. The relationships with your doctors, nurses, and therapists play such a key role in day-to-day life. They were party to some of my innermost and private thoughts and feelings, which I had shared willingly, believing that my dignity would be preserved. I did not expect to be judged and I thought I would be treated with empathy. I felt so vulnerable when they let me down. That betrayal in trust was devastating.
Patients treated by mental health services quite often escalate their behaviour and complaints because they do not feel heard. This happened to me, and since then, as a professional, I have seen it happen to others on many occasions. Tragically, when patients ‘up the ante’, there is a significant risk of irreversible damage or loss of life. Sadly, it is within the mental health service that acts of self-harm have flourished and spread. Historically, it was on mental health wards that patients learned about self-harm from one another, what responses will be elicited, by whom and for what reasons.
Of course, in the present day, this is aided and abetted by the internet. Suddenly, self-harm has become a commonly used method of eliciting help, even by young children. It has become the ticket of entry to provoke a response from even the most impenetrable of healthcare systems. Self-harm causes understandable alarm and panic from friends and family alike—it is seen as an indicator of serious distress and fills everyone with a desire to urgently remedy ‘the problem.’
Those who remain patients within the psychiatric system really do need to feel understood and often require considerable help to break away from their dysfunctional coping mechanisms. All too often, it is the response of healthcare professionals that reinforces the pattern of self-harm behaviours and thereby hinders, rather than helps, recovery.
As I see it, part of the solution to the increasing and global use of self-harm as a method of eliciting help is to understand how we have unwittingly medicalised very normal reactions to life’s complex circumstances.
Distress and emotional pain are part of being human, without which we will not be able to function or grow into adulthood. Pain has always been a warning system to us, teaching us what is or is not harmful—it serves us well in evolutionary terms. Yet it seems that we worship the idea of being continuously free from all pain and suffering, to the extent that it has taken on the proportions akin to religion—and this has been heavily exploited by western economic systems.
As a consequence, our tolerance of ‘normal’, adaptive or helpful distress and turmoil has declined.
Surely we must re-learn what to expect from ourselves—recognise that it is natural for our moods and feelings to fluctuate and be responsive to the circumstances around us. We need to know that it is perfectly ok to feel what have been labelled as ‘negative’ emotions like sadness in response to difficult situations; that grief is appropriate to experiences of loss, and that the goal of ‘happy all the time’ is based on fantasy. When we accept that suffering is a valuable part of life, as much as ageing is the inevitable consequence of living longer, then perhaps, our general angst will diminish.
Perhaps we should be turning our gaze away from the pseudo-scientific medical models and learn from the ancients. The old-world religions such as Buddhism give us far more insight into the attainment of peace and contentment, as well as guide us on how to live in harmony with others. Surely this is far preferable to taking psychiatric drugs or seeking out nebulous industry-driven formulas to enhance ‘wellbeing’.
I do not belittle any individual who engages in self-harm. It takes a certain courage, yet that very same attribute would better served, if used curiously, to explore what it is that is behind the distress which drives such behaviour in the first place. It can take considerable tenacity and nerve to relinquish the idea of a quick fix or to delve into the past and change past outlooks and responses. Such priorities may be time consuming and costly, but it is well worth finding the right therapy or help and can be life changing.
If I could live my life over again, I would not have sought help for my emotional crisis from any doctor. The psychiatric treatments I underwent did nothing to help me come to terms with my troubled past. Self-harm did not serve me well either; it exacerbated the torment and prolonged the agonies. Not only that, though never intended, it hurt those whom I loved.
Self-harm is a dangerous game. It can escalate from something that starts as relatively trivial to become very serious and I have seen far too many patients die as a result and far too few fully recover.
I am lucky that I did not lose my life and also that self-harm lost its mastery over me. I have come through stronger, am fully recovered and choose to share my experience only to help others do the same. I believe that it is necessary to recognise that it is not just self-harm behaviour that is dysfunctional, it is also the psychiatric system which has given it grounds to flourish. I am one small voice amongst those who share such views. But together, I believe the world really can turn back the rising tide of those who feel the need to use self-harm as a distress signal, to access what I believe is a fundamentally flawed ethos—the bio-medical model of psychiatry.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.