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'The distress increases until you think you will burst'


A Nursing Times reader replies to the negative comments drawn from a news story on patients who self-harm and the nurses who lack the skill to treat them.

Reader response

This comment is in response to “Nurses lack the skills to treat self-harm

Researchers from the University of Nottingham argue that not all nurses have received sufficient training to support or help individuals who self-harm, leaving these patients with a negative view of the care they receive from those employed to treat them.

Some nurses and other healthcare professionals, often working in emergency departments, have negative and sometimes discriminatory attitudes towards this vulnerable group of patients who they may perceive as attention-seeking or manipulative and dismiss them as time wasters.

Some of the comments following this article support these negative views of nurses. which are unfortunately far from rare and which I have also witnessed throughout my professional practice. Such unacceptable attitudes identify a necessity for further education and training to further understanding of the underlying psychopathology of self harm and how best to offer consistent, compassionate and constructive care to meet their complex and specific needs and to eliminate stereotyping, stigmatisation and discrimination that also impacts upon the attitudes of the public towards individuals with this and other mental health disorders.

Imagine this

You were a normal healthy individual until a series of disasters radically affected your life. You now feel pushed to survive on the fringes of society, with no family, your one-time close friends, mostly married, are scattered around the globe, and you no longer seem able to fit into any social group.

When you correspond with your friends or contact them for an occasional chat they appear preoccupied and too busy with their families and their own affairs to show much interest. You had a steady permanent job which you loved but because of illness in the family, before the last member died, you gave it up to help at home as there was, at the time, no other alternative and nobody else to help.

After a prolonged period as a carer you make several attempts to re-enter employment but despite your professional qualifications, higher degree and many years of experience, these were unsuccessful. Desperate for some type of job you eventually accepted a series of jobs which proved unsuitable and unsustainable as you sank further and further into depression after the gap left by the death of your loved ones.

Despair led you to seek help, and you underwent a course of psychotherapy which lasted a number of years. Once again, with the help of a careers advisor, you made a desperate attempt to return to work and submitted, what was considered by your advisor and others, an excellent CV. However, with age against you and rising unemployment, after more than 50 refusals, you ended up exhausted, demoralised and with diminishing self-esteem which pushed you into putting your whole life under scrutiny.

On the brink of financial disaster, there seemed to be no other recourse but to apply for a job seekers allowance, and then on the advice of a psychiatrist, incapacity benefits even though this was totally against your will and your principles, and despite that fact that you didn’t feel physically ill, just very downcast, prone to depressive episodes, feelings of guilt for your inability to find a job and a social outcast. At the time you were at least consoled by the fact that this would only be a solution for the short term.

This also gave rise to feelings of extreme frustration at not being able to move on, especially after investing your resources in a higher degree in your professional field, and at a time when you had felt at the peak of your career and with ambitions to climb the ladder. Time out at this point, to reflect on the future was needed, even in the knowledge that the longer the break the harder it was to re-enter the labour market. Retraining was not an option because of age and the further personal financial costs involved.

Now imagine the effects this had on you and what led you to seek support in A&E

One cannot predict the date and time of a crisis. The psychotherapeutic support you continue to receive is only available during office hours and by appointment. Despite reassurances there are other organisations there to help in times of crisis, this is not always so in practice.

The only alternative emergency service readily available appears to be the A&E of the local hospital whose purpose is to serve the public 24 hours a day for any medical emergencies, including mental health crises. You realise these departments are overloaded and you don’t wish to bother them or “waste their time”. You grit your teeth and tell yourself that you must pull yourself together as you have heard others say so often when referring to individuals with mental health difficulties.

You have nobody else to confide in as you fear how others may react or change their attitude towards you if they think you are “mentally unstable” and may even perceive you as a danger to society. It’s getting later and later and the problems and the crisis grow out of all proportion until you feel you must take action. The extreme distress and the inner pressure you feel increases and increases until you think you will burst - like the cover blowing off a pressure cooker.

You may find yourself trapped in a dark tunnel with no way out and may even lose the will to live. Eventually, seeing no way out of this most terrible and devastating situation, there are many different “coping” strategies you might try such as, nevertheless, calling a friend even if it’s just for a chat (but nobody around), drinking a cup of tea or coffee, smoking a cigarette, watching TV, listening to music, going for a walk or jog, doing some sport (depending on the time of day) or physical exercise, crying, screaming (not always appropriate), scratching, beating yourself, banging your head against a wall, having a hot bath, going to bed, drinking alcohol, taking drugs, medication, an overdose or harming yourself.

Assuming for the purpose of this article that you harmed yourself, as you have done several times before under stress and seem unable to stop yourself, you go, or somebody finds you and takes you, to A&E. You may by this time be feeling extremely rough and really don’t want to go there and may (possibly based on previous experience) even have reflected on what type of reception you might get and how long you may have to wait, but there seems to be no other option.

Besides, talking to staff there who may be total strangers may seem to you like an intrusion into your privacy.

Now imagine these two scenarios in A&E

Scenario one

The department appears hectic but the nurse is kind and understanding and takes a few unhurried moments to talk to you and shows a genuine interest, giving you the opportunity to express your concerns. He or she is experienced and empathetic and has an understanding of the subjectivity of psychic pain (ie how the patient describes their own suffering, no matter how strange or unbelievable, rather the nurse’s interpretation of what the patient relates). After a short wait a mental health specialist is called to see you and you have a long talk in which they calm you and reassures you that you are in safe hands. He or she makes an assessment of your current situation, evaluates your risk of further self-harm and decides whether a hospital admission or any other immediate measures are necessary.

Scenario two

The staff are totally indifferent to your arrival, you may be ignored completely or they may be very brisk and businesslike to mask their lack of ability to cope with your situation. At worst, they may express either implicitly or explicitly that you are wasting their time, or they may at least make you feel that way, giving you the impression that they have other more important things to do or other patients to attend to. (Their appearance of busyness may include retreating to the staff room for a chat or to drink coffee or play cards outside their official breaks). You may even be sent away without having a chance to discuss your problems.

Now bear in mind that you, or somebody you care about, could be in this patient’s shoes at any time in your life and require the assistance of nurses in A&E.

  • Reflecting on the reception, support and assistance you received in both of the above scenarios, how you would feel, what would you think and how would you react?
  • Were your expectations adequately met in either of these scenarios?
  • Would you expect to be treated with empathy, understanding and respect or would you feel that you were wasting the staff’s time, were in their way and that they had other patients with greater or more urgent needs than you?
  • Would you like to feel that somebody professionally competent and experienced in looking after patients with DSH was willing to take the time to listen to you and talk through your problems with you whilst acknowledging your reasons for your distress which led you to harm yourself?
  • Would you like to feel that you were in a safe and secure environment where you could trust the person you were talking to and confide in them in the knowledge that any information you give would be passed only to others directly involved in your care, and with your consent?
  • Would you expect to receive constructive practical support and advice with the offer of a follow up appointment if required?
  • Did this encounter with the emergency services relieve you immediate distress?
  • If you felt that you were not respectfully or fairly treated, and that your immediate needs were not being met what would you like to have seen done differently?
  • What effect did this encounter with the emergency services have on your condition?
  • How would you relate these experiences to others who might be in a similar situation?
  • How would you answer the questions on a survey of service provision for those who self-harm?
  • What advice would you give to others in a crisis about where to attend if they appear to be in danger of harming themselves or following an episode of deliberate self harm?
  • If, after imagining yourself in both of these scenarios, your experience of the standard of care you received did not meet your expectations, what recommendations would you make to improve the quality of the emergency services for the care of individuals who have harmed themselves?


Would it not be better for everybody concerned if a consistent attitude and treatment policy were adopted by nursing staff nationwide to treat patients like the person in this example, who I imagine is quite realistic and typical of quite a few people presenting to A&E, in essence no different to any other patient, with the dignity and understanding he or she merits.

An understanding needs to be shown of what may have led him/her to such desperate, and possibly attention seeking measures, in order to provide the appropriate support in an emergency situation and in the longer term. A satisfactory and mutually agreed follow up must be ensured rather than merely dismissing them with a list of names and addresses which may not lead anywhere.

With the appropriate training and experience, far greater satisfaction may be derived from a job well done with compassion, empathy and understanding than all the stress unleashed by anger when confronted by a patient one is unable to cope with and who is deemed to be wasting the nurses’ time.

Nurses on the general register have to be prepared to care for patients with a wide and increasing variety of conditions and act according to their code of professional conduct and ethics as well as adhering to local or national policies and guidelines such as NICE.

No patient should ever be confronted with an attitude of arrogance by healthcare personnel nor should they be told, or led to believe, that they are wasting their time. Such attitudes are a sign of ignorance.

Confidence in the ability to support this group of patients with their often highly complex needs can be highly rewarding, but is best achieved by undergoing the appropriate training, in what is considered by many as a fascinating area of study of personality, human behaviour and psychopathology. Such training should be a requisite for all nurses on the general register.


Although deliberate self harm is often considered to be a voluntary act it is associated with impulse control disorders. It may also be triggered during a dissociative or psychotic episode which sometimes occurs in individuals who have an underlying personality disorder or serious mental health disorder.

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Readers' comments (12)

  • I have had experience from health professionals which has ranged from impatience, indifference, A Nurse falling asleep while taking a history, to one particular nurse in A&E looking concerned an taking time to talk and enquire about a psych consult. One gem in amongst the dross.
    As part of my training I dont think mental health issues have been properly discussed. One portfolio piece on a psych disorder of your personal choice in relation to the Older Adult is not an adequate preparation for dealling with the huge variations in mental health encountered on the ward. After all people who are mentally ill have physical illnesses too. This seems to be forgotten due to the branch system of nursing in this country asigning us our individual boxes of knowledge.

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  • bob cat

    Good article, I must admit I would have expanded on the appalling reception often received by people with non-physical injury and distress, but that's my want to challenge the comments directly on this site! I agree that the responses of A&E or any other first contact are hideously uneducated and unwilling to challenge their own perceptions and judgemental stances. I think what needs to be made much more clear in training and day to day nursing is the boundary between personal thoughts and professional position, and then how the personal spills and leaks out into the pofessional, regardless.
    I also agree that the branch system of training has fragmented how we perceive and care for people, and needs reintegrating.

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  • Many thanks Bob for your excellent comments which reinforce my thoughts in connection with the above article I wrote.
    As you suggest, and as I would also like to further point out to the readers of this article and comments, there appears to be a need for training in attitudes as well as just the theory followed by practice to gain experience in caring for ALL patients who are put in our charge regardless of their pathology. Care includes providing the initial help, or first aid, patients require before transferring them to the appropriate services with specialists for any ongoing treatment they may require. (With so many differences in values and attitudes, it seems that everything has to be spelled out to everybody else nowadays letter by letter in order to make things understandable).
    I am still naive in thinking that all nurses, and other HC professionals, have common and shared values and attitudes central to the care of each and every patient which pointed them towards a career in nursing. Maybe, however, their attitudes changed and they became disillusioned after their exposure to modern day health services or else they are too easily influenced by some of their predecessors and seniors who lack a caring attitude towards individuals with vulnerable mental states. It should be remembered however that everybody's mental state can and does change continuously both positively and negatively, and more so in some of the more challenging stages of their life. I emphasise once again for the readers that this vulnerability, which can lead to a psychopathological condition, can affect anybody at any time necessitating professional intervention and expertise and, as we all realise, providing the most appropriate intervention at an early stage may help to reduce or even prevent later exacerbation of that condition and this means approaching the patient with a positive, friendly, caring and confident attitude.

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  • Life can be so short I just find it so desperately sad that people waste there time treating others so badly and often to their own gain. There is so much to be done and so much of interest to share in this wonderful and fascinating world of ours. There are so many more rewards to treating others well even when they are down and unable to respond.

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  • These brought back memories when I was a student nurse helping out with a washout for an overdosed patient in A & E a good while ago. During the procedure, the doctor asked the patient what she had eaten previously .
    She replied "Kentucky fried chicken".
    He then moved his ear towards her abdomen and made "clucking noises", commenting that was what he was hearing!!. Both he and the Staff Nurse burst out laughing.
    I observed the red face of the patient filled with further pain; she never responded to the professionals insensitive cruel jibes.
    I must confess that I was so shocked that I became mute for a good while. I never worked in A & E again after my placement was over.

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  • i found this a reasonable article until the "imagine this" part. at this point i feel the reality of most self harm issues was lost along with one of the major hurdles for professionals supporting them.

    the experiences of abuse (the individuals perception of their experience is what is key here) and associated self loathing can lead to individuals projecting awful feelings onto professionals trying to care for them. along with this the rejection of care by people who feel worthless and undeserving of care or may even feel they deserve punishment can leave professionals struggleing to be supportive.

    repeated contact to anyone with this way of managing their difficult emotions and not just people who use self harm as a coping strategy can strengthen hostility responses. blaming nurses as uncaring or focusing on self harm strengthens negative perceptions and does not fully challenge the quality of training being provided to all nurses.

    it is not self harm per-se which is the issue but the powerful emotions of distressed and vulnerable people who struggle to access support.

    and on a final point; it is important to be aware that "attention seeking behaviour" is in itself is a negative perception and demeans what is actually a very effective (if destructive) coping mechanism and avoiding terming coping stratagies as such is a more respectul way to proceed

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  • please note the purpose of this article is to identify a gap in the training of general nurses and their inability to cope when confronted by patients who self-harm. My intent is to challenge the attitudes of nurses who are often critical of these patients, labelling them as time wasting as they may not fully understand what has led this group of vulnerable patients to harm themselves or the underlying psychopathology associated with this type of behaviour. The poor reception and treatment they may receive in A&E, as well as other areas where general nurses work, often gives these patients a negative image of the services they receive. My article, to which I gave the title 'Put yourself in their shoes' was written in response to discriminatory comments from some nurses following the article 'Nurses lack skills to treat self-harm' with the intent of influencing such poor attitude and the treatment of patients in desperate need of help, support and treatment and to eliminate discrimination and stigma as such poor attitudes tend to bear a strong influence, in their turn, on the general public where nurses and other healthcare personnel should be setting a more positive example. Unfortunately the editors changed the title, taking a key phrase from the case history I used as an example in the article describing how a patient may feel. However the substitute title, given by the NT editors detracts from the original purpose and impact intended by the author.

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  • bob cat

    Anonymous | 18-Oct-2010 2:45 pm:
    interesting difference in intention. What you seem to be talking about is understanding through empathy, what the NT transformed that into was understanding by being a spectator to and of distress via a sensationalist title?
    Is this a microcosm of what happens at large, a lack of engagement with people and how we feel, and the trade-off in ticking boxes?

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  • important points raised by Tim Stokes which further proves the point that general nurses who encounter patients who self-harm need extensive training in this area. Many thanks, the author

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  • interesting article in the Guardian on the lack of care of those who self harm

    Patchy NHS services may be risking lives of self-harmers. Less than half of psychiatrists surveyed felt they or their team were sufficiently well trained to assess those who have self-harmed, says study

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