Self-harming youngsters put at risk by ‘cycle of shame’

Young people who self-harm only seek emergency hospital care as a last resort due to a deep sense of shame and unworthiness, a study at the University of Exeter has found.

The research, published in the British Journal of Psychiatry and supported by NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula (NIHR PenCLAHRC), shows that young people who self-harm avoid Accident and Emergency departments wherever possible. They say they have received punitive treatment from staff, and these experiences perpetuate a cycle of shame, avoidance and further self-harm.

Dr Christabel Owens, Senior Research Fellow at the University of Exeter Medical School, and her co-authors Lorraine Hansford, Professor Tamsin Ford, and Dr Siobhan Sharkey, found that young people who self-harm visit A&E only when their injuries are too serious to manage at home or when they develop complications.

The researchers analysed the perceptions of A&E treatment in 31 young people between the ages of 16 and 25 who engage in self-harm, looking at their views on what constitutes a ‘positive clinical encounter’ using data from an online discussion forum.

Findings showed that, when forced to seek medical help, they did so with feelings of shame and self-loathing. These intense negative emotions were reinforced when the young people received what they perceived as punitive and stigmatising treatment from A&E staff.

One young person described how, following a visit to A&E, she felt like ‘going home and finishing the job’ (i.e. making a more determined effort to kill herself). Another said that she ‘just wanted to get back home, hide under the duvet and die of shame’.

The young people described positive encounters as those in which they received ‘treatment as usual’ or non-discriminatory care, delivered with kindness, which had the potential to challenge their negative self-evaluation rather than perpetuate it.

Dr Christabel Owens, of the University of Exeter Medical School, said: “Presentation at an accident and emergency department is a key opportunity to engage with a young person who self-harms and sometimes to prevent suicide, and this opportunity is frequently being missed.”

The paper calls for further research into new models of care for the vulnerable group of young people.

Dr Owens added: “It is easy for staff working in busy NHS A&E departments to regard those who present with self-inflicted injuries as mere ‘time wasters’ and ‘attention seekers’. From the perspective of those who have self-harmed, however, nothing could be further from the truth.

“Unfortunately, there seems to be a persistent belief among staff who work in A&E that being too nice will encourage ‘difficult’ patients to keep returning and cause the system (and those who work in it) to collapse under the strain. Our research suggests the opposite, namely that compassionate care is good for everyone concerned.”

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