The National Suicide Research Foundation tells us there were 12,216 presentations of Deliberate Self Harm (DSH) to Irish emergency departments during 2011. They note the highest rate of DSH was among 15-19 year olds.

The purpose of this article is to stimulate discussions and reflections among paramedics around DSH, to identify beliefs around this issue and perhaps, to challenge some of these beliefs.  The Paramedic may be the first point of contact for increasing numbers of mental health patients. Our focus is on repairing physical injuries with little attention being given to the patient’s experience.

Research tells us attitudes are an important concept that relate to emotions, cognitions and behaviours (Ajzen, 1988). An attitude involves a tendency to react in a certain way when confronted by certain stimuli (Oppenheim, 1992). The attitudes practitioners hold towards patients who self harm is an area worthy of exploration. Being met with hostile cognitions and rejecting behaviours may be an additional risk factor for patients presenting with DSH. Morgan & Priest tell us the attitudes of others may be just as important as the psychopathology of the person who dies by suicide (1991).

In Ireland there appears to be a deficit of published research on the attitudes of Paramedics towards patients who present with self harming behaviours. The vast majority of the national and international literature seems to focus on emergency department staff and other allied health professionals in both primary and secondary care. The National Strategy for Suicide Prevention, 2005-2014 cites enhancing awareness and challenging attitudes as a key objective thus it seems appropriate to focus on attitudes in relation to this patient group at this time.

Foster et al define DSH as a non fatal act that causes physical or psychological harm to the self (1997). The National Institute of Clinical Excellence, (N.I.C.E.) defines DSH as an expression of personal distress usually made in private by an individual who hurts himself or herself (2004). Freeman provides us with a number of examples of self harming such as burning, biting, laceration, asphyxiation, head banging, substance misuse, obesity, smoking, inserting or swallowing objects, binge drinking, food restriction, scratching, purging, binging and body piercing. (2010).

DSH is not typically considered an attempt to die by suicide rather it is an attempt to cope with distress, emotional pain, intense anger or frustration. DSH may bring a momentary sense of calm, a release of tension followed by guilt, shame and a return of painful emotions. DSH may be planned or impulsive.

Hawton et al provides us with a number of risk factors associated with DSH such as employment difficulties, housing, finances, inter-personal difficulties, challenges at home or school (2003) further risk factors are provided by Bennett such as deficits in problem solving, despair, guilt and self neglect (2008).

Halgin & Whitbourne argue there may be many individuals who never become the focus of medical or clinical attention because their injuries are explained away as accidents (2009) In children the injuries may be explained as normal “war wounds” this suggests the figure of 12,216 provided earlier may simply be the tip of the iceberg. Those who do engage in self harming behaviours are 100 more times likely than the general population to die by suicide (N.I.C.E. 2004)

Deliberate Self Harm has a huge impact on the day to day life of the individual. They often try to keep what they are doing secret and they try to hide their scars and bruises but the burden of guilt and secrecy is difficult to carry. It can affect everything from what they want to wear, the kinds of sports and physical activities they take part in as well as close physical relationships including sexual relationships. Young people who self harm are all too aware of the stigma of self harm. It can impact on their relationships with their friends, family and their sense of self worth. Young people start self harming to cope with their problems and their feelings. It can set up an addictive pattern of behaviour from which it can be very hard to break free (Mental Health Foundation, 2006)

One common myth about deliberate self harm is that it is about “attention seeking” most self harm is actually done in secret for a long time. It can be very hard for young people to find enough courage to ask for help.

Above all individuals who present with DSH want to be seen by empathetic health professionals who are able to listen, be supportive and non judgemental (Burke et al, 2008).

One respondent to the Mental Health Foundation revealed “They concentrated on patching me up, never have I been asked any questions regarding whether this is the first time I have self harmed, if I was to do it again, or how I intended to deal with it (2006, p.31). Another respondent recalled being told they were wasting staff time and resources which compounded their distress and led them to discharge themselves prematurely. The National Collaborating Centre for Mental Health found 43% of respondents had avoided emergency services because of previous negative experiences (2004). Warm, Murray & Fox reported, medical personnel are recognised as providing the most unsatisfactory support (2002) and N.I.C.E. reported the quality of care and attitudes from staff are unsatisfactory (2004)

Nadine & Barrowclough found male staff, express less sympathy, greater frustration and irritation than their female colleagues (2005) Their findings supported the work of Weiner, who argued causal attributions of controllability and stability, mediates positive affect and optimism in the observer as being influential, in deciding whether help is offered or withheld (1980)

Byrne & Hegman  found a striking number of staff had been attracted to working in the emergency department because of the excitement and drama they believed such work would involve (1997) The respondents distinguished between interesting patients (majors) and less interesting patients (minors) who were described as boring and repetitive. The preferred patient among these respondents was the trauma patient (1997). The patient who could be perceived as being responsible for their own conditions were rated less favourable and considered less worthy of care, concern or empathy (Grief & Elloitt, 1994). Staff with longer experience within emergency departments actually felt more anger towards patients presenting with DSH (Friedman et al, 2006).

Anderson et al found both doctors and nurses find it challenging to care for young people this aspect of their work was frustrating because they did not always have the time or resources to care for the young person (2003)

Mc Carthy et al provide us with an Irish perspective from within the emergency department of Cork University Hospital. They concluded that staff did hold positive attitudes towards DSH (2010) however they cautioned these findings were not consistent with patient surveys and required further research. They noted higher mean scores were associated with specific training. They found a positive impact from in-service training on attitudes towards DSH. They suggest in-service training could play an ongoing role in supporting staff in their work with this patient group. Conlon & O’ Tuathail provide us with another Irish perspective. They found positive attitudes towards self harming behaviours. They noted attitudes towards DSH has a direct impact on the quality of care provided and the nature of the helping relationship (2012)

Mc Loughlin found nurses in Northern Ireland did appear to generally have positive attitudes towards DSH albeit with some stated limitations (1994)

Patterson et al refers to a complexity of attitudinal structures relating to this patient group. They point out there may be a variety of feelings among staff experiences such as powerlessness, empathy, moral judgement, carer confidence or competence when working with this patient group. They note it is important to acknowledge, nurses with high levels of antipathy do not equate to “bad” nurses (2007).
It seems the literature, informs us that the DSH patient presents with a set of complex and challenging needs. It seems some staff  believe they lack the necessary skills and feel they cannot help, some feel helping is futile while others perceive DSH as manipulation and a waste of staff time and resources.
The literature suggests employers provide access to structured time, space and opportunities to learn and reflect upon care experiences, personal reactions, attitudes and behaviours in the context of current understandings of DSH.

It seems the Paramedic is uniquely placed to influence in a positive way, the dominant narrative in relation to individuals who present with self harming behaviours. It might be helpful to establish baseline attitude measures with a view to measuring these over time with a particular emphasis on pre-hospital care in an Irish context.

Brian O'Sullivan, MIACP (April 2015)
PCI College Lecturer
Article first published: The Journal of Paramedic Practice 2014 6:3 pp. 116-118

Brian is a Psychotherapist in private practice based in Laois, Ireland. Brian has a number of years of experience working with young people aged 11-25 years of age and their families. He is also a registered and practising Paramedic in Ireland. He earned a Bachelor of Arts Degree in Psychotherapy and Psychometric Testing. He is currently completing a Master of Science Degree at the Family Therapy Unit, Department of Child & Family Psychiatry, Mater Misericordiae Hospital & University College Dublin.

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