How Would We Deal With Self-Harm Incidents in an Ideal World?

Warning: possible self harm triggers.

One day recently when Julie had cut herself quite badly, I took her to the local GP surgery.  It was the middle of the day, and she happened to have an appointment with the nurse there anyway (to check on a previous wound), so I thought it was worth a punt.  A couple of the older GPs in the surgery will sometimes do suturing for us, but they have to be on duty with time to spare, and crucially you have to persuade the support staff - receptionists and nurses - to ask them if they will do it.  Most of the support staff are firmly of the belief that suturing is something that can only be done in hospital and will often refuse to even ask the GP.  But this time we were lucky: the right GP, a nurse who took pity on us and a free slot.  We waited about 90 minutes, and the procedure took 15, during which he had a chat with Julie, who he has got to know from various incidents over the years.  It was a very low key response: everyone was kind, though clearly concerned.  The whole visit was short enough that I could stay to support her during stitching, and we were home before her regular team finished for the day, so they gave her support over the phone.  By the evening, we were all watching our favourite TV show together and Julie was looking better and it was clear that the crisis had passed.

A week or two later Julie came to tell me she had harmed again: it was 10 minutes past 5 on a Friday night and I was cooking dinner.   The GP surgery had closed, and her regular support team had gone home for the weekend.  The only available option was to go into the district hospital, as we usually do.  I checked her over for anything that needed urgent attention; I knew there was little point rushing her over for anything that could wait.  What had she eaten that day?  Not much, of course - so I finished cooking dinner first and fed her.  I finally dropped her off at the hospital accident and emergency entrance at about 7 in the evening, with money in her pocket for a taxi home.  Friday night is not a great time to pitch up at A&E: she wasn't seen until 1 in the morning and then had to wait for the psychiatrist.  What kind of conversation can you have with a psychiatrist in the middle of the night?  She finally came home at 5, and spent the following day in a state of morose disintegration.  From long and bitter experience, the exhaustion of missing a night's sleep greatly increases the likelihood of a follow-on incident.

This is not to denigrate the service the hospital provides: they do a good job in managing the overwhelming demand for emergency services.  But the contrast with the previous experience is stark.  It is pretty much impossible to stay with Julie when the wait is so long: she self harms so regularly that we've long ago had to make the hard decision to leave her to it.  When she was younger, having one parent tied up in a hospital waiting room could pretty much bring the family to its knees.  We often had to miss work as a result, and it became virtually impossible to carry on with normal life such as shopping for food or paying bills.  Now she is 18 we leave her to it to minimise the chaos, but we do know that busy A&E waiting rooms are challenging environments, especially for a vulnerable young woman.

The advantage of the hospital is increased access to specialist support.  In a different stage of her illness, once she leaves her current service, Julie may benefit from this.  At the moment it can be a mixed blessing: waiting for the psychiatrist is an additional lengthy wait after the immediate treatment for injury has finished, and duty psychiatrists are apt to get edgy about sending her home.  The problem is that they do not know her - in 5 years we have rarely seen the same person twice - and they do not know her support team.  Sometimes they have never heard of the service who deal with her, because it is small; and whether familiar or not, they cannot phone them outside office hours.  I have regularly been called out of bed in the small hours to persuade an anxious psychiatrist over the phone not to put Julie back in an inpatient facility "for safety", and often had to make the long journey to the hospital to collect my daughter in person.

The ideal care might look like a hybrid of these two experiences.  In an ideal world, Julie's regular team would continue to provide care after 5pm and at weekends.  In an ideal world, treatment for minor physical injuries would be just part of the service they provide: they would stitch her up, run blood tests, and arrange for her to talk to someone on site at the same time.  Or they might liaise with her GP if she turned up at his surgery first.  In an ideal world she would talk to someone familiar who had the specialist skills needed to work with her during her crisis, focusing on how she got to this point (again) and how she could have prevented it.  In an ideal world the response would be low key, friendly but firm, not dramatising the crisis but using it as a lever to break open the assumptions and habits that bring her through their doors repeatedly.  In an ideal world, family would be welcomed and encouraged to stay, given practical information and advice and emotional support.

In an ideal world, of course, Julie would stop self-harming.