Why are self-harm services so poor?

In the latest addition to the BMJ series What your patient is thinking, an anonymous contributor writes of their personal experience of seeking help for repeated self-harm: “I am more than a body to stitch up and label”. Their conclusion is familiar and depressing “I do not expect long term input from NHS mental health services anymore, but there should at least be crisis input available for self-harm”.

I say familiar because it is no news to anybody, surely, that self-harm services are not in a fit state for the scale and importance of the task they should fulfil. Of course, a significant part of the problem is the shameful under-funding of our mental health services, a policy pursued with gleeful vigour by the UK government since the banking crash of 2008. But that alone won’t do as an explanation – we have known about poor services for decades and it’s not the first time I’ve touched on the topic in my blog yet there is still no sign of real improvement. Why is it that so little changes? Apart from the serious external constraints, I see three factors that are internal to mental health services.

The first is attitudes. I’m not going to rehearse the well-known argument about negative attitudes among staff – they exist, they’re unprofessional, they’re not universal. They affect the immediate individual exchange, but in a way what’s more important is the resulting lack of priority given to self-harm services when they are in competition for limited resources. One aspect of this that isn’t often enough pointed up is the unwillingness of clinical psychology services, and more recently IAPT, to get involved. The IAPT therapies manual (v.4, 2020) only mentions self-harm once, to say that the risk needs to be assessed without saying what to do about it. A typical local IAPT service will therefore say “In line with National IAPT standards, the service does not work with…people who present with active risk of significant self-harm”.

A second problem is muddled thinking about the nature of self-harm and especially what it means to say that self-harm is non-suicidal. The big culprit here is the idea of non-suicidal self-injury and how readily what should be (if it means anything) a description of an act becomes a description of a person. The result is that repeated self-harm is not seen as serious, or at least not serious enough, to merit special attention even though it is in fact a risk for pretty much all the poor outcomes you can think of in psychiatry.

Third, and lying behind much of these other factors, is the damaging idea of personality disorder, who you are as a mental illness, and especially the idea of borderline or emotionally unstable personality disorder. Inherent to this diagnosis is the notion that somebody has a sort of inbuilt emotional instability to which self-harm is a response. This formulation comes with a downplaying of experienced life adversity as causal, and with an over-emphasis on framing responses in terms of personal responsibility rather than need for specialist help. It flies in the face of what we know about the many reasons for self-harm that simply aren’t captured by thinking of it as a symptom of an abnormal personality.

Mental health services are off the pace here. Self-harm is a hugely important mode of presentation by people who want and need help and we should rethink how we are going to respond in more effective ways than we currently do. Otherwise we’ll be reading pieces like this one in the BMJ for another 25 years.