the clean blades debate

[helenic]

Topic of the moment is self-harming and the minimising-harm/enabling controversy, as sparked by an article in the Times entitled "self-harmers to be given clean blades". Much of what needs to be said already has been, particularly in the discussions here and here, and the extremely well-written entries by arkady (here), rathenar (here) and forthwritten (here).

Acknowledging that self-harm is a serious issue that needs to be taken as seriously as drug addiction (although both could benefit from less prejudice and misinformation in public debate about them) is entirely a good thing. Providing bandages, clean dressings, and safety information to self-harmers are also, in my opinion, good things. However, I don't think blades should be given to people who come into the clinic with self-inflicted injuries. They should be treated without judgment or prejudice by people who have information on the phenomenon rather than an outdated set of assumptions; they should be referred to a mental health specialist if only for a preliminary meeting; they should be given first-aid advice. If the NHS is handing out free first-aid kits so much the better. But with blades, the potential harm is greater than the potential good. Infection is a danger, but it can be treated, and I'd rather see it continue to be treated (and treated more effectively) than see people who previously had not used scalpels be encouraged to start doing so. Even if clean blades were only given to people who already had severe self-harm habits (so that scalpels wouldn't be an "upgrade" in terms of the severity of their cuts) and who had already got infected (and therefore couldn't be trusted to be relatively responsible about their addiction), if this was made public it could easily encourage less severe self-harmers to worsen in order to get the free blades - and the status they could quickly come to represent. And while many people who are trying to recover find that possessing the blades represents a necessary safety net - that knowing you could is essential to continuing to choose not to - I have also had periods of my life when having the means conveniently to hand enabled me to self-harm when otherwise I might have been able to cope with the situation by other methods.

I don’t think self-harm is necessarily the worst outcome of a desperate situation. It is a short-term coping mechanism, and a very effective one. However, because of its addictive nature recovery should be the first focus of treatment - affirmation that it’s not the worst thing in the world and cycles of guilt are futile, but that there are longer-term mechanisms which don’t promote dependence, don’t carry physical risks, and don’t leave visible permanent scars. At the risk of sounding unsympathetic, the fact that it can be an addiction is on occasion presented as a licence to indulge.

While I can envisage individual cases where providing clean blades might minimise risk, therefore, on a general scale I think these are outweighed by the dangers of enabling a behaviour which is frequently begun by people under the influence of others, and who, if they hadn’t been exposed to the idea and the opportunity, might well have not “needed” to start at all. I do believe that if someone is damaging themselves for the sake of attention then this is a signal that something is wrong (and that a part of their life which has been ignored has issues which need to be addressed) rather than merely a childish, indulgent behaviour to be mocked and condemned. On the other hand, there are other less damaging and less addictive ways of attention-seeking, and I think in many cases, particularly younger ones, addressing the causative factors is far preferable to enabling a habit that has not yet deeply taken root.

For the same reasons, I don't think "SI dos-and-don'ts" should be available in waiting rooms or to anyone who mentions self-harm. To a mind already inclined to the self-destructive, the "don'ts" could all too easily be misused. The fact that this information is online is irrelevant - if people have not already sought it out for themselves, it should not be distributed pre-emptively. Someone admitted to A&E with serious damage from self-harm, on the other hand, should definitely be given information on an individual basis. It’s surely self-evident that giving someone who has deeply lacerated their belly and stomach safety information, risk warnings, and suggestions of less dangerous options, is very different than saying to someone with scratches on their forearm “and under no circumstances must you cut your breasts, because it’s very dangerous and easy to cut deeper than you mean to”. As with EDs, my stance is fundamentally pro-reality. Acknowledge that the recovery process is extended and difficult and offer support during it, but equally don't do anything that will risk making less unwell people worse, and do emphasise the benefits of recovery above all else. Just because it's difficult doesn't mean it's impossible, doesn't mean it's not worth it, and doesn't mean you shouldn't try.

The other point in the article was about the possibility of nurses or mental health practitioners counselling patients while they self-harmed. It was not made clear what the intended context of this was - whether A&E, clinics, psychiatric wards, in-patients or out-patients - but the majority response from self-harmers seems to be that it is an intensely private thing, and that being obliged to do it in front of someone would be needlessly traumatic rather than helpful. It might discourage someone from self-harming in the short term, but if they’re in-patients then the old point about “just because I’ve had to stop doesn’t mean I’m better” stands, and if not what’s to stop them doing it privately when they get home? This idea is clearly motivated from a sympathetic standpoint, which is laudable, but I can’t see it as really being effective.

Overall, reading this article inspired me with confidence - not because of the details, which need work, but because of the shift in attitudes it demonstrates. Many people working for the NHS and passing these resolutions won't have first-person experience of self-harm, and no matter how many self-harm patients you've seen, unless you've done it you're more like to miss the point. I'm not surprised the details are flaky. But they're trying, and that's such a massive change that I'm thrilled. Of course the proposals should be criticised, but not to the extent that the idea will be dropped altogether. This needs to be thought about and as far as I'm aware it's the first time it has been, in an official and publically sympathetic way. That needs to be maintained and encouraged, rather than condemned entirely for not having insight I wouldn't expect them to have. We now have a place to stand on which we can get the details right and correct the more misguided aspects of the effort, and that's incredibly significant.

Comments

[ashfae.livejournal.com]

And while many people who are trying to recover find that possessing the blades represents a necessary safety net - that knowing you could is essential to continuing to choose not to - I have also had periods of my life when having the means conveniently to hand enabled me to self-harm when otherwise I might have been able to cope with the situation by other means.

My experience dictats the latter rather than the former, certainly. I was only able to start dropping the habit by getting rid of all my blades. Combined with willpower and pointed self-distraction, but it was most definitely an out of sight out of mind thing. If I had the blades, I used them--so I stopped letting myself have access to them, or anything else sharp.

Granted, it wasn't a solution...there were still fingernails and other such methods. But it definitely helped cut down on things.

This is true for most of the other people I know who've gone through periods of self-harm, too. Granted, I don't think any of us were particularly severe cases.

I'm glad to hear it's at least being treated seriously. For me it was like a very weird addiction, and I still, years and years later, feel the cravings now and then.

[libellum.livejournal.com]

I wouldn't be surprised to find out that most people had gone through both phases. When I first stopped cutting at 18 or so I did keep the blades, as a safety net I guess - I know they're there if I need them, so I can sleep easy. Also opening the drawer and looking at them and closing the drawer again re-strengthened my resolve. The thing is that I've never bought blades, I've always made my own out of razors or specially sharpened kitchen knives, so there's a ritual act involved before the self-harm act itself. Or scissors - I used scissors and very little else between 2001-2004. So I've never had a "stash" of blades to throw away in a symbolic manner, and if I had there would still always have been other things I could use just as effectively, so it wouldn't have done any good.

These days one of the ways I know I'm better is that there are boxes of scalpels in the house, for other reasons, and until writing this comment it had never even occurred to me to steal one for self-harm purposes.

The cravings never really go away. I think that's almost universally true.

[mr_magicfingers]

All I can say is that I'm glad I didn't have access to free scalpels back in the day. To be honest, that doesn't bear thinking about.

[libellum.livejournal.com]

*nods*

It's an interesting one. I mean, I was never hospitalised for self-harm; there were several occasions when I could have been, but I did my own first aid and my own laundry and didn't tell anyone. So I wouldn't have had access to them. But then, I didn't realise pharmacies sold razorblades and scalpels - I'd nick scalpels from the laps at school and prise the blades out of cheap disposable razors. It was so private I didn't really look around for more publically available methods. I don't know how common that is, and I don't know what the common factors are between people who end up in hospital with self-harm injuries. Public episodes? Extreme violence - using broken bottles rather than neat little blades? Or simply damaging themselves much worse than I did? I'd be fascinated to know how many hospital admissions are self-referred and how many by other people, just to get an idea of which corner of the demographic these changes would actually affect.

[proctalgia.livejournal.com]

I have to say that my feelings on self harm in general (and, ergo, the provision of clean blades) is somewhat.. confused. I know that the 'proper' feeling to have is one of sympathy for self-harmers. I'd be lying if I said that I felt much of that. I've never accepted that self-harm should be 'problematised' to the degree that it is: unlike most vices (drinking being the obvious example) self-harm is constructed as an error irrespective of its intensity. It is intolerable, in toto - the idea of a 'moderate' self harmer joining the moderate drinkers is culturally alien: all self harm is thought of as abhorrent, etc.

If one drinks a little and says that he has control over his drinking, he's not an alcoholic. If I argue - and this is the truth - that my self harming was never a problem to me, that the scars I have do not bother me, that I like pain and I like bleeding, and that, furthermore, my actions were entirely rational, then this would be thought of as symptomatic of my destructive behaviour: even the denial of a problem is configured as a symptom of the 'disorder'.

In other words, if our culture is going to talk about self-harm - which is not all that rare these days, sadly - it only does so through a banal discourse of illness: diagnostics and prognosis (Underlying all the vapid- politically correct talk of mental 'health problems' is the age old conception of a diseased mind). I cut, burned, starved myself, plotted my own death, and never ever thought of that as a problem. Why? To put this at its most simple - I've never understood what the fuss was/is all about. I think it is a far more interesting to ask why self harm is not socially acceptable given that, for many, it is clearly an efficacious coping mechanism - whereas other destructive behaviours, drinking, smoking, etc. are - than to ask why people self harm (the latter question not being all that mysterious whether one takes a 'biological' or a 'sociological' perspective). What I do not like is the taboo against saying that self-harm has a positive function and that there are people, such as myself, who had not at the time and lack still today the slightest interest whatsoever in being 'helped' or 'recovering'.

For similar reason, I can't get heated over other people's self harm. I think self harm can be regarded as, for most, a particularly potent way of communicating ennui to a society that is receptive to the terminology of its blood. But only the blood of victims, not of the proud. A society might listen to the language of self harm but only if the messenger subordinates his behaviour to the discourse of therapeuticism: those who call for a change in social attitudes to self harm never have in mind a revolution of social paradigms. But I for one want something a little less banal. Whereas, once, the act of harming the self with razors may have communicated great suffering, now it seems to communicates little that is profound. Maybe it was once a given that the self-harmer had something profound, or at least interesting, to 'say' about the human condition. Now, the language of self-harm having, in many senses, become normalised but ensnared within the confines of a disease/d paradigm, so many are fluent who have no valuable message.

[proctalgia.livejournal.com]

As such, I find it difficult to 'interact' with the concept of self harm. I do not have any great sympathy for self harmers, and I do not have disdain for self harmers: I feel nothing for them, if they want to cut their arms off, I couldn't care less. It seems to be a case of: You cut yourself ....and? Self harm is no longer, in my mind, sufficient as a communicative device and I do not feel capable of tailoring my thoughts to self harm, qua self harm. For the self harmer, I feel nothing. I would never censure others but nor would I pay them any special thought. What I dislike with self-harmers is that the vast majority - excluding the contribution and the links here - that pervade internet forums, that occasionally speak on radio, etc., never say anything interesting: not only do they adopt what I think could be referred to as a semiotic language of self-harm, but also the spoken language of pharmocracy. It is though they have no real personal story: just serried cliche. It seems, though, that it has become enough to say that one self-harms to vouchsafe that one's 'suffering' is taken seriously when this should surely be the departure point, not the conclusion, for the telling of somebody's personal tale.

As I warned, my feelings are this matter are confused. Such that this comment is confused. It might be argued that I'm simply offering a convoluted charge of "attention-seeking" - although, with resepct, I would not agree that that encapsualtes what it is that I want to say even if I do confess that I find it difficult to take most self-harmers seriously these days (I found Kelly Holmes's recent whining risible: and I do think that a lot of people, certainly not intentionally, are jumping on a semiotic bandwagon because self-harm has become a principal means for symbolising 'uncivil' emotion - in the Elisian sense of the word: in other words, establishing a metalanguage through proto-behaviour. It is not deliberate, of course, and it is no doubt not a conscious choice, but a case can be made - at least I think so - that the linguistic power of self harm has take ascendency over its root 'biological fucntion' for a fair few people: it is about relieving stress, no doubt, but it also about *manifesting* stress.

-
I hope that I have written something that is not total hokum. In summation I might say that: (1) whenever I read/hear a self-harmer recounting his life history, I don't feel empathy as much as I do abject boredom and world weariness and (2) self-harm should be liberated from medicalised thinking so that people, such as myself, who feel more like gods than like victims when rewarding themselves with abuse, can tell our tale too.
daniel -

[(Anonymous)]

The biggest and most damaging shit-storm we ever had on Uk.People.Support.Depression was the day that someone posted that he'd gone out and bought sterile blades for someone in the house that he knew was going into a crisis and would definitely self-harm.

Mentally-ill people in crisis had no access to emergency medical services in that postcode at that time; the local A&E was particularly mediaeval in its attitude and brutal in its mistreatment of depressed people in sh-ers in particular. There is no way that he or I could've persuaded her to go.

And compelling her would've blown her trust in just about the only people she had left, who knew and understood and would've given a toss if she bled out and died on the lino.

In the absence of anything better, I guess the clean blades were about the only thing he could do. I personally take the view - untrained and unprofessional as it may be - that there are worse things than the release of cutting. And yes, she cut herself in front of him: nothing he said, no gesture, no affection, no distress, no attempt to be the only calm and understanding person left in the world would stop her.

She got stitches, eventually. She's never spoken about the treatment she received there and I can only hope that she speaks to her psychiatrist about it, some day.

And yes, I've gone out to the all-night chemist for lint, micropore dressings and butterfly plasters for someone in the house. But not blades: thankfully, I haven't been confronted with that decision, yet.

Back to your point, and that article in the Times. It is a ghastly admission from a senior public official that all he can do, in the face of his own ability to secure effective treatment for people who are that ill, is to look at marginally minimising severe harm, and hand out scalpel blades to people who are in fact and in law a danger to themselves. But I don't have it in me to criticise his decision: I suspect that he knows the realities, he's seen the truth close enough to go home with the bloodstains on his cuffs, and he is just as frustrated as we are by his inability to change anything for the better.


Apologies for the anonymous post, but there's no way my LJ-Tag goes up on a public post about UKPSD. It's not just my name, the link carries a risk of identifying individuals I knew, or still know, who really do need the anonymity.