For years now in the U.K. an effort has been underway to train the medical personnel in A&E departments (the equivalent of emergency rooms) about self-injury and how to cope with a patient who presents with a self-inflicted injury. Just recently, efforts are being made in this direction in the U.S, It's crucial work, for the people are often the self-injurer's first contact with the medical system, and if handled badly could prevent someone from ever seeking treatment again.

Horror stories abound: people being stitched without anesthesia, people being accused of attention-seeking and wasting time, people being roughly handled by emergency workers. In many cases, self-injurers do not seek treatment for their wounds unless the wounds are severely infected and beyond their capability to treat at home any longer.

In a 1998 paper, Clarke and Whittaker said, "...we believe that the act is not seen as strictly a 'proper' medical event at all, and that massive elements of a psychosocial and moral kind are suspected, by professionals, to be involved." In other words, professionals are unwilling to assess and treat self-inflicted injury as a medical problem; they call in psychiatric staff when sometimes it isn't necessary because they misinterpret the event as an indicator of extreme suicidality.

Clarke and Whittaker also state that practitioners must recognize the client's autonomy, which ultimately means recognizing and accepting that self-harm is something they do: "Tacitly we accept that some people abuse drugs and we appropriately supply them with clean syringes. Similarly we should give self-mutilators clean blades and first-aid kits."

A more moderate approach is taken by a bimonthly support group, the North West Self-Injury Interest Group. Started in 1995 by Christine Hogg and Maureen Burke to provide education and support to medical professionals, the group acknowledges the difficulty of caring for self-injurers but seeks to provide resources to allow medical professionals to do so in a way that validates caregiver and client. They have succeeded somewhat in their goal of ending the negative stereotypes and punitive treatment that is too often the experience of self-injurers seeking medical help (Hogg and Burke, 1998). You can get information and order their resource pack for training medical professionals by calling +44 151 471-2460.

The National Self-Harm Network in the U.K. is compiling incident reports of mistreatment in A&E departments, campaigning for more private and humane treatment of self-injurers, and publishing a workbook (The hurt yourself less workbook) that will help those who self-injure explore their self-harm, be kinder to themselves about it, and learn ways to get the treatment they need and want (Batty, 1998). The hurt yourself less workbook is available from NSHN, PO Box 16190, London, NW1 3WW. NSHN are also running workshops and preparing a workbook for caregivers on therapeutic approaches to self-harm.

In an interesting experiment in the U.K., Crawford et al. (1998) found that after a brief education presentation about self-harm, doctors and nurses had more positive attitudes about self-injurers, were able to distinguish better which self-injuring clients should be admitted and which discharged to home, and filed more complete notes, improving communication between the A&E staff and the hospital parasuicide team and resulting in better care for patients. They found that junior house staff were able to accurately assess patients using a form and the "SADP" suicidality/depression checklist, and that staff felt more confident in their ability to deal with deliberate self-harm.

In the U.S., some movement is being made to allow self-injurious patients greater autonomy (Loughrey, et al., 1997), but unfortunately restrictive settings with strict no self-harm contracts are still the norm here.

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