Self-harm is poorly understood in society even among those who in their working lives as school teachers, pastors, social workers, housing officers, police, prison officers and even nurses and doctors encounter people who harm themselves. People who harm themselves are subject to stigma and hostility. In contrast to the trends in completed suicide, the incidence of self- harm has continued to rise in the UK over the past 20 years and, for young people at least, is said to be among the highest in Europe. This high level of self-harm among different age and social groups is a worrying feature of our society.
The focus of this report is to enquire into and report on why people harm and kill themselves and to consider the role (including the limits of the role) that psychiatrists and other mental healthcare professionals play in their care and treatment. The experiences and views of people who harm themselves as well as those of their carers, health professionals and third-sector workers are central to this enquiry. As there is much policy and guidance on self-harm and suicide prevention, the report does not attempt to retrace this same ground but rather examines the evidence of practice on the ground, including the implementation of the National Institute for Health and Clinical Excellence (NICE) guidelines on self-harm (National Collaborating Centre for Mental Health, 2004).
This report is the second in the Royal College of Psychiatrists’ programme of work on the broad issue of risk. The College report Rethinking Risk to Others was published in July 2008 (Royal College of Psychiatrists, 2008a) and a new Working Group was set up under the chairmanship of John, Lord Alderdice, to examine risk, self-harm and suicide. This clinical issue is an integral part of the role of the psychiatrist in ensuring the good care and treatment of patients.
Our central theme is that the needs, care, well-being and individual human dilemma of the person who harms themselves should be at the heart of what we as clinicians do. Public health policy has a vital role to play and psychiatrists must be involved and not leave these crucial political and managerial decisions to those who are not professionally equipped to appreciate the complexities of self-harm and suicide. But we must never forget that we are not just dealing with social phenomena but with people who are often at, and beyond the limit of what they can emotionally endure. Their aggressive acts towards themselves can be difficult to understand and frustrating to address, but this is precisely why psychiatrists need to be involved to bring clarity to the differing causes for the self-destructive ways in which people act and to assist in managing the problems for the people concerned, including family, friends and professional carers, who sometimes find themselves at the end of their tether in the face of such puzzling and destructive behaviour.
The report is divided into three parts. In Part I, we give some background information on self-harm in the UK and on understanding why people harm themselves. In Part II, we examine some of the public health policy issues, and in Part III we concentrate on the practice of healthcare professionals and others who work with people who have harmed themselves and are at risk of harming themselves, as evidenced particularly by a survey and consultations with College Members and Faculties. The important role of the third sector is also examined.
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