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The ‘ Bill of Rights ‘ For Those Who Self Harm
The Bill of Rights For Those Who Self Harm spells out the basic human rights that self-harming patients deserve and should not be shy about demanding.
1. The right to caring, humane medical treatment. Self-injurers must receive the same level and quality of care that a person presenting with an identical but accidental injury would receive. Procedures must be done as gently as they would be for others. If stitches are required, local anesthesia must be used. Treatment of accidental injury and self-inflicted injury must be identical.
2. The right to participate fully in decisions about emergency psychiatric treatment (As long as nobody’s life is in immediate danger) When a person presents at the emergency room with a self-inflicted injury, his or her opinion about the need for a psychological assessment must be considered. If the person is not in obvious distress and is not suicidal, he or she must not be subjected to an arduous psych evaluation. Doctors should be trained to assess suicidality/homicidality and must realize that although referral for outpatient follow-up may be advisable, hospitalization for self-injurious behavior alone is rarely warranted.
3. The right to body privacy. Visual examinations to determine the extent and frequency of self-inflicted injury must be performed only when absolutely necessary and done in a way that maintains the patient’s dignity. Many who SI have been abused; the humiliation of a strip-search is likely to increase the amount and intensity of future self-injury while making the person subject to the searches look for better ways to hide the marks.
4. The right to have feelings behind SI validated. Self-injury does not occur in a vacuum. The person who self-injures usually does so in response to distressing feelings, and those feelings must be recognized and validated. Although the care provider might not understand why a particular situation is extremely upsetting, she or he can at least understand that it *is* distressing and respect the self-injurer’s right to be upset about it.
5. The right to disclose to whom they choose only what they choose. No care provider should disclose to others that injuries are self-inflicted without obtaining the permission of the person involved. Exceptions can be made in the case of team-based hospital treatment or other medical care providers when the information that the injuries were self-inflicted is essential knowledge for proper medical care. Patients must be notified when others are told about their SI and as always, gossiping about any patient is unprofessional.
6. The right to choose what coping mechanisms they will use. No person should be forced to choose between self-injury and treatment. Outpatient therapists should never demand that clients sign a no-harm contract; instead, client and provider should develop a plan for dealing with self-injurious impulses and acts during the treatment. No client should feel they must lie about SI or be kicked out of outpatient therapy. Exceptions to this may be made in hospital or ER treatment, when a contract may be required by hospital legal policies.
7. The right to have care providers who do not allow their feelings about SI to distort the therapy. Those who work with clients who self-injure must keep their own fear, revulsion, anger, and anxiety out of the therapeutic setting. This is crucial for basic medical care of self-inflicted wounds but holds for therapists as well. A person who is struggling with self-injury has enough baggage without taking on the prejudices and biases of their care providers.
8. The right to have the role SI has played as a coping mechanism validated. No one should be shamed, admonished, or chastised for having self-injured. Self-injury works as a coping mechanism, sometimes for people who have no other way to cope. They may use SI as a last-ditch effort to avoid suicide. The self-injurer should be taught to honor the positive things that self-injury has done for him/her as well as to recognize that the negatives of SI far outweigh those positives and that it is possible to learn methods of coping that aren’t as destructive and life-interfering.
9. The right not to be automatically considered a dangerous person simply because of self-inflicted injury. No one should be put in restraints or locked in a treatment room in an emergency room solely because his or her injuries are self-inflicted. No one should ever be involuntarily committed simply because of SI; physicians must make the decision to commit based on the presence of psychosis, suicidality, or homicidality.
10. The right to have self-injury regarded as an attempt to communicate, not manipulate. Most people who hurt themselves are trying to express things they can say in no other way. Although sometimes these attempts to communicate seem manipulative, treating them as manipulation only makes the situation worse. Providers must respect the communicative function of SI and assume it is not manipulative behavior until there is clear evidence to the contrary.
“Self-injury is a public health problem that has been neglected too long. The Bill of Rights for self-injurers is a significant and important first step in bringing this problem into public consciousness and in addressing therapeutic considerations. The Bill of Rights is a unique document that deserves widespread attention. I wholeheartedly support it.” – Armando R. Favazza, MD