Safe spaces and locked spaces: self-harm on acute wards

Trigger warning – discussion of suicide and self-harm

During my most recent series of crisis admissions, I was admitted to an acute ward in a psychiatric hospital after maxing out the two-week stay at a crisis house and feeling that I was unable to keep myself safe after one night back at home. Because in the past I’ve had trouble getting mental health professionals to believe me when I’ve said I was at risk, I now have an advance directive* which states (among other things):

“It is extremely difficult for me to ask for help before hurting myself and it has taken me a long time to reach a point where I can do so. If I am asking for help to stop me from hurting myself, it is because things are so bad that I can’t keep myself safe at home with the help of my family, and my usual coping strategies (e.g. distraction) aren’t working […] Sometimes the only way I can be safe is to be somewhere I physically cannot hurt myself, so the most helpful thing might be to go into hospital or a crisis house. If this were not the case, I probably would not be asking for help. If I say when in crisis that I need to be put somewhere safe, please believe me as feeling disbelieved or not trusted is very upsetting and makes it much harder to tell someone when I am in a crisis.”

It did the job, this time – I asked the staff in A&E to read my advance directive, told them I couldn’t keep myself safe overnight, and (eight hours after walking into A&E) was admitted. But there is more than one kind of safety: there is the physical safety that comes from not having access to anything you can hurt yourself with, and there is psychological safety, which comes from supporting you to fight the self-destructive urge. To move on from a crisis, and to prevent relapse, you need both. In practice, the two are worlds apart.

The gap is particularly wide for women, since being kept physically safe might actually mean being trapped in a room on your own with male security staff guarding the door. Many general hospitals have a Section 136 suite – Section 136 is the section of the Mental Health Act which makes it legal for police to escort someone in a psychiatric crisis to a “place of safety” against their will and keep them there for up to 72 hours while their mental state is assessed. But S136 suites are often used as general mental health holding areas; I wasn’t sectioned, but waited in the suite in UCLH (which, by the way, wins the award for London’s grimmest hospital toilet facilities) for about 4 hours while waiting to be found a bed, and for most of that time there was nobody within my sight or hearing but the two male security guards outside the door. It didn’t make me feel very safe, and you don’t have to exercise your empathy very far to see how some women with, say, PTSD, might be pretty triggered by that situation.

At the point of admission, I think I needed to be on a ward rather than in a crisis house as a locked environment where I had no control over medication was probably the only place I would not have tried to overdose. But I felt so guilty for getting myself put somewhere I couldn’t act on that urge that I refused food for days and, when I did eat, I self-harmed quite severely. The nurse in charge of my care shouted at me (“How many times did I tell you to approach staff if you felt like hurting yourself?!”) and the ward was completely unequipped to deal with the physical side of things: in a hospital with 7 wards, none of them had enough steri-strips to deal properly with my injuries, and on one arm the nurses didn’t close the wound properly, so that the strips intended to close my cut ended up stuck to the inside of an open wound (ouch). In the end I took the steri-strips off them and did it myself, one-handed.**

The places I should have felt safest – the places I was put when I was at most risk to myself – were frightening, unfriendly, and, in the case of the ward, unable to keep me either physically or psychologically safe. Realistically, self-harm is going to happen on wards; someone determined enough, and unwell enough, will find a way around any checks for objects they could hurt themselves with (although the checks that were done were in this case pretty meaningless). Staff on an acute pysch ward need to be able to handle the physical and psychological consequences of self-harm without resorting to frustration, anger or blame.

So although I’m relieved that my advance directive worked, I have mentally revised my definition of safety. A locked space might be a place where I can hit rock bottom psychologically and stay alive (even if only because, to be brutally frank, I would be checked on often enough that I would probably be found before actually dying). But a locked space will not be a safe space until at least two changes take place: one, there is an understanding built into the system of how frightening it is to put yourself in strangers’ hands; and two, there is a monumental shift in the way self-harm is managed in inpatient units.

*a document written with the professionals involved in my care detailing what is helpful and unhelpful in a crisis

**I realise this might be more detail than is entirely appropriate to make public, but I felt like it was necessary to make my point. I’m sorry if it grosses anyone out!


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