What is self-harm, and where does it come from? These are the two questions that I am trying to answer in my new, open access book A History of Self-Harm in Britain: A Genealogy of Cutting and Overdosing (2015).
The question really depends upon when and where you ask. In Britain during the 1950s and 1960s, the terms ‘self-harm’ and ‘self-damage’ largely signify taking an overdose of medication. It is also called ‘attempted suicide’, ‘self-poisoning’, ‘pseudocide’ and ‘propetia’ (from the Greek for ‘rashness’). The studies from which such terminology emerged were rooted in hospital Accident and Emergency departments (A&E). At this point, the overdose is generally understood as a disordered communication – a ‘cry for help’ – and is assessed by psychiatrists attached to hospitals, alongside another particular group of professionals: psychiatric social workers (PSWs).
But the idea that ‘self harm’ essentially indicates ‘overdosing as a cry for help’ changes during the 1980s. In particular, the practice of self-cutting as a form of tension release or emotional regulation gains more prominence. Initially studies of self-cutting emerge from inpatient units in North America and Britain. Despite being called things like ‘delicate cutting’ or ‘wrist-slashing’, these studies actually document a wide range of behaviours including self-burning, skin-picking, smashing windows, and swallowing objects such as pins or dominoes. However, self-cutting is repeatedly emphasized as being archetypal in some way (this is a topic I discuss in much more detail in another paper).
Despite this emphasis on self-cutting, the behaviour presenting at hospitals doesn’t really change: between 80 and 95 per cent of the cases under the label ‘self-harm’ in hospital statistics remain self-poisoning. However, there are now huge numbers of studies from psychotherapists, counselors and psychiatrists documenting ‘self-cutters’.
The behavioural stereotypes inaugurated during the 1980s remain substantially intact today. ‘Self-cutting as emotional self-regulation’ is still largely presumed to be the behaviour and motivation indicated by the term ‘self-harm’. The key questions are, why have things changed, and why at that point? The answers are still murky, even after 250+ pages of the book. I am pretty clear on why self-poisoning emerges as a national concern in the 1960s: changes in mental health law in 1959 mean that more psychiatric assessment and therapy can take place at general hospitals (rather than the remote Victorian-era asylums). This increase means that increasing numbers of people are assessed psychologically after arriving at A&E having harmed themselves. Thus, what is normally quite a small amount of damage physiologically speaking can be assessed in terms of a person’s mental state, home life and romantic attachments. Thus we have more possibility for a ‘cry for help’.
PSWs take the lead here, following up patients by visiting them at home and bringing to bear assessments of various life stresses (such as an alcoholic spouse, sexual infidelity or a difficult adjustment to married life). Suicide law also changes in 1961, meaning that people who take overdoses are no longer breaking the law. This allows the government to recommend that all ‘attempted suicides’ are psychologically assessed. Previously it would have been difficult to do this given the technical illegality of such actions (even if it is rarely prosecuted post-1945).
The reason why self-poisoning, rather than self-cutting, predominates at hospital A&E departments is rather mundane. If somebody is discovered having taking an overdose, even only ten tablets, how many laypeople would be comfortable leaving it to chance and advising the person to ‘sleep it off’? These cases, even if thought by doctors to be ‘trivial’, are much more likely to end up at A&E. However, self-cutting of the forearms (the archetypal site) seems much less physically lethal, and more people are comfortable dealing with this physical damage with their own first-aid skills. Thus it is more likely to emerge through counseling, rather than at A&E.
Reasons for the shift in the 1980s from cutting to overdosing in popular usage of the term ‘self-harm’ are much more unclear. Partially it has to do with the delegation of self-poisoning assessment away from hospital psychiatrists in the 1980s. Fewer research psychiatrists coming into contact with the behaviour on such a regular basis leads to a drop-off in studies. But there is another order of explanation that interests me.
In broad terms British society in the 1950s and 1960s is that of consensus politics, of active welfarism and social support, the post-War settlement, the NHS, social work, and commitment to social housing. By the 1980s, exemplified by the ascent of Ronald Reagan in the USA and Margaret Thatcher in Britain, there is a sense of something new: rolling back the state, championing the logic of the market and the virtues of competition and self-regulation. As far as the social setting and social intervention are obvious and necessary in post-1945 Britain, we are told post 1980 that there is ‘no such thing as society’.
It seems to me that we have a form of self-harm in the 1960s that is socially-embedded, accessed by social workers, and fundamentally understood as interpersonal behaviour. It is a very ‘social’ form of self-harm. In the 1980s, the kind of self-harm that resonates is one that focuses upon individual emotional states, and the practice of self-regulation. The very idea of ‘crying for help’ is recast as negative and manipulative; it is never totally free of those implications in the 1960s, but there is a much more prominent understanding of humans as social, communicative beings. This sense of communication is entirely recast in a negative light in the 1980s. Clinicians who want this behaviour taken seriously as a clinical problem (rather than something to be ignored as manipulative) therefore stress the internal emotions, the overwhelming tension, and dismiss or downplay any communicative aspect.
Self-harm has become internal and non-communicative. It has become self-regulatory and not interpersonal. It is difficult not to see this change as relating to the much larger economic and political shifts of the late 1970s and early 1980s. The history of psychiatry can help us to understand that the categories that we use to understand human behaviour are unavoidably tied up with broader political and social circumstances. When we cast mental health or mental distress as internal or external, as social or biological, we are lining up (like it or not) with much broader political questions about the nature of humans. I should end on one of my favourite quotations from Michel Foucualt, words uttered in the course of the debate with Noam Chomsky in their famous debate on human nature:
“The real political task in a society such as ours is to criticize the workings of institutions that appear to be both neutral and independent, to criticize and attack them in such a manner that the political violence that has always exercised itself obscurely through them will be unmasked, so that one can fight against them.”
Even as we attend to self-harm, the ways in which we understand the behaviour, and the ways in which the behaviour is experienced at a deep level, resonate with dominant constellations of power.
In the huge clutter of concepts and shorthands and commonsense with which we make sense of the world, visions of human nature lurk. Before we can contest them, before we can agree with them, we must see that they are there at all.
Chris Millard is Wellcome Trust Medical Humanities Research Fellow in the School of History, at Queen Mary University of London. ‘A History of Self-Harm in Britain: A Genealogy of Cutting and Overdosing’ is published now by Palgrave Macmillan. It is available, open access (thanks to the Wellcome Trust), from the following link: A History of Self-Harm in Britain: A Genealogy of Cutting and Overdosing.