What Is Self-Harm, And How Do We Know It?

Image: Annie Spratt

Wednesday 20th March, 2019

By Chris Millard

The media coverage surrounding the tragic suicide of Molly Russell was entirely consistent with one set of understandings of what is considered ‘self-harm’ today. This idea most often focuses upon self-cutting, as exemplified in the exchange between Nick Clegg and a BBC journalist - ‘slit wrists!’ and ‘smeared blood!’ - covered in previous blogs in this special section. This version of ‘self-harm’ is exceptionally narrow and does not hold up in other contexts even today, and it is further undermined if we look back into the recent past.

Given the dominance of ideas of ‘slit wrists’ and ‘smeared blood’ it might be surprising to learn that the group of people recorded as ‘self-harmers’ at the A&E departments of British hospitals are overwhelmingly (c.90%) people who have taken an overdose of medication. There is much controversy around whether overdosing is an act of ‘self-harm’ or an attempt at suicide. It is even more confusing to learn that the term ‘deliberate self-harm’ (the ‘deliberate’ part has now been dropped as offensive and/or inaccurate) was first proposed in 1975 to describe a group of people, 95% of whom had taken an overdose. 

Just to add even more to the confusion, back in the 1950s, studies of what was called ‘attempted suicide’ focused upon people who had taken overdoses. However, these people were not understood (by psychiatrists and social workers) as actually attempting to die; the people in these studies were thought to be harming themselves in order to communicate their otherwise unbearable distress to those around them, in order to get help and support. This ‘attempted suicide as a cry for help’ therefore seems much more like what we would call ‘self-harm’ today (although important differences remain).

In some ways, the easy elision between self-harm and suicide is understandable. Certainly the commentary around Molly Russell’s suicide has presumed and strengthened that link. However, we should be careful of starting at an act of suicide, and then reading backwards, searching for self-harm. 

The idea of self-harm as we know it today, which is focused upon the acts of self-cutting and self-burning, was first named as a clinical problem because it needed to be separated from suicide. In the 1960s in the USA and Britain, in residential units for psychiatric patients, adolescents began to be recorded as cutting themselves, in addition to a large number of other ‘problematic’ behaviours. These included breaking windows, setting fires, smashing crockery, absconding from hospital, swearing, and refusing to take medication. It seems strange to put these behaviours alongside what was called ‘scarification’ or ‘self-mutilation’. As time went on, those behaviours were relegated to secondary importance, and self-cutting was emphasized. Still, the self-cutting was seen as new and interesting and troubling precisely because it did not seem to be related to suicide or a wish to die in any simple way. 

In the late 1960s in the USA, and in the early 1980s in Britain, it became more common, in the published medical literature, to separate episodes of self-cutting from any sort of simple intent to die. Instead, self-harm was figured as a coping strategy, an attempt to release otherwise unbearable tension.

The boundaries of self-harm, the actions associated with it, and their supposed meanings, are still in flux and subject to change. It would be beneficial if the media commentary could take a breath and appreciate a little of the complexity behind human behaviour, its uncertain roots, and its ambiguous meanings. Perhaps when a young person has died by their own hand, this is too much to ask. However it is not helpful for people to reflexively blame social media, assume contagion, and clamour to shut down Instagram posts without some careful reflection. The rush by some people to police and squash self-harm content online seems as rash and dangerous as the problem they imagine themselves to be addressing.

Chris Millard is Lecturer in the History of Medicine and Medical Humanities at the University of Sheffield. His main research interests concern the history of mental health in Britain, including self-harm, suicide, illness behaviour, child abuse, the history of patient experience, and connections between mental health and welfare.

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