Abstract
Chris Millard’s excellent first monograph – happily, available as a free Open Access ebook – puts into historical perspective an issue widely agreed to be a significant mental health concern in the twenty-first century. Taking as his starting point the first stirrings of sustained psychiatric interest in ‘attempted suicide’ in the first decades of the twentieth century, Millard’s principle story is of the emergence of the concept of self-harm as a ‘cry for help’ (usually associated with an overdose of medication) in the middle of the century, and its supersession from the 1970s onwards by the model of self-harm as a means to relieve unbearable inner tension (usually associated with self-cutting).
The ways in which we make sense of ourselves, of our minds and our bodies, Millard argues, correspond to the wider political constellations in which we find ourselves embedded. Specifically here, transformations in the concept of self-harm are mapped onto two key shifts in twentieth-century British political history: the construction of the post-war consensus in the 1940s and 1950s, and its dissolution from the late-1970s onwards. In the context of a post-war welfare economy, characterized by nationalized industry and collective provision of housing and healthcare, an understanding of self-harm (self-poisoning with medication) emerged which was socially-situated, collective and communicative: a pathological ‘cry for help’ in response to dysfunctional social or interpersonal relationships. Between the 1950s and the 1970s, doctors and commentators understood this phenomenon to have reached epidemic proportions. With the rise of neoliberal economics, particularly in the last two decades of the century, this model was replaced by an understanding of self-harm (self-cutting as tension release) which was private, non-communicative, and rooted in the pathological psychology or neurochemistry of the individual.
If Millard paints this epistemic shift in necessarily broad brushstrokes, his command of detail is also impressive. The framework of his argument is filled out through careful, source-based historical analysis, focusing on the complex interactions between legislation, institutions, therapeutic ideas and medical practice. An important factor in the growing visibility of self-harm as a cry for help, Millard argues, was the increasing integration of general and psychological medicine in the middle third of the twentieth century through a series of legislative and administrative changes culminating in the Mental Health Act 1959. The increasing proximity of the two spheres made possible an understanding of self-inflicted physical injury as an expression of psychological disorder. At the same time, the diffusion of psychiatric techniques into the community, which accompanied deinstitutionalization, made possible an understanding of attempted suicide as a socially-embedded form of pathological communication.
While self-cutting was initially seen as a ‘methodological quirk’ (p. 157) by investigators primarily concerned with overdosing, the two increasingly came to be seen as psychologically distinct. Institutional settings are important here. The overdosing epidemic first presented in casualty departments, but clinical concerns about self-cutting emerged from studies of psychiatric inpatients in the 1960s and 1970s, where explanations focusing on internal psychopathology were privileged. In the last decades of the century, the new models of self-harm formed in these studies were able to stabilize. Overdosing began to recede from psychiatric discourses on self-harm, while cutting – understood as an internally-focused tension-release mechanism – rose to prominence. (The definition of ‘non-suicidal self-injury’ in DSM-5 published in 2013 – the first edition of the manual to include a discrete self-harm category – is notable for its exclusion of overdosing.) The central concept of mid-century discussions of self-harm – the socially-embedded, communicative act – was eclipsed by a wholly private, individually-centred model of a pathological response to inner tension.
In setting out his argument, Millard is explicit about his own political motivations for writing: namely, a deep unease regarding the ascendancy of ‘neurological and neo-liberal explanations’ of human behaviour, ‘to the detriment of socially aware, collective approaches that emphasise the environment and the interpersonal parts of human existence’ (p. 208). This privileging of the social over the biomedical is reminiscent of the anti-psychiatric writing of a Szasz or a Laing, but it also situates Millard’s work within more contemporary debates about the way we view mental health, echoing, for example, theorist Mark Fisher’s concerns about the ‘privatisation of stress’ under the increasingly pervasive ‘capitalist realism’ of twenty-first century Britain (Fisher, 2011).
Millard’s focus on the present is evident not just in the argument of A History of Self-Harm in Britain, but also in its execution. The book is written entirely in the present tense, a tactic, Millard explains in an eloquent methodological introduction, intended to emphasize the fact that history – the writing of history – always takes place in the present. History is formed according to our ‘present tools, … capacities, vocabularies and ideas’, and, as such, is always subject to revision and reassessment (p. 7). Writing history necessarily involves making choices, and these choices are necessarily determined by ethical and political concerns. The use of the present tense – combined with a refreshingly liberal use of the first person – destabilizes any assumption that the past is fixed or immutable, or that history writing can exist outside the ideological choices or presuppositions of its author. This book (along with Sarah Chaney’s forthcoming history of self-harm, reaching back into the nineteenth century) will add an important historical dimension to our understanding of a subject of clear contemporary clinical and social interest. But as much as it is a contribution to a particular history, Millard’s book will stand out as a critical intervention in the theory and practice of historiography, reminding historians and their readers that the writing of history is, of necessity, a present-focused, politically-charged and provisional exercise, and that we must be held responsible for the choices we make.