What we talk about when we talk about self-harm
More than a symptom of mental distress
In professional (clinical) discourse, the definition of self-harm is pretty well established now. Rather clunkily the World Health Organisation defines it as: “an act with non-fatal outcome, in which an individual deliberately initiates a non-habitual behaviour that, without intervention from others, will cause self-harm, or deliberately ingests a substance in excess of the prescribed or generally recognised therapeutic dosage, and which is aimed at realising changes which the subject desired via the actual or expected physical consequences”.
More succinct is the definition adopted by the UK’s National Institute for Health and Clinical Excellence “self-poisoning or self-injury, irrespective of the apparent purpose of the act’”.
Really the only debate among clinicians is whether it’s a good idea to include motivation in the definition. Those who do think it is a good idea will typically go with the staggeringly popular term non-suicidal self-injury. Those who (like me) think it isn’t a good idea take note, for example, of the ambivalence and uncertainty about motivation that so many people express and the apparent paradox that a non-suicidal act is a risk for a suicidal one. There’s a strong tendency for those who write about non-suicidal self-injury to conflate episodes and people. People with alcohol dependence may prefer drinking wine or beer or spirits, and there may be differences between those who major in one or the other (gender, wealth, social class or whatever) but basing an analysis of problem drinking upon preferred tipples doesn’t seem a very interesting way to think about the underlying problem.
Looking outside the rather limiting arena of diagnostic labelling, I have been struck by the diversity of places in which the idea of self-harm crops up, and I have wondered what that tells us about what self-harm means in the day-to-day world. Here are some examples.
Eating disorders and alcohol or drug misuse. One of the commonest questions I have been asked by people who learn that I have an interest in self-harm is whether that interest includes eating disorders. Certainly there is overlap between these states – self-harm commoner in those with eating or substance misuse problems, and both those problems commoner in people with self-harm. Conventionally however a distinction is drawn: harm to the body is not the intended aim even of life-threatening anorexia nervosa or addictive alcohol or drug consumption.
Punishing routines. Here I include extreme sports like ultra-marathon of high altitude marathon running, transient phenomena such as the ice bucket challenge, and sadomasochistic (BDSM) activity – explicitly sexual or otherwise. Here again, infliction of damage is not (or is rarely) the intended aim but rather the infliction of pain or the enacting of role play involving dominance or passivity.
Body modification can take many forms – typically tattooing, piercing or (less commonly) scarification. Although Favazza draws strong parallels in his classic text on the topic, they are generally considered separate behaviours on the basis that although the resultant bodily changes are intended that are seen as aesthetically desirable and therefore neither harm nor damage, and they are, except in extreme cases, seen as socially sanctioned rather than signs of individual pathology.
Mortification of the flesh – something of a cross between punishing routines and body modification, practices like flagellation and prolonged fasting are perhaps less common than they were. Their aim is to damage the body but with reasons that are socially sanctioned by at least a sub-group of the population – usually undertaken for religious or political purposes.
Organisational self-harm is the term I apply, for now, to instances that crop up in the media of self-harm used to describe an action undertaken by a corporate body or group of people and regarded as self-defeating by its critics. Examples might include a football team getting rid of a favourite player or manager mid-season, or the UK’s decision to leave the EU. Here the idea seems to be that damage may not have been intended but the guilty party’s actions were so reckless as to consequences – “What on earth were they thinking?” – that the harm might as well have been intentional.
Some of this is widely recognized in the self-harm literature, some of it less so. With the exception of the link to eating disorder it is largely ignored in the mainstream media but quite well represented in social media – for now, unless it is to be clumsily suppressed in the name of “regulation”. What it speaks to is self-harm as a phenomenon with social and cultural meanings that needs to be responded to in ways that go beyond melodrama and appeals for more investment in mental health services. A public debate along these lines has hardly got off the starting blocks.