Chris Millard. A History of Self-Harm in Britain: A Genealogy of Cutting and Overdosing. Houndmills, Basingstoke, Hampshire: Palgrave Macmillan, 2015. 268 pp. $31.00 (cloth), ISBN 978-1-137-52961-9.
Reviewed by Paula Hellal (Birkbeck University of London)
Published on H-Disability (May, 2016)
Commissioned by Iain C. Hutchison
This book looks at how “self-harming” behavior has been interpreted in Britain over the decades since the 1930s. The author considers the medical, social, and political contexts as he charts the shift from overdosing to self-cutting. Millard’s study is based on two principal sources: medical and psychiatric journals, and government documents. He intends his work “to show how clinical ideas and medical diagnoses (such as ‘self-harm’) are intimately related to the specific, practical contexts in which they emerge and function. It also shows how shifts in concepts of self-harm correspond to much broader political trends” (p. 1). Millard analyzes in detail how ideas about self-harm changed over the course of the twentieth century. He identifies three phases: self-harm seen as a relatively straightforward and genuine attempt to die; a later interpretation of the behavior as having a complex communicative intent; and latterly a clear focus on self-harm as a method of regulating unbearable emotional distress. Millard’s thesis is that these interpretations cannot be isolated from the social and political context. Although the book considers all three phases, Millard focuses on the middle phase: an explanation of self-harm as communicative and socially embedded. This explanatory model co-occurs with the establishment of the welfare state. The switch to understanding self-harming behavior as non-communicative and related to the individual’s inner state comes about during a shift in the political climate in the 1970s “from a welfare based socially interventionist consensus to one of individuated market oriented competition” (p. 199). Millard, discussing his motivation for the book, regrets the current emphasis on neurological rather than sociological explanations. He accepts that, to a degree, his work can be seen as politically motivated: “The collective aspect of human life is being forgotten in these neurological and neo-liberal reimaginings of human nature” (p. 209).
The first chapter examines early-twentieth-century suicide (or attempted suicide) cases that focus on throat cutting. As in later chapters, the cases are discussed for the light they throw on medical, economic and legal perspectives. Millard highlights the economic costs of caring for would-be suicides before the establishment of the National Health Service (NHS). The financial implications were bound to medical and therapeutic considerations. Was throat cutting, by its nature necessitating surgical intervention, a matter for the voluntary hospitals or “the mental blocks of workhouse infirmaries” (p. 42)? Were the police responsible for guarding against a repeated attempt? The data is mainly from hospital observation wards, the patients compulsorily admitted, and with emphasis on physical restraint. Psychiatric concern centered on determining whether suicidal tendencies were due to organic disease or mental disturbance. The chapter ends with a review of Frederick Hopkins’s (1937) suicide study that highlighted the growing awareness of the social environment in mental health--in particular, the possible roles played by various social factors including relationship difficulties in the etiology of suicide.
The second chapter briefly considers the impact of the Second World War, the founding of the NHS, psychiatric social work, and the growing interest in child guidance on the understanding of self-harm as an act influenced by social and environmental factors. Millard describes how the greater interaction between psychological and general medicine saw self-harm cases observed and treated by psychiatrists and psychiatric social workers, which resulted in growing emphasis on the importance of social environment in both cause and treatment. He considers seminal studies of attempted suicide from the 1950s. The newly established NHS resulted in new specialisms and the establishment of observation wards. Millard looks in detail at work emerging from Ward 3 in the Royal Infirmary of Edinburgh, which “facilitates consistent psychological scrutiny of patients presenting with a somatic injury” (p. 72). He goes on to trace the development of psychiatric social work and home visiting in the early decades of the twentieth century and examines research (in particular the work of Ivor Batchelor and Margaret Napier in Edinburgh) that focused on “broken homes” and “maternal deprivation.”
In chapter 3, Millard turns to consideration of the law and, in particular, the Mental Health Act (1959) and the Suicide Act (1961), with the aim of demonstrating how these acts “combine to lay the foundations for epidemic self-harm in Britain” (p. 98). The Mental Health Act (1959) integrated physical and mental health, removed legal obstacles to the treatment of mental illness, and initiated a move toward community care. The Suicide Act (1961) decriminalized attempted suicide, with the result that the government started to promote psychiatric intervention, with different therapeutic regimes becoming integrated at general hospitals. Government intervention focused psychiatric attention on self-harming patients, with the result that their behavior started to “assume national (even ‘epidemic’) significance” (p. 37). Decriminalization altered the debate “through which attempted suicide is conceptualised” and made possible a “highly social” interpretation of self-harm as a communicative act with complex intent (p. 118). Millard traces the origins, and social, religious, and legal contexts, of the Suicide Act. He examines Erwin Stengel’s work and analyzes the complexity of the philosophical and legal questions that arose from behavior that was increasingly interpreted as being “communicative” or “hysterical.”
In chapter 4, Millard looks at self-harm as a result of domestic distress. He focuses on self-poisoning and discusses research undertaken in Edinburgh, particularly the work of Neil Kessel, who considered self-poisoning the result of emotional isolation and failure to adapt to domesticity. The role of psychiatric social workers is again examined: “As mental health care becomes increasingly organized around outpatient departments, the twin practices of home visiting and social history-taking have even more potential to fabricate a credible social space around any given case of mental disorder” (p. 131). Adverse domestic settings, and medical and societal anxieties around prescription drugs including sleeping pills, all come to the fore. There is a gendered interpretation of domestic stress. With “feminine lack of resilience and male lack of support” implicated, a “specifically feminine aspect to self-poisoning” starts to emerge (p. 138). Millard looks at how many of the old observation wards became treatment units, investigating the prevalent ideas, practices, and assumptions. As he points out, during the 1960s those admitted to hospitals following an overdose “are not being asked about their internal, emotional states … or about their family history of mental illness. They are being questioned about their social setting, their relationships with others … all this in order to make sense of the attempt” (p. 152)
In the final chapter, Millard looks at self-cutting. He discusses the “abrupt levelling off” of overdosing by the 1970s--with self-cutting emerging in 1960s and 1970s: “The rise in the prominence of this behavior coincides with a decline in self-evidence for self-poisoning as communication, a cry for help” (p. 155). Millard points out that overdosing came to be seen as an earnest attempt to end life whereas self-cutting started to acquire a quite different interpretation, strongly influenced by American psychoanalytical research. In Britain, cases are mainly from psychiatric patients (as opposed to overdosing cases admitted to hospital accident and emergency departments) and are predominantly female. Millard reminds the reader that the current concern with self-cutting as an “epidemic in the community” obscures the psychiatric hospital origin of the early research. He discusses how explanatory models of self-cutting shift from “sociologically informed perspectives towards an approach more focused upon an internal psychopathology which involves intolerable psychic tension” (p. 191).
In his concluding chapter, Millard summarizes his arguments and examines his motivation for the study along with some methodological points. His central argument is that neurological explanations have displaced the importance of social context. Self-cutting, originally seen as a “methodological quirk” in hospital self-poisoning studies, is later redefined as behavior that may have some communicative function, but is primarily due to internal emotional factors (an explanatory model widely accepted today).
This historical study of self-harming behavior provides detailed analysis of changing practices, assumptions, and ideas in medicine and psychiatry. It roots intervention and etiology in the context of social, legal, and cultural changes. The study shows how ideas change and the processes involved in initiating and sustaining change. Millard highlights the work of key investigators: Hopkins, Batchelor and Napier, Stengel, and Nancy Cook, Neil Kessel, and Norman Kreitman. Alongside analyzing the changing explanations of self-harm in the middle and latter decades of the twentieth century, Millard also considers, in less detail, how care for individuals with mental health problems has moved from the asylum to the community; the role the law has played in the provision of psychiatric care; and how sexism in psychiatry resulted in an interpretation of behavior based on perceived feminine weakness. However, there is little sense of the actual numbers involved despite mention of “epidemics,” and very little attention is given to sources other than academic or governmental. This reader would have liked more analysis of changing societal attitudes to mental health problems. The work might also have benefited from further exploration of the identified gender issues. Another omission is more disappointing (for this reader at least): there is no sense of patient experience, no patient voice. Millard is, however, aware of this possible criticism and addresses it directly in his conclusion. His focus on hospital practices and changing psychiatric ideas about the importance of the social environment in self-harming behavior “does not leave very much space for the patient experience of self-cutting or overdosing” (p. 198). He acknowledges that “the patients and their experiences recede in this telling, as do the psychiatrists to an extent” (p. 199). He holds that his focus on “practices, arrangements, ideas, concepts” enables “new connections to be made around self-harm, society, psychology and politics” (p. 199): a claim that this reader would support.
. Frederick Hopkins, “Attempted Suicide: An Investigation,” Journal of Mental Science 83 (1937): 71-94.
. Ivor R. C. Batchelor and Margaret B. Napier, “Broken Homes and Attempted Suicide,” British Journal of Delinquency 4 (1953): 99-108.
. Erwin Stengel, “Attempted Suicide and the Law,” Medico-Legal Journal 27 (1959): 114-20.
. Neil Kessel, “Self-Poisoning- Part 1,” British Medical Journal 2, no. 5473 (1965): 1265-70, and “Self-Poisoning- Part 11,” British Medical Journal 2, no. 5474 (1965): 1336-40.
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Paula Hellal. Review of Millard, Chris, A History of Self-Harm in Britain: A Genealogy of Cutting and Overdosing.
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