Abstract
Introduction
A number of mental health concerns during the 1990s crystallized around ‘Prozac’, cohering and refracting heterogeneous issues around ‘depression’, psychoactive medication and the influence of pharmaceutical companies (Wurtzel, 1994; Healy, 1997; Shorter, 1997). In a significant shift, the first decade of the 21st century might be characterized as the ‘decade of self-harm’. Mental health workers have been among the most prominent producers of an avalanche of information attempting to categorize, analyse, explain and treat ‘self-harm’. Since 2004 the Royal College of Psychiatrists has produced no fewer than four reports on the issue (Royal College of Psychiatrists, 2004, 2006, 2008, 2010). A set of National Health Service guidelines on the treatment of self-harm jointly produced by the National Institute for Clinical Excellence (NICE) and the National Collaborating Centre for Mental Health (NCCMH) sparked a media furore in 2004, as did a 2006 debate at the Royal College of Nursing Congress, about ‘the nurse’s role in enabling patients to self-harm safely’. 1
More broadly, the pop music sub-genre ‘emo’ became associated with self-harm (as had
‘Nu-Metal’ before it). The
This article makes two interrelated points. First, it demonstrates that the contemporary phenomenon of ‘self-harm’ is rooted in, and substantially created through, a relatively discrete corpus of studies issuing from North American psychiatric inpatient facilities in the late 1960s and early 1970s. Second, it shows that these 1960s–1970s articles expend considerable intellectual and practical effort to establish a stable ‘syndrome’. This effort foregrounds young, feminine patients along with acts of ‘cutting’; it excludes or significantly subordinates other symptoms or patients. This article offers an explanation for these subordinations and exclusions. The current phenomenon of ‘self-harm’ is thus shown to be a relatively recent invention, and a highly specific historical object, despite the claims made in recent literature for its transcendental, ever-present status. The article also contains an implicit feminist thread throughout. This syndrome unequally pathologizes those identified as female; unpicking its gendered construction is a contribution towards exposing this inequality. More broadly, this is an attempt to write history as ‘critique’, to ‘open the possibility for thinking (and so acting) differently’ (Scott, 2007: 23).
Current literature: ‘Self-harm’ as ‘female cutting’
This phenomenon of ‘self-harm’, ‘repeated self-injury’, or ‘self-mutilation’ appears reasonably stable in professional and popular registers; there are a number of characteristics that recur predictably under these different headings. The relative stability of the descriptive terms fosters confidence that broadly ‘the same thing’ is being described. While there are debates on whether ‘self-poisoning’ (or ‘overdosing’) should be included, or whether a certain level of ‘suicidal intent’ disqualifies behaviour from being ‘self-harm’ (Tantam and Huband, 2009: 1, 12; Sutton, 2007: 105–14), these debates are very much peripheral to the central project of psychological treatment, epidemiological analysis and (more recently in Britain) changing staff attitudes at accident and emergency departments.
This stability is interrogated historically here, traced back to a point, or set of points,
in the 1960s, from where the modern psycho-clinical object of ‘self-harm’ originates. The
stability is addressed through analysis of two structural characteristics
2
that run through this phenomenon, making it distinctive, separate and stable – making
it an object for analysis. These two characteristics are that ‘self-harm’ is an activity
carried out principally by those gendered female, and that the stereotyped behaviour
involves cutting the skin. There is nothing particularly special about these characteristics
– they are necessary for any class of objects to exist. They are the particular emphases
that differentiate tables from chairs, mammals from reptiles, or depression from
schizophrenia: they
To this end Adrian Wilson reminds us that ‘concepts-of-disease, like all concepts, are human and social products which have changed and developed historically, and which thus form the proper business of the historian’ (Wilson, 2000: 273). Ludmilla Jordanova observes that this theoretical position opens up myriad intellectual and analytical possibilities: ‘[b]y stressing the ways in which scientific and medical ideas and practices are shaped in a given context, it enjoins historians to conceptualise, explain and interpret the processes through which this happens’ (Jordanova, 2004: 340). 3 The characteristics that structure ‘self-harm’ have not always been what they are now – they have a history.
The
Independent on Sunday (2009) warns that it is specifically
The existence of the gendered stereotype is most clearly demonstrated by attempts to
address it directly; for example: ‘Self-harmers “include boys too”’ (British Broadcasting Corporation News, 2008). Jan
Sutton attempts to explode the ‘myth’ that it is only a ‘female behaviour’. She claims that
‘it is important not to lose sight of the fact that males do self-injure, despite them
appearing to be in the minority’. However, she undermines this position, and her subsequent
analysis goes on to reinforce existing stereotypes: ‘Why the possible genders divide? …
Common theories about why men are in the minority centres on differences in socialisation.’
From ‘appearing to be’ and ‘possible’, we end up with ‘men
Digby Tantam and Nick Huband are perhaps the most equivocal in their appraisal of the
gendering of this behaviour, finding that ‘community studies are inconsistent about whether
self-injury is more common in boys than girls’ (2009: 4).
5
However, their work opens with one of the clearest statements of differentiation
between ‘self-injury’ and ‘self-poisoning’ – they disqualify themselves from commentary on
the latter – which gives the object of their research similar stability: This book focuses on people who repeatedly injure themselves by cutting, burning, or
otherwise damaging their skin and its underlying tissue. This ‘self-injury’ is one of
the two main types of self-harm, the other being self-poisoning with household or
agricultural chemicals, or with medication. … Self-injury and self-poisoning are often
regarded as sufficiently similar to be considered as two facets of one problem. This
fits with the observation that many of those who cut themselves also take overdoses, but
it is not consistent with the very different cultural and psychological roots of
self-injury and of self-poisoning. (Tantam and Huband, 2009: 4)
As well as the explicit differentiation, they compress the varied
‘
However, Liz Frost reminds us that ‘[t]his disputed term – self-harm, deliberate self-harm
and self-mutilation, being the three most commonly used – can refer to a variety of
behaviours’ (2000: 19). Jane Hyman, author of
Louis Arnold, author of a number of pamphlets on ‘self-injury’ for the Bristol Crisis
Centre for Women, is explicit: ‘The most common [form of ‘self-injury’] is probably cutting,
often of the arms, as well as many other areas. Cuts are usually quite superficial’ (Arnold, 2002: 2). Armando Favazza and
Karen Conterio state of their ‘typical cutter’: ‘Skin cutting is her usual practice’ (1989: 283). The Royal College of
Psychiatrists claims that ‘the most common form of self-injury is cutting’ (2010: 21) and
the explicitly psychoanalytic Fiona Gardner claims in Men’s unwillingness to exhibit
She is also explicit about collapsing ‘self-injury’ into one possible type of the
behaviour: ‘[c]utting, often referred to interchangeably in this book as
This object for psychiatric, psychological and sociological intervention draws its
stability, its distinctiveness,
‘Female cutting’ from an historically specific corpus of studies
Many of these texts do not treat the behaviour historically (e.g. Hyman, 1999; Sutton, 2007; Tantam and Huband, 2009). Those that do – principally
academic psychology and sociology – draw unsustainable, transcendental linkages across
centuries, while deploying almost identical narratives from 1800 onwards. Plante argues that
‘[c]utting is not simply a bizarre new phenomenon of the twenty-first century. … Throughout
ancient and modern history and across primitive and contemporary cultures, self-inflicted
bodily damage has been an important and highly symbolic act. … History abounds with
innumerable examples’ (2007: 5–6). Adler and Adler open their book with the concise
statement that ‘Self-injury has existed for nearly all of recorded history’ (2011: 1). This conforms to Adrian
Wilson’s description of the dominant approach to the history of medicine, where … diseases
The most epic and indulgent example of this brings together the Passion of Jesus Christ, Tibetan tantric meditation, North American Plains Indian mysticism and the writings of Franz Kafka and the Marquis de Sade (among others) in a ‘history’ of self-mutilation (Favazza, 1996: 2, 11–16). In accounts such as this, in Wilson’s words, ‘the historicity of all disease concepts, whether past or present, has been obliterated’ (2000: 273).
This is a dizzying array of literature, covering academic sociology, self-help, internet
ethnography, popularizing texts, and books for practitioners, counsellors and clinicians. In
all of the writing on this supposedly ‘hidden’ subject, there appears only one sensitive
historical treatment, critiquing the unchanging profile. Barbara Brickman argues that ‘[i]n
the late 1960s and 1970s a cutter profile was created … typically a white, adolescent girl’.
She points out that ‘that picture of the typical “cutter” appears again and again in popular
articles and fiction’ (Brickman,
2005: 87). As we have seen, we can add psychiatric, sociological and self-help
texts to the popular registers with which Brickman is concerned. However, for all her
awareness of gender concerns, she reproduces the collapse of ‘varied mutilations’ into
‘cutting’: … [e]xcluding other forms of self-mutilation such as burning, head-banging,
self-biting, ingestion of harmful items and chemicals, etc. I selected delicate
self-cutting because it is one of the most frequently observed (and reported) forms of
self-mutilation and because of the instances of cutting in popular media. (Brickman, 2005: 90)
She therefore discounts the idea that the behavioural rather than the gendered stereotype is worthy of investigation. She too gives ‘cutting’ pride of place.
The connection between the late 1960s and the present is more extensive and systematic than
Brickman demonstrates. Modern texts’ references lead to a coherent corpus of studies from
the late 1960s and 1970s, issuing principally from a set of psychiatric institutions in the
north-eastern USA. A comprehensive survey in 1976 mentions ‘classical studies’ of
self-mutilation published in the late 1960s (Simpson, 1976: 290).
6
These are all studies published in academic clinical journals, aimed at physicians
and psychiatrists. There is very little literature on self-harm outside of this rather
rarefied space during the 1960s, apart from a couple of references to Hannah Green’s (Joanne
Greenberg’s) novel
These ‘classical studies’ refer to each other to a substantial extent (especially Pao, 1969; Burnham, 1969; Nelson and Grunebaum, 1971; Asch, 1971; Rosenthal, Rinzler, Wallsch et al., 1972), and these texts became increasingly aware of each other. This coherence was no doubt aided by the fact that 13 of these studies issued from just four institutions: the Eastern Pennsylvania Psychiatric Institute, Massachusetts Mental Health Centre, Mount Sinai Hospital (New York) and Chestnut Lodge (Maryland). This coherence and awareness built up the sense of significance and discreteness implied by Simpson’s description of them as ‘classical’. However, this author initially discovered them independently of Simpson’s literature review, combing the references of contemporary texts (e.g. Walsh and Rosen, 1988; Cross, 1993; Favazza, 1996; Strong, 2000; Gardner, 2001; Plante, 2007) and then using the references of the 1960s–1970s studies to find more. This led back to five studies, all published in 1967 (Crabtree, 1967; Goldwyn, Cahill and Grunebaum, 1967; Graff and Mallin, 1967; Graff, 1967; Grunebaum and Klerman, 1967). The texts that constitute this corpus are regularly – and even reverently – cited in the contemporary literature up until 2007, after which point they seem to fall away somewhat, a point addressed below.
The main studies are briefly sketched out here and their links to the contemporary
literature demonstrated. Harold Graff, a psychiatrist with varied interests including
addiction, recreational drugs and issues of social class in psychoanalysis, wrote a key
paper, ‘The Syndrome of the Wrist Cutter’, in 1967 with his colleague Richard Mallin (Graff and Mallin, 1967). In the same
year, Harvard psychiatrists Henry Grunebaum and Gerald Klerman produced the article ‘Wrist
Slashing’ (Grunebaum and Klerman,
1967). Both of these texts are prominently quoted in Walsh and Rosen’s
Another significant development in 1967 was a symposium entitled ‘Impulsive Self
Mutilation’ (Pao, 1969; Kafka, 1969; Podvoll, 1969; Burnham, 1969) held at Chestnut Lodge, ‘a small,
private psychiatric hospital in Rockville, [Maryland] specializing in the long-term
residential treatment of severely ill (and usually chronic) psychotic and borderline
patients’ (McGlashan, 1984: 573).
Despite its size, Chestnut Lodge was a highly influential psychoanalytic institution,
ranking alongside the Menninger Clinic in Kansas. Not only was it the setting for the
above-referenced series of studies on the outcomes of various psychiatric conditions (the
‘Chestnut Lodge Studies’) by Thomas McGlashan, it was the site for Alfred Stanton and Morris
Schwartz’s
The three main participants in the 1967 symposium were Ping-Nie Pao, a specialist in the treatment of schizophrenics, John S. Kafka, whose interests lay in the experience of time and reality in mentally ill patients, and Edward Podvoll who, among other achievements, founded the Windhorse Project, an experimental psychiatric community. Robert C. Burnham (described upon his death by Kafka as a ‘psychoanalyst’s psychoanalyst … a superb teacher and a subtle clinician’ [Washington Psychiatric Society, 2008]) chaired the subsequent discussion. Fiona Gardner calls the Chestnut Lodge symposium ‘[o]ne of the most valuable collections of papers’ (2001: 21). Lori Plante uses Pao’s term ‘delicate self-cutting’ without referencing him (2007: 7); Gardner takes this loaded word from Pao explicitly (Gardner, 2001: 7). A BBC article buries this term in a list without comment: ‘[t]he practice of self-harming is known by other names – self-inflicted violence, self-injury, delicate cutting, self-abuse or self-mutilation’ (Erlam, 2010).
In Favazza’s study with Karen Conterio, it is claimed that ‘most of the detailed
information about chronic self-mutilators has come from a handful of psychoanalytically
oriented case studies’ (1988: 23)
including a case study by Loren Crabtree Jr (1967), who later worked on the psychoanalytic
concept of ‘transference’ with Harold Graff in Pennsylvania (Graff and Crabtree, 1972). Favazza and Conterio’s
list of references also contains a predominantly theoretical article by Peter Novotny (1972) who worked at the
famous Menninger Clinic in Kansas; J. S. Kafka of the Chestnut Lodge symposium is also named
(Favazza and Conterio, 1988:
23). Lori Plante acknowledges a change in the 1960s, arguing ‘modern psychiatric attention
to self-injurious patterns of cutting and burning only emerged in the 1960s’ (2007: 8).
Adler and Adler state broadly that ‘[s]tudies from the 1960s to the 1980s then noted the
rise of “wrist-cutting syndrome,” associating it with unmarried, attractive, intelligent
young women’ (2011: 14; they
reference Graff and Mallin, 1967;
Grunebaum and Klerman, 1967;
Pao, 1969; Asch, 1971; Rosenthal, Rinzler, Wallsch et al.,
1972). In other words, this relatively discrete and self-referential corpus of
psychiatric texts produced ‘self-injurious patterns’ in new and distinctive ways. Many of
the contemporary texts are rooted in this corpus,
The year 1967 seems to have been an important one, with the Chestnut Lodge symposium being held (though published in 1969), and the much-referenced papers by Grunebaum and Klerman and by Graff and Mallin being published. In addition, an article on the subject by Goldwyn, Cahill and Grunebaum, Crabtree’s case study, and another offering from Graff, entitled ‘The Chronic Wrist Slasher’ (1967), made it into print. These texts produced a very specific rendering of self-mutilation.
The specificity of 1960s ‘self-harm’: ‘An attractive young woman’ and the ‘primary symptom of the slash’
Despite the above-mentioned claims for the virtual omnipresence of this behaviour this
article now demonstrates just how much the current ‘self-harm’ archetypes are a product of
the 1960s. It is not the case, of course, that discussions on ‘self-mutilation’ started in
the 1960s, in a vacuum. The subject has broad ancestry at least as far back as the 19th
century (for example, Chaney,
2011a, 2011b). Indeed,
many of the recent sociological and self-help texts refer to American psychoanalyst Karl
Menninger and his classic
The self-evidence of ‘self-harm’ as ‘female cutting’ starts to fracture if traced back before the late 1960s. For example, Chaney notes that the behaviour of ‘self-cutting’ is ‘not emphasised in nineteenth-century writings’ (2011b: 280). In a case study of ‘self-mutilation’, published in 1932, the self-mutilating patient ‘manually fractured phalangeal articulations of the left hand. … (On the next night she dislocated both thumbs)’ (Conn, 1932: 252).
The emphatic gender dynamic observed both in the contemporary and the 1960s texts did not
figure in Menninger’s work during the 1930s. Most striking is his case study of a
‘self-mutilating’ male mechanic: His arm jerks, carefully observed, proved nearly always to be body blows … his hands
were covered with the scars of minor injuries. ‘Whenever I get a knife in my hand’, he
said, ‘and naturally I have to do that a lot, I always cut myself’ … Three of his teeth
were missing as a result of backhand blows given himself in the mouth while working with
heavy wrenches. (Menninger,
1935: 418–19)
This case is not seen as any more or less typical than the mutilations of a ‘rather pretty woman of thirty’ who killed her baby with a hammer and then amputated her own forearm by having it run over by a train (ibid.: 408–9).
A comment made in 1937 about potential roots of ‘physical self-mutilation’ named two possible mutilative behaviours that sprang to mind, but seem strange to a post-1960s audience: ‘[i]nfantilism, underdevelopment of the sexual organs, and homosexuality may be the basis of physical self-mutilation (scratching the nipples, mutilating the sex organs)’. It went on to speak of ‘[s]elf-mutilation by tickling the palate to provoke vomiting, letting blood from the nose or exposure to cold’ (Dabrowski, 1937: 6, 18). To label self-induced vomiting as ‘self-mutilation’ seems strange in the modern environment where ‘bulimia’ is produced as a separate (but associated) phenomenon. Even as late as the 1950s, a ‘unique case of self-mutilation’ was reported in 1953 where, after some months of diagnosing the problem as bronchitis, it was established that the 42-year-old woman in question had been inserting sewing needles into her chest (Mann, 1953: 220). There is no attempt to structure these examples through an assertion of the primacy of ‘female cutting’.
This is not to say that all self-mutilators reported before the 1960s could
This effort was extensive and pervasive; these two structuring characteristics are related in turn here. The earlier (1967–70) studies established a ‘typical cutter’, summed up by Graff and Mallin: ‘The typical cutter was an attractive young woman, age 23, usually quite intelligent’ (1967: 36–7). Differing clinical diagnoses were irrelevant according to Goldwyn, Cahill and Grunebaum, ‘because they [the patients] were all attractive young women’ (Goldwyn, Cahill and Grunebaum, 1977: 583). Robert C. Burnham noted that ‘[a]n interesting epidemiological feature of this syndrome is that it occurs predominantly in young attractive females’ (1969: 223). Graff remarked that ‘[w]ith few exceptions, the wrist slasher is an attractive, intelligent woman’ (1967: 62). The stability of this profile was noted in accounts after 1970. Stuart Asch, working at the Mount Sinai Hospital in New York, reported ‘a new clinical picture that is almost rigidly consistent’ (1971: 603). A different group of clinicians at this hospital noted that ‘[m]any observers have been struck by the similarities in cutting gestures and the patients’ personality types’ (Rosenthal, Rinzler, Wallsch et al., 1972: 1363).
Rinzler and Shapiro observed that ‘[t]he patient is almost invariably female … (males are rare)’ (1968: 485) and Novotny claimed that ‘[t]he most striking aspect of self-cutting is its higher incidence in women than in men’ (1972: 505). Graff and Mallin argued that ‘[a]ll reports agree that most such difficulties are found in girls’ (1967: 40). 8 Ping-Nie Pao took this further, into the realm of femininity rather than just being female. He described the males that exhibited this behaviour as ‘“pretty boys” and quite effeminate’ (1969: 197) and Asch followed suit, asserting that ‘boys who cut are quite effeminate’ (1971: 612). 9 These articles consistently establish a typical, gendered cutter around which the ‘syndrome’ is based. The precise ways in which this inequality was established are tackled in due course.
These articles’ consistent efforts to render ‘self-mutilation’ as ‘cutting’ were just as
important. Simpson demonstrated an awareness of this difference, but still emphasized the
importance of the particular form: ‘[s]elf-mutilation, specifically in the form of
wrist-slashing, is a relatively common phenomenon’ (1975: 429).
10
The words ‘cutting’ or ‘slashing’ (
Burnham opened the symposium’s discussion (on ‘Impulsive Self-Mutilation’) by arguing that
‘the impulsive, intentional cutting of their own skin is a major symptomatic act’ (1969:
223). Podvoll saw ‘cutting as the preferred form of mutilation’ (1969: 213) and John Kafka
argued for the primacy of cutting, but included another form of ‘mutilation’ alongside it,
describing his patient ‘whose
Identity, authoritative knowledge and the reproduction of stereotypes
Tracing references and isolating a point at which similarities become apparent (as shown
above) is all very well.
11
However, two points need to be explored at this juncture. First, in some of the most
recent publications (from approximately 2007 onwards), the explicit nature of this textual,
reference-based link decreases; contributions such as Sutton (2007), Tantam and Huband (2009) and the Royal College of Psychiatrists (2010)
do not include the Chestnut Lodge symposium, Grunebaum and Klerman or Graff and Mallin in
their references. So we must ask how it is that these reports are still (re)producing the
stereotypes (Adler and Adler do cite them, but in a cursory way [2011: 14]). Second, it is
just as urgent to come to a position on how these structuring characteristics of ‘cutting’
and ‘femininity’ travel from the north-eastern United States to the UK, where many of these
texts are produced. It is important to make clear that it is not being suggested here that
UK clinicians are even necessarily aware of work produced more than 40 years ago in
Pennsylvania, New York, or Maryland. That said, it is notable that after the Chestnut Lodge
symposium was published in the
Roger Smith argues that ‘knowledge of people changes the subject matter. … When we develop our knowledge of human beings, we do not just change knowledge but potentially change what it is to be human’ and this can bring ‘into being new ways of thinking, feeling, acting and interacting’ (Smith, 2005: 56). Ian Hacking pursues a similar argument, that ‘[t]he systematic collection of data about people … has profoundly transformed what we choose to do, who we try to be and what we think of ourselves’ (1990: 3). Rhodri Hayward adds that ‘[l]abelling someone as a kleptomaniac for instance, does not simply change the way we regard their behaviour; it also changes the way they understand their own motivations and the ways that they behave. It initiates what [Hacking] has termed a “looping effect” – an ongoing process of feedback between language, practice, category and person’ (Hayward, 2011: 525; Hacking, 2002). So the 1960s studies appear less relevant as the more modern studies reproduce their findings; as self-harm becomes further entrenched as ‘female cutting’, the more people gendered as female have access to a resonant behavioural pattern said to signify ‘distress’ – the ‘looping effect’.
One result of this is that historical roots of a behavioural pattern are disguised by its
success – the behaviour becomes not only self-evident, but
The existence of ‘looping’ and of ‘making up’ oneself should not be presumed, or treated
like an article of faith: these processes and the
Adler and Adler’s internet ethnography in
This assumption/imposition of an identity, and the narrowing/stabilizing of a stereotype can usefully be considered as two aspects of the same process of ‘looping’ or ‘feedback’. Ideas about ‘human identity’ – partially because many humans experience themselves as ‘self-conscious’ – are curiously potent. Once these stereotypes become established, it grows increasingly difficult to see how the ‘professionally produced’ diagnoses can be considered as meaningfully distinct from behaviours performed by those constituted as subjects of these analyses: in short, the already unstable boundary between ‘authoritative knowledge’ and ‘subject’ collapses.
To approach ‘self-harm’ in this way means that the ways in which people produce, relate to and reproduce authoritative knowledges about ‘self-harm’ can become the object of analysis; the behaviour is not simply seen as inevitable or transhistorical, either as a basic response to some sort of undifferentiated ‘distress’ (Royal College of Psychiatrists, 2010: 21) or, more flamboyantly, as ‘a behaviour that is culturally and psychologically embedded in the profound, elemental experiences of healing, religion and social amity’ (Favazza and Conterio, 1988: 27).
1960s intellectual work on gender and behaviour: ‘Femininity’, ‘cutting’ and ‘slashing’
Having established that contemporary ‘self-harm’ concerns are substantially rooted in the
1960s, and that the possible identities forged there are potent resources for continuing
human action and (self-)understanding, it is vital to subject these identities to historical
critique (following Scott, 2007).
It is not enough simply to
The success of this identification of ‘self-harm’ with ‘female cutting’ should not disguise
that it was achieved through practices of exclusion and emphasis. Structural characteristics
that underwrite ‘stereotypes’ or ‘identities’ do not just appear out of thin air, or out of
the monolithic, important-sounding substitutes of ‘culture’ or ‘environment’ or the
‘experience’ of clinicians. Brickman offers the astute argument that self-harm is
stereotyped as female because: … the medical discourse on ‘delicate’ cutting pathologises the female body, relying on
the notion of femininity as a disease … one begins to wonder if ‘mutilation’ would be
used so readily to describe wounded skin on a less appealing body. (Brickman, 2005: 89, 98)
There is clearly a productive line of analysis, but when accounting for this situation historically, Brickman attributes it to a rather indistinct ‘particular social bias’ (2005: 88). This may indeed be the case – with a net cast that wide, how could it not be? Pushing further, there are far more prosaic, practical ways in which this phenomenon was produced as feminine.
Adjusting the composition of the groups under consideration was quite common and perhaps the most obvious exclusionary process. Graff and Mallin’s sample was originally ‘21 females and one male’. However, ‘[t]he male, a 56-year-old dentist, was excluded from the study because we felt he was atypical’ (1967: 36). In another study, 11 men (out of 35 patients in total) had a history of wrist cutting, ‘but the findings were so different from those of the women that they will be presented in a separate paper’ (Rosenthal, Rinzler, Wallsch et al., 1972: 1363). This paper was never published as far as I am aware, so the presentation of a syndrome that affected only women was artificial to say the least. A 1972 study in London comprised 24 patients who had mutilated themselves, 5 males and 19 females. Of these, 2 males and 13 females were repeat self-cutters, but ‘in view of the extremely small number of men there seemed little point in comparing them formally with matched subjects’. Thus the men were excluded from the crux of the project (Waldenburg, 1972: 16).
Ping-Nie Pao’s gendered exclusions were perhaps the most audacious, marrying numerical exclusion with basic gender stereotype: ‘Of the 32 patients in our series, five were coarse cutters and 27 were delicate cutters’. Unsurprisingly, women predominated among ‘delicate cutters’ and men among ‘coarse’: ‘[o]f the five coarse cutters, four were male and one female, whereas 23 of the 27 delicate cutters were female’ (Pao, 1969: 195). While these groupings were artificial and obviously gendered, it is of interest to note that the divides were not completely ‘clean’ in either case. However, the four male ‘delicate cutters’ were not mentioned again, except, as seen earlier, to call them ‘“pretty boys” and quite effeminate’ (ibid.: 197). In other cases, authors selected patients themselves from clinical records (e.g. Asch, 1971). Thus the exclusion of men was achieved by the assumption that females are exemplary.
In these specific articles from the 1960s and 1970s there are several ways in which samples were produced as gendered. This is even before it is recognized that these studies were predominantly from private psychiatric inpatient facilities where women outnumbered men in this period. However, further analysis of these institutions’ characteristics is beyond the scope of this article.
The work around ‘cutting’ is, if anything, even more strenuous. Edward Podvoll and Harold Graff (from Chestnut Lodge and the Eastern Pennsylvania Psychiatric Institute respectively) both made a conscious effort to promote ‘cutting’ or ‘slashing’ even while noting many other symptoms. Graff claimed that ‘slashing is actually a part of a whole constellation of symptoms which make up a major behavioural pattern … not only the primary symptom of the slash, but the sexual promiscuity, the alcoholism, the addiction to drugs’ (1967: 64). ‘Slashing’ was explicitly cast as ‘primary’, and the other behaviours in this pattern were relegated to secondary status without explanation. He acknowledges a ‘whole constellation of symptoms’, but this does not get in the way of the ‘wrist-slasher’ of the title, or problematize the syndrome pattern he was establishing by their exclusion.
Podvoll speculated even further about the primacy of ‘cutting’, observing that although ‘the self-destructive potential of these patients often extends to burning, biting, toxic ingestion and starvation, they usually return to cutting as the preferred form of mutilation’. This was supposedly because ‘it seems to be the most difficult for the staff to manage – as though no other outward signs would more adequately express their inner distress’ (Podvoll, 1969: 213). Podvoll shows that there are many other symptoms that, while not excluded, were certainly not emphasized, contributing to the establishment of the behavioural stereotype. 12
In two of the articles from the Mount Sinai Hospital (1971 and 1972), a very distinctive
form of mutilation was mentioned, that of carving letters or words into the skin. The latter
article started with a list, in a similar manner to Podvoll and Graff: ‘Almost half engaged
in some other form of self-mutilation, including burning themselves with a cigarette or an
iron; scratching, gouging or rubbing glass fragments into their faces; repeatedly
traumatising fresh fractures; and carving initials in their skin’ (Rosenthal, Rinzler, Wallsch et al.,
1972: 1364). This last behaviour was also mentioned the previous year by Asch (who
was using the same data as Rosenthal … [t]he self-mutilation performed by one girl … [involved the use of] a knife to
scratch the letters ‘LOVE’ on her thigh, just deep enough for blood to flow. … When I
[Asch] wondered at the choice of the letters ‘LOVE’ she confessed that her original
impulse was to cut ‘HATE’ but that she had stopped herself ‘because that didn’t seem
very nice’. (Asch, 1971:
612–13)
This cutting of letters was not seen as going against or modifying any kind of syndrome pattern or stereotype, even though this kind of communication in words or letters seems at least as significant for the patient as the cutting.
Kafka and Novotny recorded additional distinctive behaviours. Kafka’s patient’s foremost symptom was cutting herself and interfering with wound healing, but she ‘also swallowed pills indiscriminately, refused to take medication, and/or cheated on taking medication’ (1969: 207). Thus out of five ‘deviant behaviours’, three involved medication, and only one involved cutting. One may also assume that refusal to take medication and ‘cheating’ on taking it would not have been classed as ‘mutilation’, but this was not seen to affect her status as a ‘mutilator’ (‘swallowing pills indiscriminately’ is rather more ambiguous 13 ). In a similar way, Novotny described ‘patients who insert in their lacerations needles and similar foreign bodies’, but again, this action is not seen as nearly as important as the act of self-cutting, which was constitutive of the stereotype and his article’s title, ‘Self-cutting’ (Novotny, 1972: 510).
Crabtree’s patient’s symptoms were so varied that they were not even unified by the
attribute of actions involving her own body. When she was admitted to an adolescent unit, … [f]acial scratching persisted, soon replaced by deep lacerations of the forearms …
her inability to refuse a dare. She attempted to break windows; she set fires at various
places … she took an overdose of aspirin requiring emergency treatment; she swallowed a
needle. (Crabtree Jr, 1967: 93)
This is a very broad range of ‘deviant’ or ‘pathological’ behaviours. Why these patients, as Crabtree noted above, were labelled ‘slashers’ is not immediately obvious. 14
Rhetorical formulations by Simpson and Pao conceived non-cutting ‘mutilations’ as ‘other
symptoms’, somewhat indeterminate, but definitely secondary. Simpson claimed that
‘ … [a]s a rule, in
The rhetorical strategy of designating non-cutting behaviours as ‘other’ or ‘additional’ helped to establish the primacy of cutting and to actively constitute one of the key structural characteristics that persists in the modern renderings of ‘self-harm’.
As well as the articles that explicitly promoted ‘cutting’ as somehow primary among
self-mutilative behaviours, there were many instances of slippage. Asch described a patient
with very varied ‘self-destructive’ desires who ‘felt that she must do something, squeeze
something, to dig at her wrists with her fingernails, to smash something, to cut herself’.
Even with these varied desires, her behaviour was only ever referred to as ‘cutting
incidents’ (Asch, 1971: 611).
(This may have been because the only desire she ever
Why cutting? Pain, blood, psychodynamics and suicide gestures
Having established that ‘cutting’ was actively promoted, emphasized and highlighted from the ‘multifarious’ observed behaviours of these patients, it is important to attempt an explanation. There are three possible and interrelated reasons for this. First, is that ‘cutting’ was supposed to be a painful behaviour, and yet was not experienced as such by many patients (a concern that is less immediately relevant to the act of overdosing, for example). ‘Cutting’ was also an act that produced blood in significant quantities (unlike either ‘overdosing’ or self-burning). Both these characteristics made ‘cutting’ appear particularly interesting to psychodynamic or psychoanalytical clinicians. Finally, the ‘self-cutting’ literature grows out of a concern to differentiate these actions from attempts at suicide.
The 1960s articles were influenced by and structured through psychoanalytic assumptions, although this was rarely mentioned explicitly. Simpson did state that most of the studies in his survey operated ‘on the basis of some pre-existing psychodynamic interpretation’ (1975: 429), and, in the secondary literature, Favazza and Conterio state that ‘[m]ost of the detailed information about chronic self-mutilators has come from a handful of psychoanalytically oriented case studies’ (1989: 23). However, neither mentions that this intellectual context has specific implications for the form of the clinical object. Nonetheless, specific psychoanalytically influenced concepts contribute substantially to emphases on an abnormal lack of pain and the presence of blood and they bring the action of ‘cutting’ to prominence.
The absence of pain when cutting was seen as one of the strongest unifying features of the early syndrome. Simpson claimed that the ‘typical absence of pain during the actual cutting is a very common and intriguing feature’ (1976: 298). Others note that ‘[c]haracteristically, they did not experience pain but felt relief as the flowing blood “drained something bad from them”’ (Goldwyn, Cahill and Grunebaum, 1967: 584). Grunebaum and Klerman asserted that the ‘absence of pain during the actual cutting is an interesting feature observed in many patients’ (1967: 529). Graff and Mallin noted that ‘the cutter is able to slash herself without pain or with pleasure’ (1967: 40). Even when patients did feel pain, they were cast as atypical: ‘Unlike most patients of this sort, [this patient] was not amnesic or anaesthetic for these episodes in general, but cut and burned (with cigarettes) herself with conscious gratification in the pain she was inflicting and experiencing’ (Burnham, 1969: 225–6).
This lack of pain is partially brought to prominence in this psychoanalytic context by
Freud’s ‘pleasure principle’ which holds that, subconsciously, humans always seek to
experience pleasure and avoid pain and so problematizes actions of self-mutilation. An early
statistical (rather than clinical) study on ‘self-mutilation’ from a large psychiatric
hospital in New York, explicitly referenced Freud, noting an ‘apparent violation of the
“pleasure principle” through self mutilation’ (Phillips and Alkan, 1961: 428). They presented some
of the ‘various theories [that] have been formulated to explain this paradoxical type of
[behaviour]’, rehearsing Menninger’s postulations on ‘focal suicide’ and Otto Fenichel’s
discussion of religiously inspired self-castrations. These discussions focus upon how these
theories remove the contradiction between subconsciously motivated ‘self-mutilation’ and the
‘pleasure principle’ that supposedly rules the unconscious (ibid.: 428–9). Although these
theories were not dealing with the mutilations typically associated with the DWCS
(self-castration, for example), they show that prominent analysts (Menninger and Fenichel)
had
As this ‘painless cutting’ did not contravene Freud’s pleasure principle, it could be more
easily slotted into a psychodynamic schema. The clinicians did not have to explain away the
pain of self-mutilation with some form of more complicated ‘exchange mechanism’ such as
Menninger’s (who
The second explanation for the prominence of ‘cutting’ involves the unique place of blood
in the clinical object of the 1960s and 1970s. Asch simply stated that ‘it is the presence
of blood that is important’ (1971: 612), and other psychiatrists claimed that the
Simpson’s literature survey concluded that ‘[b]lood has a special significance for the
self-mutilator’ (1976: 298) and reproduced this startling personal communication by a doctor
relating one patient’s reaction to blood: The real thing that excites me most is to see my blood. … Deep rich red, the colour,
the velvety warmness … invaded by liquid rubies or a vintage claret – it moves slow like
the birth of a child or like wearing an Afghan coat on a cold day. (Simpson, 1976: 299, 314)
These striking reactions to blood were not uncommon. Asch also noted a ‘specific visual phenomenon. … One patient … explained, “There was too much white, white nurses, white doctors, white sheets, white walls. It was such a relief to cut and see the red blood appear”’ (Asch, 1971: 612). These testimonies show how the emphasis on blood was, at least partially, patient-led.
While a focus upon blood was not a psychoanalytic staple to the same extent as penis envy
or castration concerns, it was analysed and mediated in symbolic ways that were
psychoanalytically inflected. It is important to ask
Some blood concerns were explicitly mediated by observing clinicians. Asch uses Menninger’s concept of ‘focal suicide’ with explicit regard to blood: ‘blood-letting could be a concrete manifestation of one of the classical dynamics of depression, a little suicide’ (1971: 615). Kafka mediated his patient’s testimony with a concept borrowed from prominent psychoanalyst Donald Winnicott: ‘Blood was described by the patient as a transitional object. In a sense, as long as one has blood, one carried within oneself this potential security blanket’ (1969: 209). Thus, the emphasis by some patients on the heightened status of blood attained further significance through psychodynamic explanatory devices, cementing its position in the syndrome, at the expense of ‘mutilative’ behaviours such as self-burning that do not produce comparable amounts of blood. There are infrequent attempts, too, to relate the production of blood to vicarious menstruation (Siomopoulos, 1974; Gardner, 2001) which also feeds into the feminization of the syndrome. There are also other practical, but little-mentioned, ideas, such as Podvoll’s contention that ‘self-mutilation’ was most difficult for staff to manage, which explicitly links the behaviour to the context inside a psychiatric hospital.
Finally, the act of cutting is prominent because the early articles spent much time differentiating the actions of their patients from attempts to kill themselves. Goldwyn, Cahill and Grunebaum were explicit: ‘these individuals lack obvious suicidal intent’ and their ‘self-inflicted injury to the wrist’ is ‘not an attempt at suicide’ (1967: 583, 587). Novotny’s opening sentence also differentiated self-mutilation from suicide: ‘Minor self-inflicted cuts of areas of the skin constitute a symptom carried out without serious suicidal intent’ (1972: 505).
This was a conscious attempt to differentiate between
A 1950s article comparing ‘suicide’ with ‘attempted suicide’ noted more generally that
‘cutting’ had the lowest completion rate for all methods of attempted suicide (Schmid and Van Arsdol, 1955: 282).
Nelson and Grunebaum, talking of apparently genuine ‘suicide attempts’, observed that wrist
slashing is ‘a notoriously poor method of suicide’ (1971: 1348). Thus, ‘cutting’ is seen as
a behaviour with enough
This may seem confusing as the ‘wrist’ part of the archetype does not feature in
contemporary literature, and it has become self-evident that ‘self-harmers’ are not
attempting to kill themselves. However, the modern phenomenon of ‘self-harm’ is rooted in
texts that were concerned with this differentiation and confusion; other actions (such as
interfering with wound healing, self-burning, or arson, all mentioned above) would not
generate the confusion that these articles were trying to clear up. Thus ‘cutting’ becomes
more noticeable. It might speculatively be argued that ‘self-poisoning’, which is
The specific intellectual context of these studies helps to explain the emergence of this
syndrome, through their potential to single out or make interesting
Conclusion
Conceptual literature on the historical nature of disease categories and psychiatric diagnoses throws new light on the history of ‘self-harm’. Durable assumptions and emphases (structural characteristics) concerning the subject profile and archetypal behaviour exist within psychiatric articles that attempted to establish this syndrome. Certain behavioural assumptions and gendered exclusions structure and produce the profile; these exclusions and emphases still largely produce the modern literature. These structural characteristics filtered a range of subjects and behaviours, producing a homogenous illness pattern involving a central act of cutting and a patient gendered female.
Once established, produced through specific exclusionary practices, a behaviour pattern can become self-sufficient, transcending its formative contexts; a wide variety of people can ‘make themselves up’ in relation to it. It is no longer simply American young women in psychiatric inpatient facilities who are seen as at ‘high risk’ for ‘self-harm’. Now, people identified as South Asian women, or lesbian, gay or bisexual, are becoming increasing prominent groups at ‘high risk’ of ‘self-harm’ (e.g. King, Semlyen, Tai et al., 2008; Husain, Waheed and Husain, 2006). Those identifying with or identified within these stereotyped groups are increasingly able to reproduce, refashion and perform them. Regarding ‘transmission’, it is interesting to note that with only a few exceptions (for example, Waldenburg, 1972; Gardner and Gardner, 1975) concerns in 1960s and 1970s Britain about harmful ‘distress behaviour’ of ‘young women’ centred around a supposed epidemic of ‘self-poisoning’ or ‘overdosing’ which was also called ‘parasuicide’ (e.g. Kessel, 1965; Kreitman, 1977). It was not until the mid-1980s at the earliest that ‘self-cutting’ became prominent. This does not mean that ‘self-cutting’ was ‘not happening’, in the UK, simply that the behaviours likely to come to light, to come into the orbit of clinicians (and stand out) in US psychiatric inpatient facilities, and those brought to National Health Service hospitals, were substantially different.
When stereotypes become established (which might register as an ‘increase’, or when hospitals become aware of ‘self-cutting’ as a problem), the profiles and archetypes laboriously constructed in the psychological literature become reinforced as people ‘make themselves up’ in relation to them; these people, in turn, become the basis for further commentary and dissemination of the stereotype in a complex and circular process. Time and space, context and practice, are crucial to the emergence and maintenance of any psychiatric or medical object. These modern experts and (perhaps less surprisingly) media commentators remain unaware of the very distinctive exclusionary practices that divided by gender and structured behaviours so that only certain characteristics ‘made the cut’ into self-mutilation stereotypes.
But in the end, to quote Roger Cooter, ‘So what? Why bother?’ (Cooter, 2010). For one thing, analysis of the
However, there is a broader applicability for analyses of this kind. The central statement
of this article and its theoretical underpinnings might be summarized thus: behavioural
patterns, diagnoses and illness categories are made by human beings, in specific contexts
through specific intellectual and practical processes of sense-making. Behaviours/diagnoses
such as ‘self-harm’ are
This analysis aims to practise ‘history-writing as critique’, characterized by Scott as
‘the attempt to make visible the premises upon which the organising categories of our
identities … are based, and to give them a history, so placing them in time and subject to
review’ (2007: 34–5). The premises of ‘self-harm’ – specifically ‘female cutting’ – have
been exposed as contingent, rooted in specific concerns and practices in the 1960s in North
America. Contemporary ‘self-harm’ is not a natural, eternal, or transcendental object; it is
thus subject to review and the possibility of change. Thus, on a more intimate level –
necessarily a more speculative, but no less important, one – if we begin to understand
psychological categories