In A History of Self-Harm, Chris Millard explores the complex history of self-harm in Britain from the 1930s to the 1980s, with a particular focus on self-cutting and overdosing. The book covers a three-phase shift in clinical concerns and ideas about the meaning of acts of self-harm and psychiatric approaches to overdosing and self-cutting during the twentieth century; this ‘shifting chain of ideas’ (2) is linked to broader changes in mental and physical health and broader political trends. In so doing, Millard stresses that the categories and concepts used to explain self-harm, as well as the motivations underlying self-harming behaviour, are best explained and understood by reconstructing the ‘social setting’. The book asks big questions about explanations of mental distress and the interactions between mental and general medicine and provides meaningful historical analysis that provokes the reader to rethink how we understand and write history.
Millard’s book is composed of five main chapters, structured chronologically, and is based primarily on a critical reading of psychiatric research publications. The focus of analysis is ‘on the ideas of psychiatrists and the clinical and administrative practices they describe’ (4). Throughout, Millard writes in the present tense. He reasons that to write in this way ‘emphasises the story being told is being told in the present, according to the present concerns, and under present constraints’ (8). While Millard’s decision to write in the present tense at first seems jarring, the outcome is a constant emphasis on the relationship between history and modern-day healthcare, medicine and politics and a constant reminder to the reader that self-harm specifically and human behaviour generally (as a clinical object) ‘is bound up and implicated with the much larger currents that ebb and flow in the wider culture’ (209).
Chapter 1 explores the treatment of attempted suicide during the first two decades of the twentieth century, by focusing on the negotiation of ‘its position between the two distinct regimes of mental and general medicine’ (61). Millard argues that the potential for violence associated with would-be suicide was inextricably bound up with the question of how far attempted suicide was suggestive of mental illness (46). During the 1930s, observation wards – often located in local authority infirmaries – were significantly associated with attempted suicide. This association was linked to the characteristic of violence and the observation ward’s ‘attributes in the field of security and restraint’ (52).
Turning to the post-1945 period, Chapter 2 shows how the experience of treating the psychological casualties of the Second World War spawned ‘a huge number of interpersonally focused psychotherapeutic practices’ (62), giving credence to what became known as the ‘psychosocial’. Central to the renewed focus on the social setting were the creation of the NHS and the expansion of social work and welfare provision. Millard emphasises first the role of the NHS in strengthening interaction between psychological and general medicine and, second, the role of psychiatric social work in bringing the social environment and ideas about the family and the home to the fore; this conceptual shift underpinned ideas of communicative self-harm. The reading of self-harm as a ‘highly psychologised, highly social’ act is further explored in Chapter 3. Millard focuses on the Mental Health Act (1959) and the Suicide Act (1961) to show how legislative changes promoted the integration of different therapeutic regimes at general hospitals and enabled broader governmental intervention. The two acts combined to lay the foundations for epidemic self-harm in Britain by the mid-1960s, by focusing psychiatric attention upon the physically injured attempted-suicide patient at general hospitals.
Chapters 4 shifts the focus back to the profession of psychiatric social work (the role of the psychiatric social worker features in Chapter 2) and describes how the profession is key to the conceptualisation of communicative self-harm. Set against the backdrop of de-institutionalisation in the 1960s, Millard reveals the development of self-poisoning and attempted suicide as part of ‘the broad turn to the social setting’ (121) and the consideration of its impact upon mental health and well-being. Patients presenting at hospitals after having harmed themselves were asked questions about their current social setting and relationships in an effort to understand the nature of their ‘distress’ and to make sense of the attempt (152). In Chapter 5, Millard investigates the rise in prominence, in the 1960s and 1970s, of a concept of self-cutting in British psychiatry, which marked ‘a significant shift away from the concern around self-poisoning’ (155). Specifically, Millard offers a critical assessment of the British literature on self-cutting, with the focus on how self-cutting comes under intensive psychiatric scrutiny in the ‘high-surveillance environment of a psychiatric inpatient ward’ (158) and is conceptualised as motivated by ‘internal emotional states, rather than communication’ (161). In his analysis of each clinical study of self-cutting, Millard details how cutting in psychiatric inpatient institutions emerged as an epidemic phenomenon and a management and behavioural problem. The move from socially embedded to internally self-regulating self-harm, Millard argues, was by no means inevitable. While the change in explanations was largely the outcome of practices of exclusion and emphasis, the corresponding ‘political fracturing of consensus around welfare and the ascendancy of a neo-liberal rhetoric of self-reliance’ (155) is also pointed to.
With this study, Millard has managed to pack a wealth of detailed analysis and knowledge into a relatively short amount of space, but the book can sometimes seem overladen with a density of information, slowing the pace of the narrative. Nevertheless, the monograph’s focus on self-harm as a constructed part of broader changes in cultural, social and political spheres provides a welcome counterweight to other histories of self-harming behaviours that have predominantly focused on psychological and psychiatric theory and practice, and it makes a weighty contribution to our understanding of the shifting conceptual frameworks of self-harm in twentieth-century Britain.
